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Sánchez-Martínez FI, Abellán-Perpiñán JM, Martínez-Pérez JE, Gómez-Torres JL. Design of a multiple criteria decision analysis framework for prioritizing high-impact health technologies in a regional health service. Int J Technol Assess Health Care 2024; 40:e21. [PMID: 38576122 DOI: 10.1017/s0266462324000205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
OBJECTIVES This study aims to develop a framework for establishing priorities in the regional health service of Murcia, Spain, to facilitate the creation of a comprehensive multiple criteria decision analysis (MCDA) framework. This framework will aid in decision-making processes related to the assessment, reimbursement, and utilization of high-impact health technologies. METHOD Based on the results of a review of existing frameworks for MCDA of health technologies, a set of criteria was proposed to be used in the context of evaluating high-impact health technologies. Key stakeholders within regional healthcare services, including clinical leaders and management personnel, participated in a focus group (n = 11) to discuss the proposed criteria and select the final fifteen. To elicit the weights of the criteria, two surveys were administered, one to a small sample of healthcare professionals (n = 35) and another to a larger representative sample of the general population (n = 494). RESULTS The responses obtained from health professionals in the weighting procedure exhibited greater consistency compared to those provided by the general public. The criteria more highly weighted were "Need for intervention" and "Intervention outcomes." The weights finally assigned to each item in the multicriteria framework were derived as the equal-weighted sum of the mean weights from the two samples. CONCLUSIONS A multi-attribute function capable of generating a composite measure (multicriteria) to assess the value of high-impact health interventions has been developed. Furthermore, it is recommended to pilot this procedure in a specific decision context to evaluate the efficacy, feasibility, usefulness, and reliability of the proposed tool.
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Affiliation(s)
| | | | | | - Jorge-Luis Gómez-Torres
- International Doctorate School, PhD programme in Economics, DEcIDE, University of Murcia, Murcia, Spain
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Kortlever JTP, Zhuang T, Ring D, Reichel LM, Vagner GA, Kamal RN. Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (N Y) 2021; 16:439-446. [PMID: 31517517 PMCID: PMC8283107 DOI: 10.1177/1558944719873399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.
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Affiliation(s)
| | | | - David Ring
- The University of Texas at Austin, Austin, USA
| | | | | | - Robin N. Kamal
- Stanford University, Redwood City, CA, USA,Robin N. Kamal, VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, MC 6342, Redwood City, CA 94603, USA.
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3
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Espinoza Suarez NR, LaVecchia CM, Fischer KM, Kamath CC, Brito JP. Impact of Cost Conversation on Decision-Making Outcomes. Mayo Clin Proc Innov Qual Outcomes 2021; 5:802-810. [PMID: 34401656 PMCID: PMC8358194 DOI: 10.1016/j.mayocpiqo.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective To understand the impact of cost conversations on the following decision-making outcomes: patients’ knowledge about their conditions and treatment options, decisional conflict, and patient involvement. Patients and Methods In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre–post-prospective study comparing care with and without shared decision-making (SDM) tools. Results The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues. Conclusion Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.
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Affiliation(s)
- Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Christina M LaVecchia
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,School of Arts and Sciences, Neumann University, Aston, PA
| | - Karen M Fischer
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Celia C Kamath
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN.,Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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Zhuang T, Kortlever JTP, Shapiro LM, Baker L, Harris AHS, Kamal RN. The Influence of Cost Information on Treatment Choice: A Mixed-Methods Study. J Hand Surg Am 2020; 45:899-908.e4. [PMID: 32723572 PMCID: PMC8139279 DOI: 10.1016/j.jhsa.2020.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 04/21/2020] [Accepted: 05/27/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To test the null hypothesis that exposure to societal cost information does not affect choice of treatment for carpal tunnel syndrome (CTS). METHODS We enrolled 304 participants using the Amazon Mechanical Turk platform to complete a survey in which participants were given the choice between carpal tunnel release (CTR) or a less-expensive option (orthosis wear) in a hypothetical mild CTS scenario. Patients were randomized to receive information about the societal cost of CTR (cost cohort) or no cost information (control). The primary outcome was the probability of choosing CTR measured on a 6-point ordinal scale. We employed qualitative content analysis to evaluate participants' rationale for their choice. We also explored agreement with various attitudes toward health care costs on an ordinal scale. RESULTS Participants in the cost cohort exhibited a greater probability of choosing surgery than those in the control cohort. The relative risk of choosing surgery after exposure to societal cost information was 1.43 (95% confidence interval, 1.11-1.85). Among participants who had not previously been diagnosed with CTS (n = 232), the relative risk of choosing surgery after exposure to societal cost information was 1.55 (95% confidence interval, 1.17-2.06). Lack of personal monetary responsibility frequently emerged as a theme in those in the cost cohort who chose surgery. The majority (94%) of participants expressed at least some agreement that health care cost is a major problem whereas only 58% indicated that they consider the country's health care costs when making treatment decisions. CONCLUSIONS Participants who received societal cost information were more likely to choose the more expensive treatment option (CTR) for mild CTS. CLINICAL RELEVANCE Exposure to societal cost information may influence patient decision making in elective hand surgery. A complete understanding of this influence is required prior to implementing processes toward greater cost transparency for diagnostic/treatment options. Sharing out-of-pocket costs with patients may be a beneficial approach because discussing societal cost information alone will likely not improve value of care.
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Affiliation(s)
- Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Joost T P Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX
| | - Lauren M Shapiro
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Laurence Baker
- Department of Health Research and Policy, Stanford University, Redwood City, CA
| | - Alex H S Harris
- Center for Health Care Evaluation, VA Palo Alto Health Care System, Palo Alto, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study. Public Health 2020; 185:338-340. [PMID: 32726730 DOI: 10.1016/j.puhe.2020.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. STUDY DESIGN Single-centre qualitative study. METHODS The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. RESULTS Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. CONCLUSION The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care.
