Hospital Prices For Commercial Plans Are Twice Those For Medicare Advantage Plans When Negotiated By The Same Insurer.

Most major insurers operate in both the commercial health insurance and Medicare Advantage (MA) markets. We investigated the ratio of commercial-to-MA prices negotiated by the same insurer, in the same hospital and for the same services, using 2022 price information disclosed by hospitals in compliance with the hospital price transparency rule. Insurers negotiated median hospital prices for commercial plans that were two to three times higher than their MA prices in the same hospital for the same service. The median commercial-to-MA price ratio in the same hospital varied, from 1.8 for surgery and medicine services to 2.2 for laboratory tests and emergency department visits and 2.4 for imaging services. In multivariable Poisson regression analysis, higher ratios were associated with system-affiliated, nonprofit, and teaching hospitals, as well as with large national insurers. These findings reflect the differences in financial incentives and regulatory policies in the commercial and MA markets. Because insurers respond to differing incentives by obtaining different negotiated prices across markets, policy and practice efforts that alter incentives for insurers may have the potential to lower commercial prices.

How did the Treatment Work for Robin? And for Dylan? Studying Individual Youth Treatment Mediators Using Single-Case Experimental Designs.

Study of individual treatment mechanisms in youth interventions facilitates evidence-based development, selection and implementation of treatment components that are most effective for each individual child. This position paper aims to bring together two important topics from the area of youth intervention research: mediators of treatment outcomes and single-case experimental design methodology. We start by outlining the benefits of studying within-person mechanisms and propose how statistical mediation analysis and single-case methods can be integrated to enable this type of research. Further, we review existing methodology for the study of individual youth treatment mechanisms and provide recommendations for the clinical practice research.

Insurer Market Power And Hospital Prices In The US.

The extent to which concentration in the health insurance market affects negotiated prices paid to hospitals is of high interest to policy makers. We examined the association between insurer market share and hospital prices, using a new source of data obtained through the federal Hospital Price Transparency initiative. We found that the market-leading insurer in the least competitive (most concentrated) insurance markets pays 15 percent less to hospitals than the market-leading insurer in the most competitive (least concentrated) markets. We also found the price relationship to be more pronounced for for-profit hospitals than for not-for-profit hospitals. Our results invite the question of whether dominant insurers are passing savings on to employers in the form of lower premiums.

The Rise Of Cross-Market Hospital Systems And Their Market Power In The US.

Although hospital consolidation within markets has been well documented, consolidation across markets has not, even though economic theory predicts-and evidence is emerging-that cross-market hospital systems raise prices by exerting market power across markets when negotiating with common customers (primarily insurers). This study analyzes hospital systems using the American Hospital Association Annual Survey Database and defines hospital geographic markets as commuting zones that link workers to places of employment. The share of community hospitals in the US that were part of hospital systems increased from 10 percent in 1970 to 67 percent in 2019, resulting in 3,436 hospitals within 368 systems in 2019. Of these systems, 216 (59 percent) owned hospitals in multiple commuting zones, in part because 55 percent of the 1,500 hospitals targeted for a merger or acquisition between 2010 and 2019 were located in a different commuting zone than the acquirer. Based on market-power differences among hospitals in systems, the number of systems in urban commuting zones that could potentially exert enhanced cross-market power increased from thirty-seven systems in 2009 to fifty-seven systems in 2019, an increase of 54 percent. The increase in cross-market hospital systems warrants concern and scrutiny because of the potential anticompetitive impact of hospital systems exerting market power across markets in negotiations with common customers.

The relationship between the conflict management strategies and ethical leadership behaviours of nurse managers perceived by nurses.

AIM: The aims of this study were to determine nurse managers' level of ethical leadership perceived by nurses and to examine its relationship with conflict management strategies. BACKGROUND: Ethical leadership is about how managers use their power in their decisions and actions, and its source is based on moral and ethical authority. Therefore, it is important to understand the impact of ethical behaviours of nurse managers in the work environment on determining conflict management strategies. METHOD: The data of this descriptive, correlational, and cross-sectional study were collected face-to-face from 285 nurses between April-June 2019. The data collection instruments included the introductory information form, the Ethical Leadership Scale, and The Rahim Organizational Conflict Inventory-II. RESULTS: Ethical leadership scores perceived by nurses in nurse managers were found 3.78, and the highest score was obtained from the behavioural ethics subscale (3.81 ± .91). In conflict management strategies perceived by nurses, it was determined that they got highest scores from collaborating style (3.76 ± .90) and lowest scores from competing style (2.90 ± .94). There was no significant relationship only between ethical leadership and its subscales and competing (r: -.038/-.041, p > .05). In other subscales, there were positive, moderate, and highly significant relationships (r: .466-.747, p < .001). The rate of explanatoriness of communicative ethics subscale in conflict management strategies ranged from 22.3% to 58.0%. CONCLUSIONS: The study shows that communicative ethics subscale significantly affects the conflict management strategies of nurse managers. Therefore, it is important for nurse managers to communicate bilaterally and be a role model for nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Ethical leaders value trust and respect in their interactions with employees and reflect what appropriate behaviour to the situation is. Nurses who perceive that their managers demonstrate ethical leadership behaviours will also evaluate their role in conflict resolution. On the other hand, the power-based, aggressive, noncompromising domination approach that the person imposes on others is not associated with the ethical leadership perception towards their managers by nurses and is a strategy that should not be preferred. Therefore, nurse managers who use appropriate conflict management strategies were seen as a role model by nurses.

