ABSTRACT
BACKGROUND: More and more Native American tribes are assuming control of their own public health care delivery systems by contracting the functions of the Indian Health Service (IHS) through the provisions of P.L. (public law) 93-638, the Indian Self-Determination and Education Assistance Act. In doing this, some Native American tribes are making decisions to create or plan their own departments of public health. In Arizona, the Gila River Indian Community has already established its own department of public health and the Navajo Nation is in the planning stages of establishing its own department of public health. METHODS AND RESULTS: This paper proposes three public health organizational delivery models to meet the public health needs of small, medium, and large Native American tribes. Information for these models was derived from interviews with officials associated with the Arizona Department of Health Services and leaders of Native American tribes. These models progress in size and complexity as we move from small to medium to large tribes. CONCLUSIONS: (a) service delivery should focus on both preventative and curative services; (b) services should be developed with input from the underserved population; (c) members of underserved populations should be trained to provide service to their communities; (d) one model of health service delivery will not be appropriate for all underserved populations; and (e) different models are required to respond to differing cultures, populations, and geographic locations.
Subject(s)
Health Services Administration , Health Services, Indigenous/organization & administration , Indians, North American , Models, Organizational , Public Health Practice , Humans , Medically Underserved Area , United States , United States Indian Health Service/organization & administrationABSTRACT
This study examines the impact of HMO penetration and competition on hospital markets. A modified structure-conduct-performance paradigm was applied to the health care industry in order to investigate the impact of HMO penetration and competition on risk-adjusted hospital mortality rates (i.e. quality of hospital care). Secondary data for 1957 acute care hospitals in the USA from the 1991 American Hospital Association's Annual Survey of Hospitals were used. The outcome variables were risk-adjusted mortality rates in 1991. Predictor variables were market characteristics (i.e. managed care penetration and hospital competition). Control variables were environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using statistical regression techniques. Hospital competition had a negative relationship with risk-adjusted mortality rates (a negative indicator of quality of care). HMO penetration, hospital competition, and an interaction effect of HMO penetration and competition were not found to have significant effects on risk-adjusted mortality rates. These findings suggest that when faced with intense competition, hospitals may respond in ways associated with reducing their mortality rates.
Subject(s)
Economic Competition , Health Maintenance Organizations/organization & administration , Hospitals/standards , Quality of Health Care , Health Maintenance Organizations/economics , United StatesABSTRACT
In response to societal and industry-wide forces, the Veterans' Health Administration (VHA) has undertaken a re-engineering process, changing the operational and management structure from individual, independent, and often competing large hospital centres into 22 integrated service networks or VISNs to provide structural incentives for efficiency, quality and improved access as well as transitioning the system to one that is grounded in ambulatory and primary care (Ashton et al., 1998). This paper presents a framework for evaluating the successes and/or failures of the recent re-organization efforts of the VHA in bringing together this multitude of medical care 'parts' or modules into an integrated, cost-effective healthcare delivery system. In total, this paper attempts to delineate an analytical framework by which the threats and opportunities as well as the strengths and weaknesses of the VHA are identified. More specifically, this paper addresses the external pressures driving reform in the VHA system and how the Veterans' Administration can respond to these pressures. Implications for the future of the VHA if its reform efforts are not successful are examined.
Subject(s)
Delivery of Health Care, Integrated/organization & administration , Hospitals, Veterans/organization & administration , Organizational Innovation , Delivery of Health Care, Integrated/economics , Delivery of Health Care, Integrated/trends , Efficiency, Organizational/economics , Hospital Restructuring , Hospitals, Veterans/trends , Organizational Culture , Personnel Management , United States , United States Department of Veterans AffairsABSTRACT
With a defined population served, contracted provider panels and the nature of care delivery integration, managed care has provided a solution, though not a panacea, to provide equitable services, standardized and prevention oriented cares to its enrolled members. Combined with the earmarked capitation reimbursement system and a series of cost containment and utilization review techniques, managed care has also demonstrated potently its capacity in cost-saving and quality promotion. Presents steps and measures related to managed care that federal government has taken to manage care and contain cost. It is crucial to identify and promulgate best practices continually, while managing utilization of resources for improving health care, containing cost, and equalizing medical care access to a greater proportion of the population. Concludes that it may take time for a universal adoption of managed care. However, Americans may actually benefit more from having a standard level of health care that managed care could achieve and provide.