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Warsame R, Riordan L, Jenkins S, Lackore K, Pacyna J, Antiel R, Beebe T, Liebow M, Thorsteinsdottir B, Grover M, Wynia M, Goold SD, DeCamp M, Danis M, Tilburt J. Responsibilities, Strategies, and Practice Factors in Clinical Cost Conversations: a US Physician Survey. J Gen Intern Med 2020; 35:1971-1978. [PMID: 32399911 PMCID: PMC7351917 DOI: 10.1007/s11606-020-05807-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Physicians play a key role in mitigating and managing costs in healthcare which are rising. OBJECTIVE Conduct a cross-sectional survey in 2017, comparing results to a 2012 survey to understand US physicians' evolving attitudes and strategies concerning healthcare costs. PARTICIPANTS Random sample of 1200 US physicians from the AMA Masterfile. MEASURES Physician views on responsibility for costs of care, enthusiasm for cost-saving strategies, cost-consciousness scale, and practice strategies on addressing cost. KEY RESULTS Among 1200 physicians surveyed in 2017, 489 responded (41%). In 2017, slightly more physicians reported that physicians have a major responsibility for addressing healthcare costs (32% vs. 27%, p = 0.03). In 2017, more physicians attributed "major responsibility" for addressing healthcare costs to pharmaceutical companies (68% vs. 56%, p < 0.001) and hospital and health systems (63% vs. 56%%, p = 0.008) in contrast to 2012. Fewer respondents in 2017 attributed major responsibility for addressing costs to trial lawyers (53% vs. 59%, p = 0.007) and patients (42% vs. 52%, p < 0.0001) as compared to 2012. Physician enthusiasm for patient-focused cost-containment strategies like high deductible health plans and higher co-pays (62% vs. 42%, p < 0.0001 and 62% vs. 39%, p < 0.0001, not enthusiastic, respectively) declined. Physicians reported that when they discussed cost, it resulted in a change in disease management 56% of the time. Cost-consciousness within surveyed physicians had not changed meaningfully in 2017 since 2012 (31.7 vs. 31.2). Most physicians continued to agree that decision support tools showing costs would be helpful in their practice (> 70%). After adjusting for specialty, political affiliation, practice setting, age, and gender, only democratic/independent affiliation remained a significant predictor of cost-consciousness. CONCLUSIONS AND RELEVANCE US physicians increasingly attribute responsibility for rising healthcare costs to organizations and express less enthusiasm for strategies that increase patient out-of-pocket cost. Interventions that focus on physician knowledge and communication strategies regarding cost of care may be helpful.
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Affiliation(s)
- Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA. .,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
| | | | - Sarah Jenkins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Kandace Lackore
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Joel Pacyna
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA
| | - Ryan Antiel
- Division of Pediatric Surgery, St. Louis Children's Hospital and Washington University School of Medicine, St. Louis, MO, USA
| | - Timothy Beebe
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mark Liebow
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael Grover
- Department of Family Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Matthew Wynia
- Center for Bioethics and Humanities, University of Colorado, Aurora, CO, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Susan Dorr Goold
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Matthew DeCamp
- Center for Bioethics and Humanities, University of Colorado, Aurora, CO, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Denver, CO, USA
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Jon Tilburt
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.,Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
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7
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Kwon R, Allen LA, Scherer LD, Thompson JS, Abdel-Maksoud MF, McIlvennan CK, Matlock DD. The Effect of Total Cost Information on Consumer Treatment Decisions: An Experimental Survey. Med Decis Making 2019; 38:584-592. [PMID: 29847252 DOI: 10.1177/0272989x18773718] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unrestrained use of expensive, high-risk interventions runs counter to the idea of a limited medical commons. OBJECTIVE To examine the effect of displaying the total first-year cost of implanting a left ventricular assist device (LVAD) on a hypothetical treatment decision and whether this effect differs when choosing for oneself versus for another person. DESIGN We conducted an online survey in February 2016. The survey described the clinical course of end-stage heart failure and the risks and benefits of an LVAD. Participants were randomized to 1 of 4 scenarios, which varied by patient identity (oneself versus another person) and description of total cost. MEASUREMENTS This study measured acceptance of LVAD implantation. Reasoning and attitudes were secondarily explored. RESULTS We received 1211 valid responses. The mean age was 38.3 y (±12.8); 53.5% were female and 84.4% were white. Participants were more likely to accept an LVAD when shown the total cost (66.2% v. 58.0%, P = 0.003) or when choosing for another (68.0 % v. 56.4%, P < 0.001). Open-ended responses indicated that acceptors wanted to extend survival while decliners feared poor quality of life with LVAD therapy. Acceptors and decliners agreed that consumers can help lower the cost of health care, but decliners were more likely to consider cost when making health care decisions ( P < 0.001). LIMITATIONS Limitations include the use of a hypothetical scenario, the use of paid participants, and differences between the respondents and the typical patient facing an LVAD decision. CONCLUSIONS In this sample, being shown the total cost increased the likelihood of accepting an expensive, high-risk treatment. The results question how well consumers understand the relationship between expensive treatments and the commons.
