Physician communication in the operating room.

In this study, communication research was conducted with multidisciplinary groups of operating-room physicians. Theoretical frameworks from intercultural communication and rhetoric were used to (a) measure latent cultural communication variables and (b) conduct communication training with the physicians. A six-step protocol guided the research with teams of physicians from different surgical specialties: anesthesiologists, general surgeons, and obstetrician-gynecologists (n = 85). Latent cultural communication variables were measured by surveys administered to physicians before and after completion of the protocol. The centerpiece of the 2-hour research protocol was an instructional session that informed the surgical physicians about rhetorical choices that support participatory communication. Post-training results demonstrated scores increased on communication variables that contribute to collaborative communication and teamwork among the physicians. This study expands health communication research through application of combined intercultural and rhetorical frameworks, and establishes new ways communication theory can contribute to medical education.

Transformation of the Urban Health Care Safety Net: The Devolution of a Public Responsibility.

Reduced spending in both federal and state programs and the closure of public hospitals have serious consequences for the health of urban dwellers, especially the poor and uninsured. Through a combination of economic factors, many municipalities have formed public-private partnerships and launched community initiatives to preserve some of the elements of the health care safety net. What once was a responsibility of municipal governments, the provision of health care to poor and uninsured populations, is now posing challenges for private-sector providers. This article identifies several factors that have contributed to the incremental demise of the publicly funded urban health care safety net and how local entities and the federal government are responding to the care of the poor and uninsured.

Health reform's impact on federally qualified community health centers: the unintended consequence of increased Medicaid enrollment on the primary care medical home.

The impact of recently passed health reform legislation may cause substantial changes in community health center (CHC) operations. The new legislation provides federal funding for center expansion, increased Medicaid enrollment, enhanced Medicare payments, training to increase primary care providers, and incentives to develop CHCs as accountable care organizations. Health reform could place CHCs in a vulnerable financial situation. Newly insured patients may seek care at private providers, whereas CHCs are left caring only for the uninsured. Thus, CHCs are unable to benefit from enhanced insurance payments needed to offset care given to the uninsured. Conversely, if CHCs participate in developing comprehensive care networks for low-income populations by strengthening referral networks, developing primary medical care homes and accountable care organizations, and investing in infrastructure, then health center medical care will be a desired option for the newly insured, and a robust safety-net system may result.

The impact of PPS on hospital-sponsored post-acute services: a case study of Delaware Medicare providers.

Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.

Prospective payment and the provision of post-acute care: how the provisions of the Balanced Budget Act of 1997 altered utilization patterns for Medicare providers.

The Balanced Budget Act of 1997 mandated implementation of the prospective payment system for determining Medicare payments to skilled nursing facilities (SNFs) and home health agencies (HHAs). This study assessed the preliminary impact of the changes in reimbursement policy on hospitals, nursing homes, and home health agencies in the United States and the mid-Atlantic region, and conducted micro-level analyses of providers in one state, Delaware. An interrupted time series analysis used aggregate and provider-specific data from the Center for Medicare & Medicaid Services. Nationally, providers experienced significant changes in the number of patients, frequency of service, and payment amounts during the years immediately following implementation of PPS. HHAs reduced the number of visits per patient. In Delaware, hospital-owned nursing homes reduced their Medicare utilization, and proprietary facilities increased their utilization. One-third of the HHAs in Delaware withdrew from Medicare participation. Additional micro-level analyses are needed to substantiate the findings of the Delaware case study and to determine why providers adjusted their utilization of services to Medicare beneficiaries.

Identification of accrual barriers onto breast cancer prevention clinical trials: a case-control study.

