Purchasers Of Health Care Services Research Articles

Incorporation of artificial intelligence in healthcare professions and patient education for fostering effective patient care

AbstractArtificial intelligence (AI) influences many aspects of modern life and has multiple applications in the delivery of healthcare. AI is designed to mimic human capabilities including pattern recognition, data analysis, and decision‐making and perform tasks more efficiently. It is capable of detecting patterns in large datasets that might elude human beings. AI has potential to improve patient care, patient safety, disease diagnosis and treatment; public health; health research; health administration; and the daily work of health professionals. In 2019, the US National Academy of Medicine emphasized the need for “physicians, nurses, and other clinicians, data scientists, health care administrators, public health officials, policy makers, regulators, purchasers of health care services, and patients to understand the basic concepts, current state of the art, and future implications of the revolution in AI and machine learning.” Therefore, it is incumbent on adult educators to incorporate AI training into health professions education and patient education.

Using Documentation to Demonstrate the Value of Care

Value-based purchasing of health care services, risk adjustment payments to health plans, and payment for meeting performance measures are not new, but they are growing and evolving. Physician practices are increasingly finding it necessary to use data to demonstrate the quality and value of care provided to patients, especially groups of patients covered under the same health plan or provider network.

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature

BackgroundStrategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.MethodsA structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.ResultsThe majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.ConclusionThere is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

Strategic Purchasing in Practice: Comparing Ten European Countries

Strategic purchasing of health care services is widely recommended as a policy instrument. We conducted a review of literature of material drawn from the European Observatory on Health Systems and Policies Health Systems in Transition series, other European Observatory databases, and selected country-specific literature to augment the comparative analysis by providing the most recent healthcare trends in ten selected countries. There is little evidence of purchasing being strategic according to any of the established definitions. There is little or no literature suggesting that existing purchasing mechanisms in Europe deliver improved population health, citizen empowerment, stronger governance and stewardship, or develop purchaser organization and capacity. Strategic purchasing has not generally been implemented. Policymakers considering adopting strategic purchasing policies should be aware of this systemic implementation problem. Policymakers in systems with strategic purchasing built into policy should not assume that a purchasing system is strategic or that it is delivering any expected objectives. However, there are individual components of strategic purchasing that are worth pursuing and can provide benefits to health systems.

Monitoring HIV-indicator condition guided HIV testing in Estonia.

The aim of the study was to assess indicator condition (IC) guided HIV testing in Estonia from 2012-2015. We used Estonian Health Insurance Fund (EHIF) data. EHIF is the core purchaser of health care services in Estonia, covering health care costs for insured people (94% of the total population). After health care services' provision, the provider sends an invoice to EHIF, which includes patient information (e.g. age, gender, diagnoses based on ICD-10) and services provided (e.g. what tests were performed). Among the ICs analysed, the highest proportion of patients tested was among those presenting with infectious mononucleosis-like illness (27-33% of patients) and viral hepatitis (28-32%), the lowest proportion of patients tested was among those presenting with herpes zoster (4-5%) and pneumonia (4-8%). Women were tested somewhat less than men, especially in cases of sexually transmitted infections (9-13% and 18-21%, respectively). Our data shows that IC-guided HIV testing rates are low in Estonia. Therefore, it is critical to follow Estonian HIV testing guidelines, which recommend IC-guided testing. In general, health insurance data can be used to monitor IC-guided HIV testing.

Development and Validation of the Keele Musculoskeletal Patient Reported Outcome Measure (MSK-PROM).

ObjectiveTo develop and validate a patient report outcome measure (PROM) for clinical practice that can monitor health status of patients with a range of musculoskeletal (MSK) disorders.MethodsConstructs for inclusion in the MSK-PROM were identified from a consensus process involving patients with musculoskeletal conditions, clinicians, purchasers of healthcare services, and primary care researchers. Psychometric properties of the brief tool, including face and construct validity, repeatability and responsiveness were assessed in a sample of patients with musculoskeletal pain consulting physiotherapy services in the United Kingdom (n=425).ResultsThe consensus process identified 10 prioritised domains for monitoring musculoskeletal health status: pain intensity, quality of life, physical capacity, interference with social/leisure activities, emotional well-being, severity of most difficult thing, activities and roles, understanding independence, and overall impact. As the EuroQol (EQ-5D-5L) is a widely adopted PROMs tool and covers the first four domains listed, to reduce patient burden to a minimum the MSK-PROM was designed to capture the remaining six prioritised domains which are not measured by the EQ-5D-5L. The tool demonstrated excellent reliability, construct validity, responsiveness and acceptability to patients and clinicians for use in clinical practice.ConclusionWe have validated a brief patient reported outcome measure (MSK-PROM) for use in clinical practice to measure musculoskeletal health status and monitor outcomes over time using domains that are meaningful to patients and sensitive to change. Further work will establish whether the MSK-PROM is useful in other musculoskeletal healthcare settings.

