The use of expensive health technologies in the era of managed care: the remarkable case of neonatal intensive care

Ethics of care for the micropreemies. Just because we can, should we?

Debates about treatment for the tiniest premature babies focus on three different approaches - universal non-resuscitation, selective resuscitation, and universal resuscitation. Doctors, hospitals, and professional societies differ on which approach is preferable. The debate is evolving as studies show that survival rates for babies born at 22 and 23 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. The doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Centers that offer and encourage treatment cite evidence that many babies born at 22 weeks can survive, that most survivors have good neurodevelopmental outcomes, and that NICU care for tiny babies is cost-effective compared to many common and uncontroversial treatments. The debate touches on many fundamental ethical issues that have been present in neonatology since its inception as a medical specialty.

Ethical implications of the shifting borderline of viability

Survival rates for babies born at 22 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. Thus, parents will be given very different advice at different centers for babies born at the borderline of viability. Those doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Yet there is strong evidence that many babies born at 22 weeks can survive, most survivors have good neurodevelopmental outcomes, and neonatal intensive care for tiny babies is cost-effective compared to many common and uncontroversial treatments. Given this growing body of evidence, policies discouraging or forbidding treatment of babies born at 22 weeks will require stronger ethical justification than has been given to date.

Ethical issues in treatment of babies born at 22 weeks of gestation

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies.

International and cross-cultural dimensions of treatment decisions for neonates

Neonatal mortality rates vary widely among countries. According to data from the World Health Organization, neonatal mortality in low- and low-middle-income countries is ∼30 per 1000 babies. In upper middle-income countries, that number was just 10 per 1000. In the highest-income countries, it was <5 per 1000. These data may not be accurate. Many countries do not report the tiniest babies as live births. Thus, their reported infant mortality rates are much lower than their actual infant mortality rates. Another big difference between countries is in the rate at which congenital anomalies are diagnosed prenatally and the rate at which pregnancies are terminated by induced abortion. International comparisons therefore reflect differences in the way countries define live birth, the comprehensiveness of the reporting of live births even by their own definitions, differences in the prevalence of congenital anomalies, the rate at which those congenital anomalies are diagnosed prenatally, and the percentage of pregnancies with congenital anomalies that end in abortion. This article reviews these differences and discusses the implications for the ways in which we think about international differences in decisions about life-sustaining treatment.

Decomposition of the drivers of the U.S. hospital spending growth, 2001-2009

BACKGROUND

United States health care spending rose rapidly in the 2000s, after a period of temporary slowdown in the 1990s. However, the description of the overall trend and the understanding of the underlying drivers of this trend are very limited. This study investigates how well historical hospital cost/revenue drivers explain the recent hospital spending trend in the 2000s, and how important each of these drivers is.

METHODS

We used aggregated time series data to describe the trend in total hospital spending, price, and quantity between 2001 and 2009. We used the Oaxaca-Blinder method to investigate the relative importance of major hospital cost/spending drivers (derived from the literature) in explaining the change in hospital spending patterns between 2001 and 2007. We assembled data from Medicare Cost Reports, American Hospital Association annual surveys, Prospective Payment System (PPS) Impact Files, Medicare Provider Analysis and Review (MedPAR) Medicare claims data, InterStudy reports, National Health Expenditure data, and Area Resource Files.

RESULTS

Aggregated time series trends show that high hospital spending between 2001 and 2009 appears to be driven by higher payment per unit of hospital output, not by increased utilization. Results using the Oaxaca-Blinder regression decomposition method indicate that changes in historically important spending drivers explain a limited 30% of unit-payment growth, but a higher 60% of utilization growth. Hospital staffing and labor-related costs, casemix, and demographics are the most important drivers of higher hospital revenue, utilization, and unit-payment. Technology is associated with lower utilization, higher unit payment, and limited increases in total revenue. Market competition, primarily because of increased managed care concentration, moderates total revenue growth by driving lower unit payment.

CONCLUSIONS

Much of the rapidly rising hospital spending growth in the 2000s in the United States is driven by factors not commonly known or well measured. Future studies need to explore new factors and dynamics that drive longer-term hospital spending growth in recent years, particularly through the channel of higher prices.

The impact of medical tourism on Thai private hospital management: informing hospital policy

BACKGROUND

The purpose of this paper is to help consolidate and understand management perceptions and experiences of a targeted group (n=7) of Vice-Presidents of international Private Thai hospitals in Bangkok regarding medical tourism impacts.

METHODS

The method adopted uses a small-scale qualitative inquiry. Examines the on-going development and service management factors which contribute to the establishment and strengthening of relationships between international patients and hospital medical services provision. Develops a qualitative model that attempts to conceptualize the findings from a diverse range of management views into a framework of main (8) - Hospital Management; Hospital Processes; Hospital Technology; Quality Related; Communications; Personnel; Financial; and Patients; and consequent sub-themes (22).

RESULTS

Outcomes from small-scale qualitative inquiries cannot by design be taken outside of its topical arena. This inevitably indicates that more research of this kind needs to be carried out to understand this field more effectively. The evidence suggests that Private Thai hospital management have established views about what constitutes the impact of medical tourism on hospital policies and practices when hospital staff interact with international patients.

CONCLUSIONS

As the private health service sector in Thailand continues to grow, future research is needed to help hospitals provide appropriate service patterns and appropriate medical products/services that meet international patient needs and aspirations. Highlights the increasing importance of the international consumer in Thailand's health industry. This study provides insights of private health service providers in Bangkok by helping to understand more effectively health service quality environments, subsequent service provision, and the integrated development and impacts of new medical technology.

Admission of term infants to neonatal intensive care: a population-based study

BACKGROUND

Neonatal intensive care and special care nurseries provide a level of care that is both high in cost and low in volume. The aim of our study was to determine the rate of admission of term babies to neonatal intensive care in association with each method of giving birth among low-risk women.