BACKGROUND: The purpose of this study was to examine factors influencing a woman's decision to participate in a breast cancer prevention clinical trial. Nine healthcare organizations in Massachusetts cooperated in the present project. METHODS: The authors performed a case-control study to compare responses between the study group (Study of Tamoxifen and Raloxifene [STAR] trial eligible, but not enrolled) and the control group (STAR trial participants) on 12 factors previously identified as barriers to accrual for clinical trials. Eight hypotheses were tested using multiple logistic regression to estimate the strength of the association for each factor on the dependent variable (study participation). RESULTS: The study samples were similar to the general population of eligible breast cancer prevention clinical trial subjects in the counties where the participating organizations were located, the state of Massachusetts, and nationally published STAR trial data. Results of a mailed questionnaire showed that when adjusting for subject demographics, and in the presence of other questions, 4 factors significantly influenced a woman's decision to enroll onto a breast cancer prevention clinical trial more than other eligible subjects: 1) clinician expertise and qualifications (P=.012; odds ratio [OR], 4.903; 95% confidence interval [CI], 1.41-17.04); 2) personal desire to participate (P=.033; OR, 3.16; 95% CI, 1.10-9.06); 3) perceived value of the trial (P=.020; OR, 2.92; 95% CI, 1.18-7.21); and 4) level of trial inconvenience (P=.002; OR, 0.10; 95% CI, 0.02-0.44). CONCLUSIONS: Addressing these issues in the relationship between patients and clinicians should improve accrual to breast cancer prevention clinical trials.

The importance of encounter form design.

Encounter forms are a key component in accurate billing and collections. They document services rendered by capturing the diagnosis and procedure codes, which serve as the basis for billing and receipt of payment for services. This article addresses the negative impact of outdated encounter forms on reimbursement and describes current best practices related to coding, the use of electronic encounter forms, and management of missed appointments. Specific recommendations are offered for ensuring that encounter forms are appropriately maintained and up-to-date.

Impact of Medicare's prospective payment system on hospitals, skilled nursing facilities, and home health agencies: how the Balanced Budget Act of 1997 may have altered service patterns for Medicare providers.

The prospective payment system is one of many changes in reimbursement that has affected the delivery of health care. Originally developed for the payment of inpatient hospital services, it has become a major factor in how all health insurance is reimbursed. The policy implications extend beyond the Medicare program and affect the entire health care delivery system. Initially implemented in 1982 for payments to hospitals, prospective payment system was extended to payments for skilled nursing facility and home health agency services by the Balanced Budget Act of 1997. The intent of the Balanced Budget Act was to bring into balance the federal budget through reductions in spending. The decisions that providers have made to mitigate the impact are a function of ownership type, organizational mission, and current level of Medicare participation. This article summarizes the findings of several initial studies on the Balanced Budget Act's impact and discusses how changes in Medicare reimbursement policy have influenced the delivery of health care for the general public and for Medicare beneficiaries.

Medicare's operational history and impact on health care.

Medicare was originally designed in the 1960s to fit into the existing health care delivery system. However, the program's early years showed an inflationary impact on health care costs. Medicare was the second largest federal domestic program and the fastest growing one, making it a target for those concerned about the size of government in general. By 1980, Medicare constituted 15% of the nation's expenditures for personal health care; and Medicare's administrators recommended substantive changes in provider payments through the introduction of the prospective payment system. Prospective payment system legislation impacted hospitals initially and later skilled nursing facilities and home health agencies. As policymakers made changes in Medicare payments to providers, providers made changes in the way services were delivered. What eventually evolved, in an insidious manner, was implicit management of the nation's health care delivery system by the Medicare program.

Managed care and the bottom line of your practice.

Managed care has greatly influenced the health care industry, particularly with regard to reimbursement for medical services. Managed care has had and continues to have a significant impact on reimbursement for physician services. When contractual relations with managed care companies are initiated and managed by medical practice administrators, the result can be beneficial to a physician practice's financial bottom line. This article discusses the necessity to develop effective working relationships with managed care companies and suggests strategies for establishing fee schedules and negotiating reimbursement contracts.

Medicare-the development of publicly financed health insurance: Medicare's impact on the nation's health care system.

It is useful for health care managers to understand Medicare's history and the impact on providers of ever-changing Medicare payment methods. Initially, Medicare payments resembled those of commercial insurance plans and Blue Cross Blue Shield plans. When Congress became concerned about the increasing costs of Medicare, new payment methods were created to limit payments to providers. The prospective payment system, imposed on hospitals in 1987 and later on nursing homes, home health agencies, and other services, has been adapted by commercial plans, Blue Cross Blue Shield associations, and state Medicaid programs. Changes in payer reimbursements require health care managers to adjust the department's charge master and exert more control of departmental costs. The story of Medicare's beginnings and development can provide some insight into the possibility of national health insurance, given the historic and current politics that limit publicly financed social programs. This article discusses the development of Medicare and its administration and serves as an introduction to the complex realities of health care reimbursement policy.