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Affiliation(s)
- Regina Kwon
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Department of Psychological Sciences, University of Missouri, Columbia, MO, USA
| | - Jocelyn S Thompson
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Colleen K McIlvennan
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,VA Eastern Colorado Geriatrics Research, Education, and Clinical Center, Denver, CO, USA
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Schlesinger M, Grob R. Treating, Fast and Slow: Americans' Understanding of and Responses to Low-Value Care. Milbank Q 2018; 95:70-116. [PMID: 28266067 DOI: 10.1111/1468-0009.12246] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Greene J, Sacks RM. Presenting Cost and Efficiency Measures That Support Consumers to Make High-Value Health Care Choices. Health Serv Res 2018; 53 Suppl 1:2662-2681. [PMID: 29479695 DOI: 10.1111/1475-6773.12839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify approaches to presenting cost and resource use measures that support consumers in selecting high-value hospitals. DATA SOURCES Survey data were collected from U.S. employees of Analog Devices (n = 420). STUDY DESIGN In two online experiments, participants viewed comparative data on four hospitals. In one experiment, participants were randomized to view one of five versions of the same comparative cost data, and in the other experiment they viewed different versions of the same readmissions data. Bivariate and multivariate analyses examined whether presentation approach was related to selecting the high-value hospital. PRINCIPAL FINDINGS Consumers were approximately 16 percentage points more likely to select a high-value hospital when cost data were presented using actual dollar amounts or using the word "affordable" to describe low-cost hospitals, compared to when the Hospital Compare spending ratio was used. Consumers were 33 points more likely to select the highest performing hospital when readmission performance was shown using word icons rather than percentages. CONCLUSIONS Presenting cost and resource use measures effectively to consumers is challenging. This study suggests using actual dollar amounts for cost, but presenting performance on readmissions using evaluative symbols.
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Affiliation(s)
- Jessica Greene
- Marxe School of Public and International Affairs, Baruch College, City University of New York, New York, NY.,George Washington University, Washington, DC
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10
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Obermair HM, Dodd RH, Bonner C, Jansen J, McCaffery K. 'It has saved thousands of lives, so why change it?' Content analysis of objections to cervical screening programme changes in Australia. BMJ Open 2018; 8:e019171. [PMID: 29440214 PMCID: PMC5829885 DOI: 10.1136/bmjopen-2017-019171] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/11/2017] [Accepted: 01/11/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The incidence and mortality of cervical cancer have halved since introduction of the Australian cervical screening programme in 1991, involving 2-yearly Pap smears from ages 18-69 years. In 2017, the programme changed to 5- yearly primary human papillomavirus (HPV) testing for women aged 25-74 years. This study investigated reasons for opposition to the renewed screening programme within the open-ended comments of an online petition, 'Stop May 1st Changes to Pap Smears-Save Women's Lives', opposing the changes, which received over 70 000 signatures and almost 20 000 comments. METHODS Content analysis of a random sample of 2000 comments, reflecting 10% of the 19 633 comments posted in February-March 2017. RESULTS Nineteen codes were identified, reflecting four themes: (1) valuing women's health and rights, (2) political statements, (3) concerns about healthcare funding cuts and (4) opposition to specific components of the new screening programme. The most prevalent codes were: placing value on women's health (33%), concerns about increasing screening intervals (17%) and opposition to the changes related to personal experiences with cervical cancer or cervical abnormalities (15%). Concern about the key change in technology (HPV testing instead of Pap smears) was expressed in less than 3% of comments, and some opposition to the changes from health professionals was noted. CONCLUSIONS Screening changes within this selected group were perceived as threatening women's health, as a political policy created by male decision-makers and as a cost-cutting exercise. Many commenters were concerned about increased screening intervals and later screening onset, but little opposition was expressed regarding the testing technology itself. This analysis may inform public education and communication strategies for future changes to cervical screening programmes internationally, to pre-emptively address specific concerns about the changes.
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Affiliation(s)
- Helena M Obermair
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rachael H Dodd
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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11
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Prior SJ, Campbell S. Patient and Family Involvement: A Discussion of Co-Led Redesign of Healthcare Services. J Particip Med 2018; 10:e5. [PMID: 33052119 PMCID: PMC7489197 DOI: 10.2196/jopm.8957] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 09/13/2017] [Indexed: 12/30/2022] Open
Abstract
The involvement of patients and their families in the redesign of healthcare services is an important option in providing a service that addresses the patients’ needs and improves health outcomes. However, it is a resource-intensive approach, and it is currently not clear when it should be used, and what should be the reasoning behind this decision. Some health systems of international standing have created a patient engagement program as a selling point. This paper discusses how co-led redesign can be beneficial in improving health service and more effectively engaging patients. Potential barriers for patient involvement are discussed. Patient involvement can be integrated into the health system at three main levels of engagement: direct care, organizational design and governance, and policy-making. The aim of this paper is to describe how co-led redesign is compatible with different levels of patient involvement and to address the challenges in delivering a co-led redesign in healthcare. Co-led redesign not only involves the collection of quantitative data for assessing the current systems but also the collection of qualitative data through patient, family, and staff interviews to determine the barriers to patient satisfaction. Co-led redesign is a resource-rich process that requires expertise in data collection and a clinical group that is devoted to implementing recommended changes. Currently, a number of countries have utilized co-led redesign for many different types of healthcare services. Resource availability and cost, process time, and lack of outcome measures are three major limiting factors.
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Affiliation(s)
- Sarah Jane Prior
- Rural Clinical School, Faculty of Health, University of Tasmania, Burnie, Australia.,Health Service Innovation Tasmania, Faculty of Health, University of Tasmania, Hospital Campus, Burnie, Australia
| | - Steven Campbell
- School of Health Sciences, Faculty of Health, University of Tasmania, Newnham, Australia
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12
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Richmond J, Powell W, Maurer M, Mangrum R, Gold MR, Pathak-Sen E, Yang M, Carman KL. Public Mistrust of the U.S. Health Care System's Profit Motives: Mixed-Methods Results from a Randomized Controlled Trial. J Gen Intern Med 2017; 32:1396-1402. [PMID: 28875447 PMCID: PMC5698226 DOI: 10.1007/s11606-017-4172-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/03/2017] [Accepted: 08/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas. OBJECTIVE To explore public perceptions of health care costs and how they intersect with medical mistrust. DESIGN AND PARTICIPANTS This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions. APPROACH We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts. KEY RESULTS Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs. CONCLUSIONS Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust.