An autonomous agent for negotiation with multiple communication channels using parametrized deep Q-network.

Agent-based negotiation aims at automating the negotiation process on behalf of humans to save time and effort. While successful, the current research considers communication between negotiation agents through offer exchange. In addition to the simple manner, many real-world settings tend to involve linguistic channels with which negotiators can express intentions, ask questions, and discuss plans. The information bandwidth of traditional negotiation is therefore restricted and grounded in the action space. Against this background, a negotiation agent called MCAN (multiple channel automated negotiation) is described that models the negotiation with multiple communication channels problem as a Markov decision problem with a hybrid action space. The agent employs a novel deep reinforcement learning technique to generate an efficient strategy, which can interact with different opponents, i.e., other negotiation agents or human players. Specifically, the agent leverages parametrized deep Q-networks (P-DQNs) that provides solutions for a hybrid discrete-continuous action space, thereby learning a comprehensive negotiation strategy that integrates linguistic communication skills and bidding strategies. The extensive experimental results show that the MCAN agent outperforms other agents as well as human players in terms of averaged utility. A high human perception evaluation is also reported based on a user study. Moreover, a comparative experiment shows how the P-DQNs algorithm promotes the performance of the MCAN agent.

Preference prediction analysis based on graph model for environmental governance conflict.

A mathematical model for decision maker's preference prediction in environmental governance conflict is established based on the graph model for conflict resolution. The rapid economic development in many countries, over the past decades, has caused serious environmental pollution. Sewage companies are the main source of contamination since they are always wavering on the issue of environmental governance because of their profit-seeking nature. Environmental management departments cannot grasp the offending company preferences accurately. The problem of how to obtain decision maker's preference in environmental governance conflict is studied in this paper. The mathematical model established in this paper can obtain a preference set of one decision maker on the promise that the ideal conflict outcome and preference of the other decision makers are known. Then, preference value distribution information entropy is introduced to mine the preference information contained in the preference set, which means that it is possible to get the preference information of conflict opponent at their own ideal conflict outcome. All of these preference sets provide the possibility to choose the appropriate coping strategies and lead the conflict to the direction that some decision makers want. Finally, the effectiveness and superiority of the preference prediction analysis method is verified through a case study of "Chromium Pollution in Qujing County" which took place in China. The preference prediction analysis method in this paper can provide decision making support for the decision makers in environmental governance from strategic level.

The Art of Negotiation: Avoiding Positional Bargaining and Getting to Yes.

Effective negotiation is a crucial part of almost every aspect of life. One should never consider conflict a "zero-sum" game; negotiation is necessary. This paper first explains how negotiation is a part of pediatric orthopaedic practice, highlights some of the reasons negotiations break down, and discusses ways to avoid these breakdowns by applying proven techniques.

Physician-nurse conflict resolution styles in primary health care.

AIM: To examine the conflict resolution styles used in the physician-nurse teamwork in primary health care, depending on individual characteristics, contextual factors, and organizational and sociocultural contexts. BACKGROUND: Conflicts significantly affect the quality of healthcare services and staffing challenges, and consequently the performance and efficiency of organizations. Their management plays an important role in any healthcare organizations and deserves the attention of researcher's healthcare management and team leaders. DESIGN: A descriptive, cross-sectional, correlational design. METHOD: Thomas-Kilmann Conflict MODE Instrument was used on a sample comprising 173 nurses and 125 physicians working in teams at the Community Health Centre Ljubljana, Slovenia, in 2018. RESULTS: The most predominant conflict resolution styles were compromising and avoiding, followed by accommodating, collaborating and competing. The predominant resolution style among nurses was avoiding, and among physicians was compromising. There were statistically significant differences in the conflict resolution style according to gender (χ2 (1) = 0.035, p < .059), education (χ2 (1) = 0.014, p < .05) and tenure (χ2 (1) = 0.025, p < .05). CONCLUSION: Our research results differed from those of other studies, possibly due to the difference in the sample and research setting. They indicated that the specifics of work and situation significantly moderate conflict in healthcare organizations. IMPACT: The established divergence of results indicates the need for future research on conflict in healthcare settings to more consistently consider the situational context and the role of management and/or leadership.