Subject(s)
Managed Care Programs/organization & administration , Total Quality Management/methods , Cost Control/methods , Decision Making, Organizational , Disease Management , Humans , Managed Care Programs/economics , Managed Care Programs/legislation & jurisprudence , Managed Care Programs/standards , Outcome and Process Assessment, Health Care , Practice Guidelines as Topic , United States , Utilization ReviewABSTRACT
This retrospective study uses discharge-level data to analyse and assess the situation of re-admissions within 15 days of discharge, for quality evaluation. The re-admission rate of the study period was 3.22%. Among those re-admission cases, 45.7% patients were re-admitted within five days of discharge, and 33.5% cases returned to hospital six to 10 days after discharge. The average length of stays of re-admissions (9.86 days for previous stay and 8.10 days for re-admitted stay) were both longer than the hospital's overall average (7.63 days) at the same period. Paediatric patients comprised the greatest number of re-admissions. Re-admissions were more likely to have higher percentage of emergency admission. Significant relationships were found between factors for re-admissions and patient characteristics (e.g. age and insurance status), admitted department, and diagnosis. Further investigation and strategies, combined with the application of severity adjustment technique to better monitor and avoid unnecessary re-admissions, need to be developed.
Subject(s)
Hospital Administration/standards , Patient Readmission/statistics & numerical data , Quality Indicators, Health Care , Adolescent , Adult , Aged , Child , Child, Preschool , Disease/classification , Female , Health Services Accessibility/legislation & jurisprudence , Humans , Infant , Infant, Newborn , Insurance Coverage , Length of Stay/statistics & numerical data , Male , Middle Aged , Models, Statistical , National Health Programs/legislation & jurisprudence , Retrospective Studies , TaiwanABSTRACT
The biochemical composition and biomechanical properties of articular cartilage from 53 human thumb carpometacarpal (CMC) joints from cadavers aged 20 to 79 years were measured and studied in normal, mildly fibrillated, and advanced osteoarthritic (OA) joints. Statistical analyses were performed to determine the correlations between the compositional measures and biomechanical properties. For these CMC joint tissues we found that water content increased, proteoglycan content decreased, and collagen content per dry weight remained unaltered with progression of OA degeneration. We also found that with disease progression, as defined by an OA staging score, the aggregate modulus (ie, compressive stiffness) decreased, along with an unexpected moderate decrease in permeability. This latter finding appears to be specific to CMC cartilage degeneration since articular cartilage from knees and hips generally demonstrates an increase in permeability with water content and OA score. Correlations between biochemical composition and biomechanical properties were found to be stronger in joints with OA than in joints without OA. This finding suggests that OA changes in biochemical composition, relative to baseline normal values, directly affect the biomechanical properties of cartilage, even though the baseline compositional values themselves do not directly determine the magnitude of the biomechanical properties in normal tissue.
Subject(s)
Cartilage, Articular/pathology , Collagen/analysis , Osteoarthritis/pathology , Proteoglycans/analysis , Thumb/pathology , Adult , Aged , Biomechanical Phenomena , Cartilage, Articular/physiopathology , Cell Membrane Permeability/physiology , Female , Humans , Male , Middle Aged , Osteoarthritis/physiopathology , Thumb/physiopathologyABSTRACT
As the information superhighway becomes clustered with various organizations sharing the hope of staying solvent with the aid of technology, managers in the health care industry are more and more looking to efficient Decision Support Systems (DSS). The focus of DSS selection has often been on evaluations that measure decision performance for determining the influence and efficacy of the tool. Such evaluations, in many instances, ignore pertinent measurements for a successful selection and implementation of a DSS. In this article, the authors present a simple but important set of evaluation factors that can "make or break" a DSS implementation in the health care industry.
Subject(s)
Decision Support Systems, Management/standards , Expert Systems , Guidelines as Topic , Health Services Administration , Contract Services/standards , Data Collection , Decision Making, Organizational , Humans , Information Management/standards , Needs Assessment , Software Design , Technology Assessment, Biomedical , United States , User-Computer InterfaceABSTRACT
The rapidly growing area of osteopathic medicine takes us beyond high technology, life-saving equipment, or at least the most accurate diagnostic test. Whether it is called 'alternative', 'complementary' or 'holistic' medicine, it cannot be ignored as a legitimate healthcare choice, with well-defined benefits for healthcare consumers. This paper examines the history, development, philosophy of practice and challenges facing the viability of osteopathic medicine. More specifically, we address the following key questions: What is osteopathy medicine? What role does osteopathic medicine play in the provision of health services? What challenges face this professional group? And is osteopathic medicine an alternative approach to healthcare?