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Affiliation(s)
- Jennifer Richmond
- Domestic Research and Evaluation, American Institutes for Research, Chapel Hill, NC, USA. .,Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | - Wizdom Powell
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA.,Health Disparities Institute, UConn Health, University of Connecticut, Hartford, CT, USA.,Department of Psychiatry, UConn Health, University of Connecticut, Farmington, CT, USA
| | - Maureen Maurer
- Domestic Research and Evaluation, American Institutes for Research, Chapel Hill, NC, USA
| | - Rikki Mangrum
- Domestic Research and Evaluation, American Institutes for Research, Chapel Hill, NC, USA
| | | | | | - Manshu Yang
- Domestic Research and Evaluation, American Institutes for Research, Chapel Hill, NC, USA
| | - Kristin L Carman
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
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Can Appealing to Patient Altruism Reduce Overuse of Health Care Services? An Experimental Survey. J Gen Intern Med 2017; 32:732-738. [PMID: 28155043 PMCID: PMC5481226 DOI: 10.1007/s11606-017-4002-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/05/2016] [Accepted: 01/18/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND A challenge to reducing overuse of health services is communicating recommendations against unnecessary health services to patients. The predominant approach has been to highlight the limited benefit and potential harm of such services for that patient, but the prudent use of health resources can also benefit others. Whether appealing to patient altruism can reduce overuse is unknown. OBJECTIVE To determine whether altruistic appeals reduce hypothetical requests for overused services and affect physician ratings. DESIGN Experimental survey using hypothetical vignettes describing three overused health services (antibiotics for acute sinusitis, imaging for acute low back pain, and annual exams for healthy adults). PARTICIPANTS U.S. adults recruited from Research Now, an online panel of individuals compensated for performing academic and marketing research surveys. INTERVENTIONS In the control version of the vignettes, the physician's rationale for recommending against the service was the minimal benefit and potential for harm. In the altruism version, the rationale additionally included potential benefit to others by forgoing that service. MAIN MEASURES Differences in requests for overused services and physician ratings between participants randomized to the control and altruism versions of the vignettes. KEY RESULTS A total of 1001 participants were included in the final analyses. There were no significant differences in requests for overused services for any of the clinical scenarios (P values ranged from 0.183 to 0.547). Physician ratings were lower in the altruism version for the acute sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios (6.14 vs. 6.83, P < 0.001), and marginally lower for the healthy adult scenario (5.27 vs. 5.57, P = 0.084). CONCLUSIONS In this experimental survey, altruistic appeals delivered by physicians did not reduce requests for overused services, and resulted in more negative physician ratings. Further studies are warranted to determine whether alternative methods of appealing to patient altruism can reduce overuse.
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Sperling D. (Re)disclosing physician financial interests: rebuilding trust or making unreasonable burdens on physicians? MEDICINE, HEALTH CARE, AND PHILOSOPHY 2017; 20:179-186. [PMID: 28275937 DOI: 10.1007/s11019-017-9751-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Recent professional guidelines published by the General Medical Council instruct physicians in the UK to be honest and open in any financial agreements they have with their patients and third parties. These guidelines are in addition to a European policy addressing disclosure of physician financial interests in the industry. Similarly, In the US, a national open payments program as well as Federal regulations under the Affordable Care Act re-address the issue of disclosure of physician financial interests in America. These new professional and legal changes make us rethink the fiduciary duties of providers working under new organizational and financial schemes, specifically their clinical fidelity and their moral and professional obligations to act in the best interests of patients. The article describes the legal changes providing the background for such proposals and offers a prima facie ethical analysis of these evolving issues. It is argued that although disclosure of conflicting interest may increase trust it may not necessarily be beneficial to patients nor accord with their expectations and needs. Due to the extra burden associated with disclosure as well as its implications on the medical profession and the therapeutic relationship, it should be held that transparency of physician financial interest should not result in mandatory disclosure of such interest by physicians. It could lead, as some initiatives in Europe and the US already demonstrate, to voluntary or mandatory disclosure schemes carried out by the industry itself. Such schemes should be in addition to medical education and the address of the more general phenomenon of physician conflict of interest in ethical codes and ethical training of the parties involved.
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15
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Costs matter: The impact of disclosing treatment costs and provider profit on patients’ decisions. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2016.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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16
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How Primary Care Physicians Integrate Price Information into Clinical Decision-Making. J Gen Intern Med 2017; 32:81-87. [PMID: 27561735 PMCID: PMC5215149 DOI: 10.1007/s11606-016-3805-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 05/04/2016] [Accepted: 06/28/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Little is known about how primary care physicians (PCPs) in routine outpatient practice use paid price information (i.e., the amount that insurers finally pay providers) in daily clinical practice. OBJECTIVE To describe the experiences of PCPs who have had paid price information on tests and procedures for at least 1 year. DESIGN Cross-sectional study using semi-structured interviews and the constant comparative method of qualitative analysis. PARTICIPANTS Forty-six PCPs within an accountable care organization. INTERVENTION Via the ordering screen of their electronic health record, PCPs were presented with the median paid price for commonly ordered tests and procedures (e.g., blood tests, x-rays, CTs, MRIs). APPROACH We asked PCPs for (a) their "gut reaction" to having paid price information, (b) the situations in which they used price information in clinical decision-making separate from or jointly with patients, (c) their thoughts on who bore the chief responsibility for discussing price information with patients, and (d) suggestions for improving physician-targeted price information interventions. KEY RESULTS Among "gut reactions" that ranged from positive to negative, all PCPs were more interested in having patient-specific price information than paid prices from the practice perspective. PCPs described that when patients' out-of-pocket spending concerns were revealed, price information helped them engage patients in conversations about how to alter treatment plans to make them more affordable. PCPs stated that having price information only slightly altered their test-ordering patterns and that they avoided mentioning prices when advising patients against unnecessary testing. Most PCPs asserted that physicians bear the chief responsibility for discussing prices with patients because of their clinical knowledge and relationships with patients. They wished for help from patients, practices, health plans, and society in order to support price transparency in healthcare. CONCLUSIONS Physician-targeted price transparency efforts may provide PCPs with the information they need to respond to patients' concerns regarding out-of-pocket affordability rather than that needed to change test-ordering habits.
