Care Delivery Mechanisms Research Articles

A163: Alternative Mechanisms of Care Delivery in Pediatric Rheumatology: To What Extent Do They Expand the Reach of Pediatric Rheumatologists?

Background/Purpose:Pediatric rheumatology (PR) practitioners are concentrated in academic centers, rather than being evenly distributed throughout the US. Alternative mechanisms of care delivery, such as secondary clinic sites and telemedicine, may function as a bridge between PR practitioners and children who live far from academic centers. The objective of this study was to determine the prevalence and distribution of alternative mechanisms of care delivery in US PR practices.Methods:PR practices were identified using the American College of Rheumatology member directory and the Children's Hospital Association hospital directory. Practice websites were reviewed to obtain data regarding secondary clinic sites and use of telemedicine. Practices were then called to confirm website data and obtain data not available on websites. Distance between each main and secondary clinic site was calculated. Geographic information system (GIS) was used to integrate study data with census data.Results:77/90 PR practices participated in phone calls and were included in analyses. 46 practices (60%) reported using secondary clinic sites; the number of secondary sites per practice ranged from 1–6 (total 96 sites). Frequency of clinics at secondary sites ranged from weekly to once per year; >80% of sites held clinics at least once each month. Distance from the main practice site to secondary clinic sites ranged from 6.2 to 2265 miles, with 65% (62/96) <60 miles from the main practice site and almost half (47/96) <30 miles from the main practice site. Census data indicate that 39% of US children live >60 miles from a main practice site and 30% of US children live >60 miles from any PR clinic site. Of the 12 states without a PR practice, 3 were served by secondary clinic sites. Seven practices (9%) reported telemedicine capability, but only 3 (4%) reported ever using it.Conclusion:Though most PR practices utilize secondary clinic sites, nearly 2/3 of those sites are <60 miles from the main practice site and nearly 1/3 of US children live far (>60 miles) from any PR clinic site. Few practices currently use telemedicine. Therefore, it is not clear that secondary clinic sites and telemedicine, as currently employed, significantly expand the reach of PR practitioners. Future studies should investigate the efficiency and effectiveness of alternative mechanisms of care delivery, to determine how best to serve children who live far from academic centers.

User-provider relations pertaining to health care delivery in Jumla district

Background Nepal’s health policy making and programming shifted over the past six decades in tune with international milieu. After 2006 revolution, radical new leadership of health ministry wrote health as a fundamental right in the interim constitution and scrapped hitherto existing user fees in peripheral health facilities. This work aimed to understand user-provider interaction at facility and community setting while people attempt utilising fee-less health care.Methods We used key informant interviews to explore the mechanism of health care delivery and general reality of Jumla districtin north-west Nepal. We used semi-structured interviews with respondents at both the providing and receiving sides. We asked open ended questions and used answers to preceding questions to generate new questions around the area of discussion.Results Health care machinery in Jumla struggled between constrained supply and elevating demand side factors. District hospital endured this challenge more than primary health care centre and health posts studied. User-provider relations were more turbulent in the hospital where targeted approach to fee removal was effected, than other facilities where charges were abolished altogether. Users and providers had their own side of the story, exemplified by experiences in accessing and delivering fee-removed health care.Conclusion We conclude that user-provider dynamics manifest in Jumla originate elsewhere. Health care programmes are crafted without people’s meaningful participation. Prescriptions trickle down all the way from international health rings to rural villages like that of Jumla – through national systems – founded on economic and political interests as contrasted to citizen’s legitimate needs. We recommend further ethnographic work to fully explore and address factors that determine user-provider relations at point of health care use.DOI: http://dx.doi.org/10.3126/hprospect.v12i2.9870 Health Prospect Vol.12(2) 2013: 31-36

Kathleen Mears Memorial Lecture: Are We Ready for 2014? An Overview of Healthcare Reform for the Neurodiagnostic Practitioner

ABSTRACT.U.S. Healthcare is not a system but a fragmentation of care delivery mechanisms. Healthcare Reform drives at reducing costs through access, quality, and efficiency. The U.S. economy contracted in 2007 and healthcare spending increased consuming an even greater and potentially unsustainable share of the economic wealth. Affordable care means “shared risk.” The Patient Protection and Accountable Care Act (PPACA) was signed into law on March 23, 2010. The bill outlines the next ten years for new policies and pilot programs. More profound for us are the many provisions that promote fundamental delivery system reform. At this time, the burden of leadership is immense. Our profession needs a large cadre of qualified leaders to shape the future.

Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use

Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.

