Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice.

BACKGROUND: Insurance coverage of vascular surgery patients may differ from patients with less chronic surgical pathologies. The goal of this study is to identify trends in insurance status of vascular surgery patients over the last 10 years at a busy academic center. METHODS: All consecutive patient visits for a vascular procedure from 2006 to 2016 were retrospectively reviewed from a prospectively collected institutional database. Data points included insurance status, procedures performed, and date of admission. The insurance status was categorized as Medicare, Medicaid, and uninsured. Samples were divided between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, chi-squared test, and regression analysis were used to determine significant trends over the study period. RESULTS: From 2006 to 2016, 6,007 vascular surgery procedures were performed. Procedure volume increased significantly from 1,309 to 4,698 between the 2 timeframes (P < 0.05), whereas the percentage of Medicaid and Medicare patients trended upward but did not achieve significance. There was a significant decrease in the percentage of uninsured patients between the cohorts (5.65% vs. 2.96%, P < 0.05). In 2012, 10.14% of patients were uninsured compared with 2.56% in 2016 (P < 0.05). CONCLUSIONS: Insurance status affects access to care and subsequent outcomes. In our busy academic center, insurance coverage for vascular surgery has significantly increased over the past decade. The number of Medicaid and Medicare patients has slowly increased, but a significant and continuing decline in uninsured patients was observed. Implementation of the Affordable Care Act during this time period may have played a role in providing coverage for patient needing vascular surgery.

Academic Medical Centers as Innovation Ecosystems: Evolution of Industry Partnership Models Beyond the Bayh-Dole Act.

Innovation ecosystems tied to academic medical centers (AMCs) are inextricably linked to policy, practices, and infrastructure resulting from the Bayh-Dole Act in 1980. Bayh-Dole smoothed the way to patenting and licensing new drugs and, to some degree, medical devices and diagnostic reagents. Property rights under Bayh-Dole provided significant incentive for industry investments in clinical trials, clinical validation, and industrial scale-up of products that advanced health care. Bayh-Dole amplified private investment in biotechnology drug development and, from the authors' perspective, did not significantly interfere with the ability of AMCs to produce excellent peer-reviewed science. In today's policy environment, it is increasingly difficult to patent and license products based on the laws of nature-as the scope of patentability has been narrowed by case law and development of a suitable clinical and business case for the technology is increasingly a gating consideration for licensees. Consequently, fewer academic patents are commercially valuable. The role of technology transfer organizations in engaging industry partners has thus become increasingly complex. The partnering toolbox and organizational mandate for commercialization must evolve toward novel collaborative models that exploit opportunities for future patent creation (early drug discovery), data exchange (precision medicine using big data), cohort assembly (clinical trials), and decision rule validation (clinical trials). These inputs contribute to intellectual property rights, and their clinical exploitation manifests the commercialization of translational science. New collaboration models between AMCs and industry must be established to leverage the assets within AMCs that industry partners deem valuable.

Practice improvement, part II: trends in employment versus private practice.

A growing percentage of physicians are selecting employment over solo practice, and fewer family physicians have hospital admission privileges. Results from surveys of recent medical school graduates indicate a high value placed on free time. Factors to consider when choosing a practice opportunity include desire for independence, decision-making authority, work-life balance, administrative responsibilities, financial risk, and access to resources. Compensation models are evolving from the simple fee-for-service model to include metrics that reward panel size, patient access, coordination of care, chronic disease management, achievement of patient-centered medical home status, and supervision of midlevel clinicians. When a practice is sold, tangible personal property and assets in excess of liabilities, patient accounts receivable, office building, and goodwill (ie, expected earnings) determine its value. The sale of a practice includes a broad legal review, addressing billing and coding deficiencies, noncompliant contractual arrangements, and potential litigations as well as ensuring that all employment agreements, leases, service agreements, and contracts are current, have been executed appropriately, and meet regulatory requirements.

Staying single in the 1990s: single-handed practitioners in the new National Health Service.

The U.K. health care system is organised around independent medical practitioners who work in community settings and act as gatekeepers for acute health interventions. Recent developments in U.K. health policy have revolutionised the environment within which all general medical practitioners (GPs) operate. The last five years in the U.K. have seen the most fundamental health service reforms since the inception of the National Health Service (NHS) in 1946: namely, the development of the internal market, an increasing emphasis on primary health care, and changes to the GP Contract in 1990. Single-handed GPs (practitioners not in partnership with other GPs) traditionally work in the most deprived areas with the greatest health and social problems. The current restructuring and the subsequent organisational and policy initiatives present particular problems for single-handed practitioners. How single-handed practitioners respond to the reforms raises particularly important debates that are significant both for themselves and for the populations they serve. Drawing upon a range of sources, this paper discusses three central issues that emerge. First, how do single-handed practices relate to the more managerial role envisaged for authorities responsible for supporting primary health care? Second, given the development of the internal market, how do single-handed practices fare in influencing local policy and priority setting? Third, to what extent can single-handed practitioners take advantage of the opportunities to hold their own budgets? Overall, in the context of recent U.K. health care reforms, what is the future for "staying single in the 1990s"?

Family doctors and change in practice strategy since 1986.

OBJECTIVES: To investigate the changes in practice strategy that have taken place since 1986. DESIGN: Comparison of practices in 1986 and 1992. SETTING: 93% of group practices (26 practices) in a single family health services authority. MAIN OUTCOME MEASURES: Changes in staffing, premises, equipment, clinic services, and incomes between 1986 and 1992. RESULTS: In 1986, 28% of practices employed a nurse; in 1992, 92% did so. Between 1986 and 1992, 14 cost-rent schemes costing more than 10,000 pounds had been started. Certain practices, designated innovators, were more likely to possess specified items of equipment than other practices. Computer ownership was widespread: 77% of practices had a computer, compared with 36% in 1986. In 1992, 16 practices had a manager, compared with 10 in 1986. Clinic services provided by more than half of practices were well established services (antenatal, for example), new services for which a payment had been introduced (such as diabetes, asthma, minor surgery), or the more readily provided "new" clinic services (diet, smoking cessation). Gross income increased, but so did practice costs, especially for innovators. Practices in the more affluent area of the family health services authority were still more likely to invest in their premises and staff, and to provide more services than those in the declining area. In the more affluent area, practices had higher costs but also higher incomes. CONCLUSION: Between 1986 and 1992, practices in this area invested heavily in equipment and services, but differences remain, depending on the location of the practice. Investment has increased, particularly in the more deprived part of the area, so that the inconsistency in standards has been much reduced. Practice incomes have risen, but so also have workload and costs.