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17
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Riggs KR, Knight SJ. The Language of Stewardship: Is the "Low-Value" Label Overused? Mayo Clin Proc 2017; 92:11-14. [PMID: 27842705 PMCID: PMC5222691 DOI: 10.1016/j.mayocp.2016.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/01/2016] [Accepted: 09/12/2016] [Indexed: 01/17/2023]
Affiliation(s)
- Kevin R Riggs
- Division of Preventive Medicine, University of Alabama at Birmingham, and Birmingham VA Medical Center, Birmingham, AL.
| | - Sara J Knight
- Division of Preventive Medicine, University of Alabama at Birmingham, and Birmingham VA Medical Center, Birmingham, AL
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18
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Hunter WG, Hesson A, Davis JK, Kirby C, Williamson LD, Barnett JA, Ubel PA. Patient-physician discussions about costs: definitions and impact on cost conversation incidence estimates. BMC Health Serv Res 2016; 16:108. [PMID: 27036177 PMCID: PMC4815215 DOI: 10.1186/s12913-016-1353-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/17/2016] [Indexed: 02/08/2023] Open
Abstract
Background Nearly one in three Americans are financially burdened by their medical expenses. To mitigate financial distress, experts recommend routine physician-patient cost conversations. However, the content and incidence of these conversations are unclear, and rigorous definitions are lacking. We sought to develop a novel set of cost conversation definitions, and determine the impact of definitional variation on cost conversation incidence in three clinical settings. Methods Retrospective, mixed-methods analysis of transcribed dialogue from 1,755 outpatient encounters for routine clinical management of breast cancer, rheumatoid arthritis, and depression, occurring between 2010–2014. We developed cost conversation definitions using summative content analysis. Transcripts were evaluated independently by at least two members of our multi-disciplinary team to determine cost conversation incidence using each definition. Incidence estimates were compared using Pearson’s Chi-Square Tests. Results Three cost conversation definitions emerged from our analysis: (a) Out-of-Pocket (OoP) Cost -- discussion of the patient’s OoP costs for a healthcare service; (b) Cost/Coverage -- discussion of the patient’s OoP costs or insurance coverage; (c) Cost of Illness-- discussion of financial costs or insurance coverage related to health or healthcare. These definitions were hierarchical; OoP Cost was a subset of Cost/Coverage, which was a subset of Cost of Illness. In each clinical setting, we observed significant variation in the incidence of cost conversations when using different definitions; breast oncology: 16, 22, 24 % of clinic visits contained cost conversation (OOP Cost, Cost/Coverage, Cost of Illness, respectively; P < 0.001); depression: 30, 38, 43 %, (P < 0.001); and rheumatoid arthritis, 26, 33, 35 %, (P < 0.001). Conclusions The estimated incidence of physician-patient cost conversation varied significantly depending on the definition used. Our findings and proposed definitions may assist in retrospective interpretation and prospective design of investigations on this topic. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1353-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wynn G Hunter
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.
| | - Ashley Hesson
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - J Kelly Davis
- Duke University, Fuqua School of Business, Durham, NC, USA
| | | | | | | | - Peter A Ubel
- Duke University, School of Medicine, 4906 Glendarion Drive, Durham, NC, 27713, USA.,Duke University, Fuqua School of Business, Durham, NC, USA.,Duke University, Sanford School of Public Policy, Durham, NC, USA
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19
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Akintobi TH, Hoffman LM, McAllister C, Goodin L, Hernandez ND, Rollins L, Miller A. Assessing the Oral Health Needs of African American Men in Low-Income, Urban Communities. Am J Mens Health 2016; 12:326-337. [PMID: 27008993 DOI: 10.1177/1557988316639912] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite improvements in oral health status in the United States, pronounced racial/ethnic disparities exist. Black men are less likely to visit the dentist, are twice as likely to experience tooth decay, and have a significantly lower 5-year oral cancer survival rate when compared to White men. The Minority Men's Oral Health Dental Access Program employed a community-based participatory research approach to examine the oral health barriers and opportunities for intervention among Black men in a low-income, urban neighborhood. A cross-sectional study design was implemented through a self-administered survey completed among 154 Black males. The majority reported not having dental insurance (68.8%). Most frequently cited oral health care barriers were lack of dental insurance and not being able to afford dental care. Attitudes related to the significance of dental care centered on cancer prevention and feeling comfortable with one's smile. The impact of oral health on daily life centered on social interaction, with men citing insecurities associated with eating, talking, and smiling due to embarrassment with how their teeth/mouth looked to others. Multivariate logistic regression revealed that those who had difficulty finding dental care were 4.81 times (odds ratio = 4.65, 95% confidence interval [1.80, 12.85]) more likely to report no dental insurance, and 2.73 times (odds ratio = 3.72; 95% confidence interval [1.12, 6.70]) more likely to report poor oral health. Community-based participatory approaches include assessment of neighborhood residents affected by the health issue to frame interventions that resonate and are more effective. Social, physical, and infrastructural factors may emerge, requiring a multilevel approach.
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Affiliation(s)
| | | | | | - Lisa Goodin
- 3 Fulton County Department of Health and Wellness, Atlanta, GA, USA
| | | | | | - Assia Miller
- 4 McKing Consulting Corporation, Atlanta, GA, USA
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20
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Huang GC, Tibbles CD, Newman LR, Schwartzstein RM. Consensus of the Millennium Conference on Teaching High Value Care. TEACHING AND LEARNING IN MEDICINE 2016; 28:97-104. [PMID: 26787090 DOI: 10.1080/10401334.2015.1077132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
ISSUE Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. EVIDENCE Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. IMPLICATIONS Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.