Health Care and Insurance Schemes and Health Outcomes: A Global Comparative Analysis

One of the largest and most urgent problems facing countries today - especially the United States - is health care. With an aging population and seemingly hard limits on resources such as doctors, organs, and medicine, each nation must attempt to distribute the available resources in a fair and efficient way without breaking the bank and, ideally, without selling out the health of its population. Nations’ attempts at creating workable health care systems result in regulatory and insurance schemes that vary widely across the globe, as countries form policies based on national values, institutions, and interests. Differing health outcomes among nations suggest that all health care delivery and insurance mechanisms are not equal. Some nations rely almost exclusively on the private sector for insurance and health care services, while others place health care and insurance squarely under government control, with wildly divergent results. This paper looks at the health systems in twenty-four countries, groups them according to common attributes in their health insurance and health care delivery regimes, and quantitatively compares the health outcomes achieved by those systems in order to answer the question: which health care delivery and insurance systems work best?

Commentary: Dinosaurs Fated for Extinction? Health Care Delivery at Academic Health Centers

Health care delivery at academic health centers (AHCs) can be viewed as dinosaur-like. Both are large and complex entities that consume many resources and are slow to adapt to competitive predatory forces. The potential for severe climate shifts, with changes in payer mix, competition from the private sector, and health care reform all occurring in the current health care system, could precipitate either the beginning of extinction for the AHC dinosaur or, hopefully, stimulate its evolution and development into a new model of health care delivery.Given the importance of clinical revenue to the entirety of the AHC enterprise, there is incentive for AHCs to maintain and indeed expand their clinical care delivery mechanisms. Yet, AHCs are institutions of investigation and inquiry. New models of care delivery and their impact on the current clinical care system must be developed through local demonstration projects and experimental clinical models. These models must be studied, and the findings should be shared with the community.The authors argue that this course of action will be challenging because traditional workflows must be restricted to improve care coordination and a changing workforce demographic. It will also require thoughtful approaches to reward innovative clinical work and new directions in strategic management by institution leaders. This commentary outlines recommendations to stave off extinction and enhance the next generation of clinical care delivery at AHCs.

Pharmacological treatment of the newly diagnosed patient with schizophrenia

The early treatment of newly diagnosed schizophrenia has ramifications for the future psychiatric and social well-being of the patient. Changes in care structures and care delivery mechanisms, in addition to financial constraints and outcome targets, provide an additional incentive to ensuring that any intervention is both successful and cost-effective.

Environmental health response clinics. A survey of program options.

Environmental Health Response Clinics are established in response to concerns about community exposures to hazardous situations (chemical, biological, radiological). They are developed in response to a demand for "clinical services" and operate outside the usual health care financing and delivery mechanisms. Prompted by their experience in California, the authors formed a focus group to identify possible goals and services. A mail survey of occupational-environmental health professionals was then conducted to evaluate the feasibility and priority of representative goals. The analysis suggests that services should focus on the specific hazard of concern and that communication and education are essential components. The tendency to "do a general physical examination" should be eschewed. Ratings for priority and feasibility were disparate for several possible goals. In some instances, a "hands-on examination" may not be the best use of resources. Environmental health professionals may serve by direct clinical service or by advising community-based practitioners. Providing routine clinical services alone cannot meet the expectations for an environmental health response clinic.