Subject(s)
Osteopathic Medicine/organization & administration , Osteopathic Medicine/trends , Primary Health Care/organization & administration , American Medical Association , Career Choice , Complementary Therapies , Forecasting , Health Services Research , Planning Techniques , Politics , Primary Health Care/economics , Public Policy , Social Environment , Social Values , United StatesABSTRACT
This article examines the relationship between hospital characteristics and costs of hospital care, using the 1991 American Hospital Association Annual Survey of Hospitals. The results discussed herein have implications for hospital executives, researchers and policymakers.
Subject(s)
Hospital Administration/classification , Hospital Costs/statistics & numerical data , Bed Occupancy/statistics & numerical data , Data Collection , Hospital Administration/economics , Hospital Bed Capacity/statistics & numerical data , Hospitals, Teaching/statistics & numerical data , Insurance, Health, Reimbursement/statistics & numerical data , Medical Staff, Hospital/statistics & numerical data , Ownership/statistics & numerical data , Personnel Staffing and Scheduling/statistics & numerical data , Regression Analysis , Salaries and Fringe Benefits/statistics & numerical data , United StatesABSTRACT
Financing long-term care services can be extremely cost prohibitive to the average United States citizen. Given the complex patchwork of multidisciplinary services that may be required, operational issues and system efficiencies often draw considerable attention. Notwithstanding these challenges, this article reviews the major sources of long-term care financing, including some lesser-known options. Potential advantages and disadvantages are presented. A descriptive analysis of existing policies and consumer practices raises the question of whether recent incremental reforms will lead to future solutions for the major constituents most affected by their implementation.
Subject(s)
Health Care Reform/legislation & jurisprudence , Long-Term Care/economics , Aged , Financing, Personal , Health Care Reform/economics , Humans , Insurance, Long-Term Care , Insurance, Medigap , Medicaid , Medicare , United StatesABSTRACT
In response to dramatic rises in health care costs, policy-makers have been debating the relative merits of competitive strategies as a means of containing costs. This article represents a study of the 29 largest MSAs for 1991. Controlling for environmental conditions in each market, the impact of competition on hospital costs was examined. Competition was found to have had a significant positive impact on overall hospital costs.
Subject(s)
Cost Control/methods , Economic Competition/statistics & numerical data , Hospital Costs/statistics & numerical data , Hospitals, Urban/economics , Catchment Area, Health/economics , Health Care Sector , Health Services Research/methods , Hospitals, Urban/statistics & numerical data , Humans , Patient Admission/statistics & numerical data , Regression Analysis , Research Design , United StatesABSTRACT
Health care represents a promising area of research due to its uniqueness. In recent years, considerable progress has been made in diversification strategy and performance research but not the study of health services strategy research. This article reviews diversification strategy and performance in health services domains. Adopting Datta, Rajagopalan, and Rasheed's (1991) framework, the authors evaluate the theoretical and empirical contributions of this research. The limitations and theoretical implications of these efforts are also explored.
Subject(s)
Health Care Sector/organization & administration , Health Services Research/methods , Planning Techniques , Financial Audit , Management Audit , Models, Theoretical , United StatesABSTRACT
This paper focuses on Medicare risk contracting in the USA. The issue of the current method of reimbursement versus Medicare risk contracting is explored. Risk sharing and payment mechanisms are described and analyzed. The strengths and weaknesses (score-card) of Medicare beneficiaries entering HMOs are reviewed. Finally, the issue of selection bias in Medicare HMOs is discussed regarding future implementation strategy.
Subject(s)
Health Maintenance Organizations/economics , Medicare/organization & administration , Risk Sharing, Financial , Aged , Capitation Fee , Centers for Medicare and Medicaid Services, U.S. , Contract Services , Humans , Information Services , Medicare/economics , Reimbursement Mechanisms , Selection Bias , Tax Equity and Fiscal Responsibility Act , United StatesABSTRACT
The relationship between organizational structure and organizational performance would seem at first to be straightforward and obvious. The more complex organizational structures will result in positive organizational performance (i.e. greater effectiveness or profitability). The premise is that the ability of an organization to achieve its mission successfully should be a result of the organizational structure. It is generally accepted that certain structural configurations are able to achieve certain goals better than others (i.e. a diversified structure as opposed to a simple structure). The research to date indicates that this is not necessarily true. The specific issue examined in this paper will be the effect of structural diversification on performance in industry and healthcare.