Predictors of patients' satisfaction with health care services in three balkan countries (macedonia, bulgaria and serbia): a cross country survey.

Background:Patients’ satisfaction with provided healthcare services is one of the factors to measure the overall quality of the delivered health care. Main objective of our study was to determine the common predictors associated with patients ‘satisfaction in three Balkan countries.Methods:We conducted web based survey among population in Macedonia, Serbia and Bulgaria using paid campaign over the social network Facebook. A questionnaire consisted of 31 questions was developed following studies on patients’ satisfaction conducted elsewhere. Descriptive analysis was performed to assess the predictors associated with patients’ satisfaction. In addition we performed content analysis to all open-ended responses.Results and discussion:In total 4118 respondents participated in the survey. Main predictors associated with low users satisfaction with the health care services in three surveyed countries are waiting time to appointments, huge administrative procedures, and attitudes of the medical personnel towards the patients. The analysis showed that there are many similarities in user experiences in three countries, but also there are some differences.Conclusions:The health care systems in these three counties are organized around centralized and monopolistic position of one health insurance fund that serves as main purchaser of health care services. Top three indicators of patients’ satisfaction across three countries are trust and overall satisfaction with the attention of the doctors, as well as satisfaction with the outcome of the treatment. Long waiting time and huge administrative procedures are determined as common predictor for lower patients’ satisfaction across these Balkan countries. Patients’ privacy protection is issue for concern in all three countries.

Board Governance: Reform-Driven Transformation and Reexamination of Fundamentals

HEALTHCARE HAS NEVER been a slow-moving industry, yet it is currently experiencing a transformation unlike any we have ever seen. No doubt we will one day look back on this time as profoundly historic. Healthcare systems, hospitals, and other providers are dismantling current models and redesigning care delivery to manage the health of populations, while also improving quality and safety and controlling costs, even as reimbursements are shrinking.These are daunting challenges that require not only transformational involving approaches and ways of but also reevaluation of fundamentals and principles to determine whether they still fit.Texas Health Resources, like Chilton Medical Center in New Jersey and Presbyterian Healthcare Services in New Mexico, has chosen to embrace these challenges, not only in terms of its strategies for healthcare delivery but also in its approach to governance.In their feature articles, Deborah Zastocki, FACHE, and James Hinton present compelling descriptions of the rapidly changing healthcare environment. Hospitals and health systems are being pushed by reform-driven imperatives to redesign healthcare delivery to provide population health, clinical integration, and accountable care across the continuum of the life span. Consumers and employers are emerging as the purchasers of healthcare services. They assume that quality, patient safety, and value are the price of entry and view competitively lower healthcare costs as their primary driver for healthcare decision making.The challenge is that health system and hospital competencies are predominantly in acute care delivery in an emerging world that also requires expertise in wellness, chronic disease management, post-acute care, palliative care, and end-of-life care. As providers endeavor to build, buy, or partner for the rest of the continuum, competitors are emerging in commercial payers, employers, physicians, and venture capitalists. As disruptive innovation becomes a driving force, the reimbursement system has not yet evolved to pay for care delivery redesign or innovation, and the transition from volume-based care to value-based care continues to take place.Most leading healthcare systems and hospitals across the country see the need to transform to meet these challenges. So why is there not a corollary healthcare transformation occurring as well? As Deborah Zastocki states, challenge is that our toolbox does not contain what is needed to build the future healthcare delivery systems required in the post-reform world. Having built an effective structure and infrastructure that have worked well in the past is not enough. Even the best program requires periodic review and change. Organizations that have not invested the time, resources, and energy in competency-based governance, comprehensive board member orientation and education programs, and carefully structured board discussions that are generative, strategic, and prospective face a major challenge in attempting to catch up.Why is there such a governance lag in healthcare organizations? It seldom is because they do not care or do not want to have good governance. One reason is that, although numerous conferences, articles, books, and forums exist where one can learn about the transformations occurring in healthcare, as well as the components needed for a program, few resources are available for evidence-based methodologies that prescribe the steps necessary to actually build a comprehensive and effective program.Governance transformation requires a multifaceted, multiyear approach that is carefully constructed and executed, as well as continually evolving and advancing with cycles of learning. The approach to transformation requires new skills, expertise, and ways of thinking, as Zastocki states, but it also requires a return to the fundamentals and reinventing them as necessary. …