Perceived Risk: The Link to Plan Selection and Future Utilization

Perceived Risk: The Link to Plan Selection and Future Utilization Abstract Enrollment of Medicare beneficiaries in HMOs may reduce the costs of providing health care but has raised concerns over adverse selection and how to adjust reimbursement levels to compensate for this potential. An adjustment based on an individual's perceived health and financial risk may be more accurate than proposed demographic, prior use of health services or current health status adjusters. Results suggest that those in HMOs may be more sensitive to the extreme cost of hospitalization than those with fee-for-service insurance, and therefore were attracted to the comprehensive care offered by the HMO. In addition, HMO enrollees, face fewer barriers to seeking health care, thus may be higher utilizers in future periods. Introduction In 1985, out-of-pocket health care costs for the elderly were greater in real dollars than before the 1965 Medicare legislation[7]. This phenomenon did not go unnoticed by the elderly. Realizing they were spending more and more of their budgets on health care, they began to look for insurance mechanisms with which to supplement their Medicare coverage. At the same time, the Federal government was also experiencing changes in the health care marketplace. The Federal government has seen Medicare expenses increase from $4.7 billion in 1967 to $64.6 billion in 1984[11]. Th is rapid increase in expenditures prompted the Federal government to expand health care delivery mechanisms for Medicare enrollees beyond the traditional fee-for-service (FFS) system through legislation supporting the enrollment of Medicare beneficiaries in health maintenance organizations (HMOs). These trends at the consumer and the payor level have resulted in the increased enrollment of Medicare beneficiaries in HMOs. In 1981, 595,000 Medicare beneficiaries (a little more than 2 percent) were enrolled in capitated systems. In 1985, the number of Medicare beneficiaries enrolled in HMO/CMP and group practice prepayment organizations reached 1,117,000 or 3.7 percent of Medicare enrollees[11]. The initial contracts between the Health Care Financing Administration (HCFA) and HMOs were structured on a cost basis. This type of contract was attractive to HMOs because it limited their risk and thus encouraged them to enroll Medicare beneficiaries. In 1985, HCFA began to move away from the signing of cost contracts with HMOs to the establishment of risk contracts [13]. Under the initial risk contracts the HMOs enrolling Medicare beneficiaries were reimbursed at 94 percent of the AAPCC (Adjusted Average Per Capita Cost). This structure gave HMOs financial incentives to provide services at lower costs (one of their claimed advantages over a fee-for-service practice). At the same time, these contracts would lower the level and increase the certainty of Federal expenditures for health care. Recently, the General Accounting Office (GAO) has recommended lowering the multiplier for the AAPCC to 89 percent[15] thus shrinking the average reimbursement and creating further pressure upon providers (HMOs) to deliver medical services at a lower rate or to exit the Medicare HMO market. Problem Statement The move to risk contracts for HMOs creates a number of concerns for the HMOs operating under these terms. The primary concern is whether or not adverse selection will occur. Adverse selection occurs when the high risk/high cost members of a population tend to disproportionately enroll in one type of insurance plan[1]. Recently, HMOs have acted as if adverse selection has occurred in their Medicare population. For example, Av-Med Health Plan Inc. in Florida, Maxicare in California, and Choice Care in Cincinnati have all withdrawn from Medicare risk contracts[14]. Their actions may be in response to adverse selection by enrollees which resulted in the costs of providing services in excess of reimbursement levels. …

The institutionalization of geriatrics.

The institutionalization of geriatrics.

Policy Innovativeness as a Trait of American States

1HE LITERATURE MAKING USE of quantitative data in the comparative analysis of policy outputs across the American states has largely been dependent upon public expenditure levels as indicators of policy efforts. One of the few potential altematives has been measurements of policy innovativeness, most recently reintroduced for political analysis by Jack L. Walker.' While policy innovation might be measured in a number of ways, Walker has been especially concemed with a general tendency toward innovativeness of state govemments, or as rural sociologists refer to it, adoptionproneness.2 Certainly, American political folklore is rich in suggesting that some states are innovators while others are laggards. Findings by others in later research, however, cast some doubt upon not only the adequacy of the quantitative measures devised

An Experimental Comparison of the Effectiveness of Three Planning Methods

Methods of planning based on systems ideas, behavioral science concepts, and heuristics were used to develop plans in a field setting, to contrast the merits of these planning approaches. Plans were evaluated by experts as well as decision makers and staff in the participating organization. Criteria such as quality, acceptance, and measures of innovation were used to contrast the plans. The perceptions of agency representatives that participated in the planning groups were also obtained. The systems method used planning groups that were composed solely of experts. In the systems method, objectives were established in the first phase of the meeting, and used as a basis to structure the development of plans. For example, the intent of the service delivery plan was established before recommendations were developed. The behavioral approach used clients, the recipients of the service to be planned, as planning groups members. These groups developed a list of priority client problems which were used as a focus to formulate plans. The heuristic approach was applied to simulate trial and error planning. In this approach, no structure was used in the generation of plan components, the leader merely recorded the ideas that were stimulated by a statement of the problem. In the heuristic approach, half the planning groups had just clients as members and the rest were made up of experts. The three methods of planning were applied to two problems—the development of plans for primary health care services, and home health care delivery mechanisms. In all, twelve distinct planning groups participated permitting a replication of each “problem-planning topic” contrast. The results of the experiment indicated that the systems approach produced better quality plans while the behavioral approach produced more new ideas. This suggests that involving an organization's client in planning of services to define their problems provides a rich array of ideas for the planning process, but that systems approaches and experts are needed to formulate these ideas and consolidate them into a viable plan. However, the participants found their experiences to be significantly less satisfactory when a systems approach was used. Several other implications of these findings for planning practice are discussed.