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Affiliation(s)
- Grace C Huang
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Carrie D Tibbles
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Lori R Newman
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
| | - Richard M Schwartzstein
- a Center for Education, Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA
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21
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Affiliation(s)
- Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 485
Lexington Avenue, New York, NY 10017, ,
Tel: 686-888-8210, Fax: 646-227-7102
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22
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Kanzaria HK, McCabe AM, Meisel ZM, LeBlanc A, Schaffer JT, Bellolio MF, Vaughan W, Merck LH, Applegate KE, Hollander JE, Grudzen CR, Mills AM, Carpenter CR, Hess EP. Advancing Patient-centered Outcomes in Emergency Diagnostic Imaging: A Research Agenda. Acad Emerg Med 2015; 22:1435-46. [PMID: 26574729 DOI: 10.1111/acem.12832] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/13/2015] [Indexed: 01/01/2023]
Abstract
Diagnostic imaging is integral to the evaluation of many emergency department (ED) patients. However, relatively little effort has been devoted to patient-centered outcomes research (PCOR) in emergency diagnostic imaging. This article provides background on this topic and the conclusions of the 2015 Academic Emergency Medicine consensus conference PCOR work group regarding "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The goal was to determine a prioritized research agenda to establish which outcomes related to emergency diagnostic imaging are most important to patients, caregivers, and other key stakeholders and which methods will most optimally engage patients in the decision to undergo imaging. Case vignettes are used to emphasize these concepts as they relate to a patient's decision to seek care at an ED and the care received there. The authors discuss applicable research methods and approaches such as shared decision-making that could facilitate better integration of patient-centered outcomes and patient-reported outcomes into decisions regarding emergency diagnostic imaging. Finally, based on a modified Delphi process involving members of the PCOR work group, prioritized research questions are proposed to advance the science of patient-centered outcomes in ED diagnostic imaging.
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Affiliation(s)
- Hemal K. Kanzaria
- Department of Emergency Medicine; University of California San Francisco & San Francisco General Hospital; San Francisco CA
- Robert Wood Johnson Clinical Scholars Program and the U.S. Department of Veterans Affairs; Los Angeles CA
- RAND Health; Santa Monica CA
| | - Aileen M. McCabe
- Department of Emergency Medicine; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
- Emergency Care Research Unit; Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Zachary M. Meisel
- Department of Emergency Medicine; Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
- Center for Emergency Care Policy & Research; Perelman School of Medicine, and the Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia PA
| | - Annie LeBlanc
- Division of Health Care Policy and Research; Department of Health Sciences Research; Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
| | - Jason T. Schaffer
- Department of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - M. Fernanda Bellolio
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Mayo Clinic; Rochester MN
| | | | - Lisa H. Merck
- Department of Emergency Medicine; The Warren Alpert Medical School of Brown University; Providence RI
- Department of Diagnostic Imaging; The Warren Alpert Medical School of Brown University; Providence RI
| | - Kimberly E. Applegate
- Department of Radiology and Imaging Sciences; Emory University School of Medicine; Atlanta GA
| | - Judd E. Hollander
- Department of Emergency Medicine; Sidney Kimmel Medical College of Thomas Jefferson University; Philadelphia PA
- National Academic Center for Telehealth; Philadelphia PA
| | - Corita R. Grudzen
- Department of Emergency Medicine; New York University; New York NY
- Department Population Health; New York University; New York NY
| | - Angela M. Mills
- Emergency Care Research Unit; Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Christopher R. Carpenter
- Division of Emergency Medicine; Washington University School of Medicine, and the Washington University Emergency Care Research Core; St. Louis MO
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Mayo Clinic; Rochester MN
- Knowledge and Evaluation Research Unit; Division of Healthcare Policy Research; Department of Health Sciences Research; Mayo Clinic; Rochester MN
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23
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Whitney RL, Bell JF, Reed SC, Lash R, Bold RJ, Kim KK, Davis A, Copenhaver D, Joseph JG. Predictors of financial difficulties and work modifications among cancer survivors in the United States. J Cancer Surviv 2015; 10:241-50. [PMID: 26188363 DOI: 10.1007/s11764-015-0470-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study is to examine predictors of cancer-related financial difficulties and work modifications in a national sample of cancer survivors. METHODS Using the 2011 Medical Expenditure Panel Survey and Experiences with Cancer Survivorship Supplement, the prevalence of financial difficulties and work modifications was examined. Logistic regression and survey weights were used to model these outcomes as functions of sociodemographic and health covariates separately among survivors in active treatment and survivors under age 65 years. RESULTS Among all survivors, 33.2% reported any financial concern, with 17.9% reporting financial difficulties such as debt or bankruptcy. Among working survivors, 44.0% made any work modification and 15.3% made long-term work modifications (e.g., delayed or early retirement). Among those in active treatment, predictors of financial difficulty included: race/ethnicity other than white, non-Hispanic [OR = 8.0; 95% CI 2.2-28.4]; income <200% of federal poverty level (FPL) [OR = 15.7; 95% CI 2.6-95.2] or between 200 and 400% of FPL [OR = 8.2; 95% CI 1.3-51.4]; residence in a non-metropolitan service area [OR = 6.4; 95% CI 1.6-25.0]; and good/fair/poor self-rated health [OR = 3.8; 95% CI 1.0-14.2]. Among survivors under age 65 years, predictors of long-term work modifications included good/fair/poor self-rated health [OR = 4.1; 95% CI 1.6-10.2], being married [OR = 2.2; 95% CI 1.0-4.7], uninsured [OR = 3.5; 95% CI 1.3-9.3], or publicly insured [OR = 9.0; 95% CI 3.3-24.4]. CONCLUSIONS A substantial proportion of cancer survivors experience cancer-related financial difficulties and work modifications, particularly those who report race/ethnicity other than white, non-Hispanic, residence in non-metropolitan areas, worse health status, lower income, and public or no health insurance. IMPLICATIONS FOR CANCER SURVIVORS Attention to the economic impact of cancer treatment is warranted across the survivorship trajectory, with particular attention to subgroups at higher risk.