Improving Value in Healthcare

Improving Value in Healthcare

Barreras para la normalización de la telemedicina en un sistema de salud basado en la concertación de servicios

Objective Despite the clear political will to promote telemedicine and the large number of initiatives, the incorporation of this modality in clinical practice remains limited. The objective of this study was to identify the barriers perceived by key professionals who actively participate in the design and implementation of telemedicine in a healthcare system model based on purchasing of healthcare services using providers’ contracts. Methods We performed a qualitative study based on data from semi-structured interviews with 17 key informants belonging to distinct Catalan health organizations. Results The barriers identified were grouped in four areas: technological, organizational, human and economic. The main barriers identified were changes in the healthcare model caused by telemedicine, problems with strategic alignment, resistance to change in the (re)definition of roles, responsibilities and new skills, and lack of a business model that incorporates telemedicine in the services portfolio to ensure its sustainability. Conclusions In addition to suitable management of change and of the necessary strategic alignment, the definitive normalization of telemedicine in a mixed healthcare model based on purchasing of healthcare services using providers’ contracts requires a clear and stable business model that incorporates this modality in the services portfolio and allows healthcare organizations to obtain reimbursement from the payer.

Bringing New Technologies to Market: Hurdles and Solutions

Bringing New Technologies to Market: Hurdles and Solutions

Evaluating Addiction Treatment Outcomes

Addiction treatment is an effective clinical intervention, though employers and other purchasers of healthcare services or health insurance frequently have doubts about this fact. Public officials and even physicians are often pessimistic about the ability of addiction treatment to generate worthwhile results. A major reason for pessimism has to do with the way people look at addiction and its treatment, not appreciating that it is a chronic disease, and that most evaluations of chronic disease interventions assess postintervention clinical status while the treatment condition is still in place—not 3 or 12 months after active treatment has been discontinued. Evaluating addiction and its treatment appropriately, contemporary, evidence-based, multidimensional addiction treatment will not be found wanting as an effective intervention for one of our nation's major public health challenges.

Pay for Performance: Rationale and Potential Implications for Urology

Pay for performance represents a new paradigm for physician reimbursement based on the value based purchasing of health care services. Government and private payers have expressed an interest in moving toward this system with several pay for performance programs already in place. The rationale behind this initiative and what it means for the practicing urologist are discussed. MEDLINE and Internet based research focusing on the topics of health care quality, measures used to implement pay for performance, and private and public sector experience with pay for performance to date were reviewed. Health care quality can be assessed through 3 types of measures, including structure, process and outcome. Structure measures involve the environment where services are provided, whereas process measures capture how a particular provider delivers health care. Outcome assessment involves the results of the services provided. These measures are best used when they are used in coordination with each other, and when they are risk adjusted. Most pay for performance systems in use today are based on these measures. However, there are little data that show whether this reimbursement paradigm actually improves the quality of heath care provided. Many questions remain regarding the implementation of a pay for performance system in the field of urology. Government and private payers are motivated to implement pay for performance. However, specific evidence based metrics for urology that fairly and accurately define quality are currently lacking. Given that implementation of a nationwide pay for performance system appears to be inevitable, urology involvement in the development and implementation of these health care quality metrics is essential.

Purchaser‐provider interaction in UK public health: improving stakeholder cooperation

PurposeThe purpose of this paper is to examine the bases of positive relations between suppliers and purchasers of healthcare services. In doing so, it examines the nature of cooperation between the providers of healthcare services (hospitals) and those who commission and purchase healthcare on behalf of patients (regional health authorities) and makes specific recommendations as to how cooperation can be better realized.Design/methodology/approachThe paper employs a qualitative interview approach for gathering and analyzing major stakeholder (provider and purchaser) perceptions of their interorganizational relations and how these interactions impact on the quest of the healthcare provider to meet the needs of the community they serve.FindingsThe paper identifies and groups relevant variables into four major themes or “core categories” that characterize purchaser‐provider stakeholder cooperation. These themes represent provider and purchaser views on those factors characterising stakeholder relationships within the purchaser‐provider dyad. This is followed by a number of suggestions as to how to improve the nature of cooperation between these stakeholders.Practical implicationsExtending practitioners' understanding of the nature of these inter‐related factors may lead to better insights of how interorganizational relations and partnerships might be managed more proactively throughout the healthcare value chain. Strategies to foster stakeholder cooperation are also suggested.Originality/valueIn the extant literature, there is a paucity of research that has illustrated multi‐stakeholder perspectives in the public sector. This paper explores the perceptions of two main stakeholders in public healthcare to map and assess management issues influencing purchaser‐provider cooperation.