Subject(s)
Hospital Administration/standards , Management Audit , Organizational Culture , Personnel Administration, Hospital , Communication , Delivery of Health Care, Integrated/organization & administration , Efficiency, Organizational , Health Services Research/organization & administration , Hospital Restructuring/organization & administration , Models, Organizational , Operations Research , Organizational Objectives , Task Performance and Analysis , United StatesABSTRACT
Medicaid is the health care program that is financed jointly by the federal and state governments. Many states are seeking ways to contain the increased budgetary strain that has resulted from the increases in Medicaid spending. For many states, managed care has been viewed as the means to hold down costs for some of the population served by Medicaid. This article examines the origins and status of Medicaid and the options available to extend coverage to the low-income population.
Subject(s)
Health Care Reform/legislation & jurisprudence , Medicaid/organization & administration , Poverty , Cost Control , Financing, Government , Health Policy , Medicaid/economics , United StatesABSTRACT
A review of the current literature on retiree health benefits finds that supplemental coverage for the majority of Medicare beneficiaries is in the form of employer-provided coverage. Findings in current literature also suggest that Medicare risk contracts can contain costs but efforts must be made to provide quality information to Medicare beneficiaries in order to increase enrollment in HMOs. Finally, a linear relationship is implied between income and the probability of supplementary insurance ownership.
Subject(s)
Health Benefit Plans, Employee , Insurance, Medigap , Medicare , Retirement , Health Maintenance Organizations , Humans , Income , Linear Models , United StatesABSTRACT
The development of managed care plans is the most dramatic change in the USA's health care system in recent decades. Despite the widespread growth, society is increasingly concerned with the quality of managed care programs. This article addresses the regulatory pressures that are being placed on managed care organisations and examines what health care practitioners can do to minimize the impact of increased regulation. We look at the major factors that are likely to bring about changes in the health care sector, and predict how these changes will affect the quality of health care that is being delivered in the near future. Addresses how quality can become and remain the primary factor in the delivery of health care services. Finally, concludes that greater involvement by the federal government is necessary to protect consumers' rights, and ensure better quality health care from managed care programs.
Subject(s)
Facility Regulation and Control/trends , Managed Care Programs/organization & administration , Quality of Health Care , Social Responsibility , Consumer Advocacy , Data Collection , Decision Making, Organizational , Health Services Accessibility , Managed Care Programs/standards , Operations Research , Policy Making , Referral and Consultation , Refusal to Treat , United States , Utilization ReviewABSTRACT
The rapid growth of new forms of managed care in the United States in recent decades has brought with it increasing concerns regarding the quality of care delivered by practitioners in these plans. This article examines the various regulatory demands that are being placed on Managed Care Organizations (MCOs). The authors look at the major determinants that are likely to bring about significant changes in the health care sector for both patients and providers and predict how these shifts will affect the quality of health care services in the near future. They discuss how the quality of health care, rather than the cost of those services, can become and remain the primary factor in the delivery of health care services. Ultimately, they conclude that increased participation by the federal government is required to protect the rights of patients and ensure better quality and accountability for health care services delivered by MCOs.
Subject(s)
Managed Care Programs/standards , Quality Assurance, Health Care , Social Responsibility , Consumer Behavior , Data Collection , Health Services Accessibility , Managed Care Programs/legislation & jurisprudence , Managed Care Programs/organization & administration , Referral and Consultation , United States , Utilization ReviewABSTRACT
Health care represents a promising area of research due to its uniqueness. In recent years, considerable progress has been made in strategic decision-making processes research but not the study of health care strategy research. This article reviews strategic decision-making in health care domains. Adopting Rajagopalan, Rusheed, and Datta's (1993) framework, the authors evaluate the theoretical and empirical contributions of this research. The limitations and theoretical implications of these efforts are also explored.
Subject(s)
Decision Making, Organizational , Health Services Research , Models, Organizational , Planning Techniques , United StatesABSTRACT
The delivery of health care in rural areas is a problem throughout the United States. The health of an individual warrants consideration near conception, as the health of a mother affects the health of an unborn child. This article evaluates the status of obstetrics care in rural Alabama and offers possible alternatives to the current delivery of care.