The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches.

PURPOSE: The combination of power and conflict is frequently reported to have a detrimental impact on communication and on patient care, and it is avoided and perceived negatively by health care professionals. In view of recent recommendations to explicitly address power and conflict in health professions education, adopting more constructive approaches toward power and conflict may be helpful. This study examined the role of power in conflicts between health care professionals in different cultural contexts to make recommendations for promoting more constructive approaches. METHOD: The authors used social bases of power (positional, expert, informational, reward, coercive, referent) identified in the literature to examine the role of power in conflicts between health care professionals in different cultural settings. They drew upon semistructured interviews conducted from 2013 to 2016 with 249 health care professionals working at health centers in the United States, Switzerland, and Hungary, in which participants shared stories of conflict they had experienced with coworkers. The authors used a directed approach to content analysis to analyze the data. RESULTS: The social bases of power tended to be comparable across sites and included positional, expert, and coercive power. The rigid hierarchies that divide health care professionals, their professions, and their specialties contributed to negative experiences in conflicts. In addition, the presence of an audience, such as supervisors, coworkers, patients, and patients' families, prevented health care professionals from addressing conflicts when they occurred, resulting in conflict escalation. CONCLUSIONS: These findings suggest that fostering more positive approaches toward power and conflict could be achieved by using social bases of power such as referent power and by addressing conflicts in a more private, backstage, manner.

Conflict, confusion and inconsistencies: Pre-registration nursing students' perceptions and experiences of speaking up for patient safety.

There is growing evidence demonstrating that nursing students encounter unsafe and poor clinical practice when on clinical placement. The impact on nursing students remains relatively under-explored, especially in the Australian context. This two-phased qualitative study used Interpretive Description to explore 53 pre-registration nursing students' perceptions and experiences of speaking up for patient safety. Results of the study identified students believe speaking up is the right thing to do, and their professional responsibility. The study results add to previous research by describing the dissonance students experience due to the inconsistencies between what is taught at university and performed in practice. Student's distress arises when observing nurses taking short cuts, justifying such actions and making excuses about poor practice. Students report experiencing dissonance, bewilderment and confusion and at times, anger when observing poor practice. The clinical environment culture influences students' decisions to speak up or remain silent. Understanding students' perceptions and responses will promote awareness and discussion essential to the future development of curricula and clinical support strategies that will enable students to speak up.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings.

BACKGROUND: There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns. OBJECTIVES: To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response. DATA COLLECTION AND ANALYSIS: Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice. MAIN RESULTS: We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies. AUTHORS' CONCLUSIONS: Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Medical social workers as mediators between patients, physicians, and the court: the case of former ringworm patients.

Facilitating benefit and resource acquisition to assist clients is a major responsibility of medical social workers, requiring them to have a thorough knowledge of community resources, legislation, and regulations. The aim of the current study was to examine knowledge of the Law for Compensation of Scalp Ringworm Victims and ringworm-related irradiation damage among 101 social workers employed in diverse healthcare settings in Israel. We found that 65.3% of the social workers were aware of the law, but only 40.6% were aware of the health effects of scalp ringworm irradiation. Media coverage and clients who underwent scalp ringworm irradiation were social workers' major sources of knowledge. Working with former ringworm patients had the strongest association with knowledge of the law and of ringworm-related irradiation damage. Results highlight the important contribution of exposure to clients' experiences and knowledge to expand social workers' knowledge of health issues.

"Hot Seat" Simulation to Teach Conflict Management Skills to Residents.

BACKGROUND: Conflict management is an important leadership skill for residents to develop, yet it is a challenging skill to practice. OBJECTIVE: We developed and evaluated a workshop that teaches conflict resolution skills to physical medicine and rehabilitation residents in a group setting with real-time faculty coaching and peer feedback. METHODS: A 4-step model for handling work-related conflicts was taught, and then residents practiced their skills during a realistic simulated conflict with a trained actor. A faculty coach supported the participant, and peers gave feedback and suggestions in real time as the scripted conflict unfolded. Immediate post-session survey results were analyzed. RESULTS: Workshops were conducted in 2015, 2017, and 2019. A total of 36 residents participated and completed evaluations out of a possible 40 residents in the cohort (90% participation rate). Post-session surveys showed that 100% of participants agreed the session content was relevant to their training and they would use the skills in the future. Ninety-seven percent (35 of 36) felt prepared to manage conflict following the session. CONCLUSIONS: This experiential workshop helped cultivate an appreciation of the importance of conflict management skills in residents' professional development and confidence in their ability to apply a conflict management framework to real-world situations.