Value-Based Insurance Design: A “Clinically Sensitive, Fiscally Responsible” Approach to Mitigate The Adverse Clinical Effects of High-Deductible Consumer-Directed Health Plans

Value-Based Insurance Design: A “Clinically Sensitive, Fiscally Responsible” Approach to Mitigate The Adverse Clinical Effects of High-Deductible Consumer-Directed Health Plans

Mapping and assessing the key management issues influencing UK public healthcare purchaser‐provider cooperation

PurposeThe purpose is to examine the bases of positive relations between suppliers and purchasers of healthcare services. In doing so, the paper examines the nature of cooperation between the providers of healthcare services (hospitals) and those who commission and purchase healthcare on behalf of patients (regional health authorities).Design/methodology/approachThe paper employs a qualitative interview approach for gathering and analysing major stakeholder (provider and purchaser) perceptions of their interorganisational relations and how these interactions impact on the quest of the healthcare provider to meet the needs of the community they serve.FindingsThe paper identifies group relevant variables into four major themes or “core categories” that characterise purchaser‐provider stakeholder cooperation. These themes represent provider and purchaser views on those factors characterising stakeholder relationships within the purchaser‐provider dyad.Practical implicationsThe paper suggests that extending practitioners' understanding of the nature of these interrelated factors may lead to better insights of how interorganisational relations and partnerships might be managed more proactively throughout the healthcare value chain.Originality/valueIn the extant literature, there is a paucity of research that has illustrated multi‐stakeholder perspectives in the public sector. This paper explores the perceptions of two main stakeholders in public healthcare to map and assess management issues influencing purchaser‐provider cooperation.

Medicare’s Next Voyage: Encouraging Physicians To Adopt Health Information Technology

Although there is growing consensus that health information technology (HIT) will be critical to improving health care quality and reducing costs, physicians' investments in technology remain limited. As the largest single U.S. purchaser of health care services, Medicare has the power to promote physician adoption of HIT. The Centers for Medicare and Medicaid Services should clarify its technology objectives, engage the physician community, shape the development of standards and technology certification criteria, and adopt concrete payment systems to promote adoption of meaningful technology that furthers the interests of Medicare beneficiaries.

Academic pediatric departments, government agencies, and children with special health care needs

Academic pediatric departments, government agencies, and children with special health care needs

Applying a Balanced Scorecard to Health Care Organizations

This article looks at the design and implementation of an integrated performance measurement system at a nonprofit community hospital–Community Memorial Hospital of Menomonee Falls, Wisconsin. In particular, the article discusses how the hospital developed and applied a balanced scorecard. Over the past decade, Community Memorial Hospital faced both market deregulation and strong competition. It responded to these environmental pressures by joining an integrated health service delivery network with other hospitals, physicians, and institutional purchasers of health care services. Ultimately, the hospital's management implemented a balanced scorecard. Its goals were to help translate the vision for the hospital and to gain consensus; to communicate the hospital's objectives, set goals, and link strategies; to allocate the hospital's resources and establish milestones; and to provide feedback and ensure learning. The hospital's balanced scorecard consists of one composite financial performance measure and 12 nonfinancial performance measures. Each performance indicator reflects a quantitative measure of a particular strategic objective. These performance measures are expressed in terms of actual performance as a percentage of expected performance and are integrated into a single, overall performance score through a subjective weighting scheme. The balanced scorecard approach to performance measurement at Community Memorial Hospital has provided an efficient and effective way to link day-to-day operating activities to the hospital's strategic objectives. © 2000 John Wiley & Sons, Inc.

Applying a Balanced Scorecard to Health Care Organizations

This article looks at the design and implementation of an integrated performance measurement system at a nonprofit community hospital–Community Memorial Hospital of Menomonee Falls, Wisconsin. In particular, the article discusses how the hospital developed and applied a balanced scorecard. Over the past decade, Community Memorial Hospital faced both market deregulation and strong competition. It responded to these environmental pressures by joining an integrated health service delivery network with other hospitals, physicians, and institutional purchasers of health care services. Ultimately, the hospital's management implemented a balanced scorecard. Its goals were to help translate the vision for the hospital and to gain consensus; to communicate the hospital's objectives, set goals, and link strategies; to allocate the hospital's resources and establish milestones; and to provide feedback and ensure learning. The hospital's balanced scorecard consists of one composite financial performance measure and 12 nonfinancial performance measures. Each performance indicator reflects a quantitative measure of a particular strategic objective. These performance measures are expressed in terms of actual performance as a percentage of expected performance and are integrated into a single, overall performance score through a subjective weighting scheme. The balanced scorecard approach to performance measurement at Community Memorial Hospital has provided an efficient and effective way to link day-to-day operating activities to the hospital's strategic objectives. © 2000 John Wiley & Sons, Inc.