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Affiliation(s)
- Robin L Whitney
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA.
| | - Janice F Bell
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
| | - Sarah C Reed
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
| | - Rebecca Lash
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
| | - Richard J Bold
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA.,Comprehensive Cancer Center, UC Davis Health System, University of California, Davis, 4501 X Street, Sacramento, CA, 95817, USA
| | - Katherine K Kim
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
| | - Andra Davis
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
| | - David Copenhaver
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA.,Comprehensive Cancer Center, UC Davis Health System, University of California, Davis, 4501 X Street, Sacramento, CA, 95817, USA
| | - Jill G Joseph
- Collaborative Cancer Care Research Group (3CRG), Betty Irene Moore School of Nursing, University of California, Davis, 4610 X Street #4202, Sacramento, CA, 95817, USA
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24
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Melnick ER, Keegan J, Taylor RA. Redefining Overuse to Include Costs: A Decision Analysis for Computed Tomography in Minor Head Injury. Jt Comm J Qual Patient Saf 2015; 41:313-22. [DOI: 10.1016/s1553-7250(15)41041-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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25
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Herrin J, Harris KG, Kenward K, Hines S, Joshi MS, Frosch DL. Patient and family engagement: a survey of US hospital practices. BMJ Qual Saf 2015; 25:182-9. [PMID: 26082560 PMCID: PMC4789699 DOI: 10.1136/bmjqs-2015-004006] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 05/28/2015] [Indexed: 11/30/2022]
Abstract
Background Patient and family engagement (PFE) in healthcare is an important element of the transforming healthcare system; however, the prevalence of various PFE practices in the USA is not known. Objective We report on a survey of hospitals in the USA regarding their PFE practices during 2013–2014. Results The response rate was 42%, with 1457 acute care hospitals completing the survey. We constructed 25 items to summarise the responses regarding key practices, which fell into three broad categories: (1) organisational practices, (2) bedside practices and (3) access to information and shared decision-making. We found a wide range of scores across hospitals. Selected findings include: 86% of hospitals had a policy for unrestricted visitor access in at least some units; 68% encouraged patients/families to participate in shift-change reports; 67% had formal policies for disclosing and apologising for errors; and 38% had a patient and family advisory council. The most commonly reported barrier to increased PFE was ‘competing organisational priorities’. Summary Our findings indicate that there is a large variation in hospital implementation of PFE practices, with competing organisational priorities being the most commonly identified barrier to adoption.
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Affiliation(s)
- Jeph Herrin
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois, USA Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kathleen G Harris
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois, USA
| | - Kevin Kenward
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois, USA
| | - Stephen Hines
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois, USA
| | - Maulik S Joshi
- Health Research & Educational Trust, American Hospital Association, Chicago, Illinois, USA
| | - Dominick L Frosch
- Gordon & Betty Moore Foundation, Palo Alto, USA Department of Medicine, University of California, Los Angeles, California, USA
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26
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DeCamp M, Farber NJ, Torke AM, George M, Berger Z, Keirns CC, Kaldjian LC. Ethical challenges for accountable care organizations: a structured review. J Gen Intern Med 2014; 29:1392-9. [PMID: 24664441 PMCID: PMC4175644 DOI: 10.1007/s11606-014-2833-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/21/2014] [Accepted: 03/02/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Accountable care organizations (ACOs) are proliferating as a solution to the cost crisis in American health care, and already involve as many as 31 million patients. ACOs hold clinicians, group practices, and in many circumstances hospitals financially accountable for reducing expenditures and improving their patients' health outcomes. The structure of health care affects the ethical issues arising in the practice of medicine; therefore, like all health care organizational structures, ACOs will experience ethical challenges. No framework exists to assist key ACO stakeholders in identifying or managing these challenges. METHODS We conducted a structured review of the medical ACO literature using qualitative content analysis to inform identification of ethical challenges for ACOs. RESULTS Our analysis found infrequent discussion of ethics as an explicit concern for ACOs. Nonetheless, we identified nine critical ethical challenges, often described in other terms, for ACO stakeholders. Leaders could face challenges regarding fair resource allocation (e.g., about fairly using ACOs' shared savings), protection of professionals' ethical obligations (especially related to the design of financial incentives), and development of fair decision processes (e.g., ensuring that beneficiary representatives on the ACO board truly represent the ACO's patients). Clinicians could perceive threats to their professional autonomy (e.g., through cost control measures), a sense of dual or conflicted responsibility to their patients and the ACO, or competition with other clinicians. For patients, critical ethical challenges will include protecting their autonomy, ensuring privacy and confidentiality, and effectively engaging them with the ACO. DISCUSSION ACOs are not inherently more or less "ethical" than other health care payment models, such as fee-for-service or pure capitation. ACOs' nascent development and flexibility in design, however, present a time-sensitive opportunity to ensure their ethical operation, promote their success, and refine their design and implementation by identifying, managing, and conducting research into the ethical issues they might face.
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Affiliation(s)
- Matthew DeCamp
- Berman Institute of Bioethics and Division of General Internal Medicine, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, USA,
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27
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Sabbatini AK, Tilburt JC, Campbell EG, Sheeler RD, Egginton JS, Goold SD. Controlling health costs: physician responses to patient expectations for medical care. J Gen Intern Med 2014; 29:1234-41. [PMID: 24871228 PMCID: PMC4139526 DOI: 10.1007/s11606-014-2898-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/25/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary. OBJECTIVE To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care. DESIGN Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services. PARTICIPANTS Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcripts PRINCIPAL FINDINGS Physicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment. CONCLUSIONS Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.