METHODS

We examined the records of 1,001,249 women who gave birth in Australia during 1999 to 2002 using data from the National Perinatal Data Collection. Among low-risk women, we calculated the adjusted odds of admission to neonatal intensive care at term separated for each week of gestational age between 37 and 41 completed weeks. We also calculated the odds of admission to neonatal intensive care in association with cesarean section before or after the onset of labor, and vacuum or instrumental birth compared with unassisted vaginal birth at 40 weeks' gestation.

RESULTS

The overall rate of admission to neonatal intensive care of term babies was 8.9 percent for primiparas and 6.3 percent for multiparas. After a cesarean section before the onset of labor, the adjusted odds of admission among low-risk primiparas at 37 weeks' gestation were 12.08 (99% CI 8.64-16.89); at 38 weeks, 7.49 (99% CI 5.54-10.11); and at 39 weeks, 2.80 (99% CI 2.02-3.88). At 41 weeks, the adjusted odds were not significantly higher than those at 40 weeks' gestation. Among low-risk multiparas who had a cesarean section before the onset of labor, the adjusted odds of admission to neonatal intensive care at 37 weeks' gestation were 15.40 (99% CI 12.87-18.43); at 38 weeks, 12.13 (99% CI 10.37-14.19); and at 39 weeks, 5.09 (99% CI 4.31-6.00). At 41 weeks' gestation, the adjusted odds of admission were significantly lower than those at 40 weeks (AOR 0.64, 99% CI 0.47-0.88). Babies born after any operative method of birth were at increased odds of being admitted to neonatal intensive care compared with those born after unassisted vaginal birth at 40 weeks' gestation.

CONCLUSIONS

The adjusted odds of admission to neonatal intensive care for babies of low-risk women were increased after birth at 37 weeks' gestation. In a climate of rising cesarean sections, this information is important to women who may be considering elective procedures.

Are newborns morally different from older children?

Policies and position statements regarding decision-making for extremely premature babies exist in many countries and are often directive, focusing on parental choice and expected outcomes. These recommendations often state survival and handicap as reasons for optional intervention. The fact that such outcome statistics would not justify such approaches in other populations suggests that some other powerful factors are at work. The value of neonatal intensive care has been scrutinized far more than intensive care for older patients and suggests that neonatal care is held to a higher standard of justification. The relative value placed on the life of newborns, in particular the preterm, is less than expected by any objective medical data or any prevailing moral frameworks about the value of individual lives. Why do we feel less obligated to treat the premature baby? Do we put newborns in a special and lesser moral category? We explore this question from a legal and ethical perspective and offer several hypotheses pertaining to personhood, reproductive choices, "precious children," and probable evolutionary and anthropological factors.

Sustaining and Improving Hospital Performance

Using data from hospitals in ten states, this study examines the effects of organizational and market factors on the likelihood of becoming high-quality/low-cost providers during the period of 1997-2001. The findings highlight the important role of previous performance, internal operations, and market competition in hospital performance improvement. Achieving high-quality/low-cost performance is also incidentally found to be associated with improved profit margins.

Local health department perspectives on linkages among birthing hospitals

OBJECTIVES

To describe perinatal linkages among hospitals, changes in their numbers and their impact on relationships among high-risk providers in local communities.

STUDY DESIGN

Data were obtained about the organization of perinatal services in 1996-1999 from a cross-sectional study evaluating fetal and infant mortality review (FIMR) programs nationwide. Geographic areas were sampled based on region, population density, and the presence of a FIMR. A local health department representative was interviewed in 76% (N=193) of eligible communities; 188 provided data about hospitals.

RESULTS

Linkages among all hospitals were reported in 143 communities and with a subspecialty hospital in 122. All but 12 communities had a maternity hospital, and changes in the number of hospitals occurred in 49 communities. Decreases in the number of Level II hospitals were related to changes in relationships among providers of high-risk care for mothers and newborns; they were associated with changing relationships only for mothers in Level I hospitals. These relations were noted only where established provider relationships existed.

CONCLUSIONS

Decreases in the number of maternity hospitals affect provider relationships in communities, but only where there are established linkages among hospitals.

Changes in hospital competitive strategy: a new medical arms race?

OBJECTIVE

To describe changes in hospitals' competitive strategies, specifically the relative emphasis placed on strategies for competing along price and nonprice (i.e., service, amenities, perceived quality) dimensions, and the reasons for any observed shifts.

METHODS

This study uses data gathered through the Community Tracking Study site visits, a longitudinal study of a nationally representative sample of 12 U.S. communities. Research teams visited each of these communities every two years since 1996 and conducted between 50 to 90 semistructured interviews. Additional information on hospital competition and strategy was gathered from secondary data.

PRINCIPAL FINDINGS

We found that hospitals' strategic emphasis changed significantly between 1996-1997 and 2000-2001. In the mid-1990s, hospitals primarily competed on price through "wholesale" strategies (i.e., providing services attractive to managed care plans). By 2000-2001, nonprice competition was becoming increasingly important and hospitals were reviving "retail" strategies (i.e., providing services attractive to individual physicians and the patients they serve). Three major factors explain this shift in hospital strategy: less than anticipated selective contracting and capitated payment; the freeing up of hospital resources previously devoted to horizontal and vertical integration strategies; and, the emergence and growth of new competitors.

CONCLUSION

Renewed emphasis on nonprice competition and retail strategies, and the service mimicking and one-upmanship that result, suggest that a new medical arms race is emerging. However, there are important differences between the medical arms race today and the one that occurred in the 1970s and early 1980s: the hospital market is more concentrated and price competition remains relatively important. The development of a new medical arms race has significant research and policy implications.