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Affiliation(s)
- Amber K Sabbatini
- Department of Emergency Medicine, University of Michigan, NCRC,2800 Plymouth Rd, Building 10, Room G015, Ann Arbor, MI, 48109-2800, USA,
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Abstract
High-deductible health plans (HDHPs) are insurance policies with higher deductibles than conventional plans. The Medicare Prescription Drug Improvement and Modernization Act of 2003 linked many HDHPs with tax-advantaged spending accounts. The 2010 Patient Protection and Affordable Care Act continues to provide for HDHPs in its lower-level plans on the health insurance marketplace and provides for them in employer-offered plans. HDHPs decrease the premium cost of insurance policies for purchasers and shift the risk of further payments to the individual subscriber. HDHPs reduce utilization and total medical costs, at least in the short term. Because HDHPs require out-of-pocket payment in the initial stages of care, primary care and other outpatient services as well as elective procedures are the services most affected, whereas higher-cost services in the health care system, incurred after the deductible is met, are unaffected. HDHPs promote adverse selection because healthier and wealthier patients tend to opt out of conventional plans in favor of HDHPs. Because the ill pay more than the healthy under HDHPs, families with children with special health care needs bear an increased cost burden in this model. HDHPs discourage use of nonpreventive primary care and thus are at odds with most recommendations for improving the organization of health care, which focus on strengthening primary care.This policy statement provides background information on HDHPs, discusses the implications for families and pediatric care providers, and suggests courses of action.
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Exploring public attitudes towards approaches to discussing costs in the clinical encounter. J Gen Intern Med 2014; 29:223-9. [PMID: 23881272 PMCID: PMC3889963 DOI: 10.1007/s11606-013-2543-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/28/2013] [Accepted: 06/06/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients' willingness to discuss costs of treatment alternatives with their physicians is uncertain. OBJECTIVE To explore public attitudes toward doctor-patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians. DESIGN Focus group discussions and pre-discussion and post-discussion questionnaires. PARTICIPANTS Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area. MAIN MEASUREMENTS Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians' role in controlling costs; receptivity toward recommended communication strategies regarding costs. KEY RESULTS Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (OR = 1.8, p = 0.004; OR = 1.6, p = 0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (OR = 2.4, p = 0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one's physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs. CONCLUSIONS This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor-patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter.
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Grover A, Niecko-Najjum LM. Physician workforce planning in an era of health care reform. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1822-6. [PMID: 24128627 DOI: 10.1097/acm.0000000000000036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Workforce planning in an era of health care reform is a challenge as both delivery systems and patient demographics change. Current workforce projections are based on a future health care system that is either an identified "ideal" or a modified version of the existing system. The desire to plan for such an "ideal system," however, may threaten access to necessary services if it does not come to fruition or is based on theoretical rather than empirical data.Historically, workforce planning that concentrated only on an "ideal system" has been centered on incorrect assumptions. Two examples of such failures presented in the 1980s when the Graduate Medical Education National Advisory Committee recommended a decrease in the physician workforce on the basis of predetermined "necessary and appropriate" services and in the 1990s, when planners expected managed care and health maintenance organizations to completely overhaul the existing health care system. Neither accounted for human behavior, demographic changes, and actual demand for health care services, leaving the nation ill-prepared to care for an aging population with chronic disease.In this article, the authors argue that workforce planning should begin with the current system and make adjustments based on empirical data that accurately reflect current trends. Actual health care use patterns will become evident as systemic changes are realized-or not-over time. No single approach will solve the looming physician shortage, but the danger of planning only for an ideal system is being unprepared for the actual needs of the population.
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Affiliation(s)
- Atul Grover
- Dr. Grover is chief public policy officer, Association of American Medical Colleges, Washington, DC. Ms. Niecko-Najjum is senior research and policy analyst, Association of American Medical Colleges, Washington, DC
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Abstract
Novel diagnostic and therapeutic options offer hope to cancer patients with both localized and advanced disease. However, many of these treatments are often costly and even well-insured patients can face high out-of-pocket costs. Families may also be at risk of financial distress due to lost wages and other treatment-related expenses. Research is needed to measure and characterize financial distress in cancer patients and understand how it affects their quality of life. In addition, health care providers need to be trained to counsel patients and their families so they can make patient-centered treatment decisions that reflect their preferences and values.
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Levit KR, Friedman B, Wong HS. Estimating inpatient hospital prices from state administrative data and hospital financial reports. Health Serv Res 2013; 48:1779-97. [PMID: 23662642 DOI: 10.1111/1475-6773.12065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To develop a tool for estimating hospital-specific inpatient prices for major payers. DATA SOURCES AHRQ Healthcare Cost and Utilization Project State Inpatient Databases and complete hospital financial reporting of revenues mandated in 10 states for 2006. STUDY DESIGN Hospital discharge records and hospital financial information were merged to estimate revenue per stay by payer. Estimated prices were validated against other data sources. PRINCIPAL FINDINGS Hospital prices can be reasonably estimated for 10 geographically diverse states. All-payer price-to-charge ratios, an intermediate step in estimating prices, compare favorably to cost-to-charge ratios. Estimated prices also compare well with Medicare, MarketScan private insurance, and the Medical Expenditure Panel Survey prices for major payers, given limitations of each dataset. CONCLUSIONS Public reporting of prices is a consumer resource in making decisions about health care treatment; for self-pay patients, they can provide leverage in negotiating discounts off of charges. Researchers can also use prices to increase understanding of the level and causes of price differentials among geographic areas. Prices by payer expand investigational tools available to study the interaction of inpatient hospital price setting among public and private payers--an important asset as the payer mix changes with the implementation of the Affordable Care Act.
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