The $74,973 Question: Are Medicare Beneficiaries Informed Users of Private Medical Care Contracts?

Health-care providers are allowed to opt-out of Medicare, privately contract with beneficiaries, and require that beneficiaries pay the full cost of services. Responses from a nationally representative sample of Medicare beneficiaries reveal that they lack the knowledge necessary to make informed decisions regarding such contracts. For example, only 4.6% of participants knew the correct answer to a real-life $74,973 question, leaving a full 95.4% vulnerable to paying a large bill, even a $74,973 bill, they should not pay. In addition to advocating that Medicare effectively monitor private medical care contracts, social workers should educate beneficiaries and/or their caregivers on the implications of entering into such contracts or refer them to their State Health Insurance Assistance Program or Senior Medicare Patrol program for expert guidance.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

Assessment of diffusion tensor image quality across sites and vendors using the American College of Radiology head phantom.

The purpose of this study was to explore the feasibility of assessing quality of diffusion tensor imaging (DTI) from multiple sites and vendors using American College of Radiology (ACR) phantom. Participating sites (Siemens (n = 2), GE (n= 2), and Philips (n = 4)) reached consensus on parameters for DTI and used the widely available ACR phantom. Tensor data were processed at one site. B0 and eddy current distortions were assessed using grid line displacement on phantom Slice 5; signal-to-noise ratio (SNR) was measured at the center and periphery of the b = 0 image; fractional anisotropy (FA) and mean diffusivity (MD) were assessed using phantom Slice 7. Variations of acquisition parameters and deviations from specified sequence parameters were recorded. Nonlinear grid line distortion was higher with linear shimming and could be corrected using the 2nd order shimming. Following image registration, eddy current distortion was consistently smaller than acquisi-tion voxel size. SNR was consistently higher in the image periphery than center by a factor of 1.3-2.0. ROI-based FA ranged from 0.007 to 0.024. ROI-based MD ranged from 1.90 × 10-3 to 2.33 × 10-3 mm2/s (median = 2.04 × 10-3 mm2/s). Two sites had image void artifacts. The ACR phantom can be used to compare key qual-ity measures of diffusion images acquired from multiple vendors at multiple sites.

Service quality in contracted facilities.

PURPOSE: The purpose of this paper is to explore the readiness of contracted and non-contracted first-level healthcare facilities in Pakistan to deliver quality maternal and neonatal health (MNH) care. A balanced scorecard (BSC) was used as the assessment framework. DESIGN/METHODOLOGY/APPROACH: Using a cross-sectional study design, two rural health centers (RHCs) contracted out to Aga Khan Health Service, Pakistan were compared with four government managed RHCs. A BSC was designed to assess RHC readiness to deliver good quality MNH care. In total 20 indicators were developed, representing five BSC domains: health facility functionality, service provision, staff capacity, staff and patient satisfaction. Validated data collection tools were used to collect information. Pearson χ2, Fisher's Exact and the Mann-Whitney tests were applied as appropriate to detect significant service quality differences among the two facilities. FINDINGS: Contracted facilities were generally found to be better than non-contracted facilities in all five BSC domains. Patients' inclination for facility-based delivery at contracted facilities was, however, significantly higher than non-contracted facilities (80 percent contracted vs 43 percent non-contracted, p=0.006). PRACTICAL IMPLICATIONS: The study shows that contracting out initiatives have the potential to improve MNH care. ORIGINALITY/VALUE: This is the first study to compare MNH service delivery quality across contracted and non-contracted facilities using BSC as the assessment framework.

Contract anesthesia: the good news and the challenge.

The dramatic pace of change in health care is intimidating, and results can be unpredictable and often negative. The practice of contract anesthesia delivery is an excellent example of how a clinical microsystem interacts with the constant change common in today's health care environment. This article identifies many of the issues of concern in contract anesthesia. Awareness of issues will afford nurses, nurse anesthetists, and managers a structure for a smooth, safe, and effective transition of contracting providers.

Health care spending and quality in year 1 of the alternative quality contract.

BACKGROUND: In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality. METHODS: Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group. RESULTS: Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1. CONCLUSIONS: The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).

Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries.

BACKGROUND: District managers are playing an increasingly important role in determining the performance of health systems in low- and middle-income countries as a result of decentralization. OBJECTIVES: To assess the effectiveness of interventions to hire, retain and train district health systems managers in low- and middle-income countries. SEARCH METHODS: We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We also searched online resources of international agencies, including the World Bank, to find relevant grey literature. Searches were conducted in December 2011. SELECTION CRITERIA: District health systems managers are those persons who are responsible for overseeing the operations of the health system within a defined, subnational geographical area that is designated as a district. Hiring and retention interventions include those that aim to increase the attractiveness of district management positions, as well as those related to hiring and retention processes, such as private contracting. Training interventions include education programs to develop future managers and on-the-job training programs for current managers. To be included, studies needed to use one of the following study designs: randomized controlled trial, nonrandomized controlled trial, controlled before-and-after study, and interrupted time series analysis. DATA COLLECTION AND ANALYSIS: We report measures of effect in the same way that the primary study authors have reported them. Due to the varied nature of interventions included in this review we could not pool data across studies. MAIN RESULTS: Two studies met our inclusion criteria. The findings of one study conducted in Cambodia provide low quality evidence that private contracts with international nongovernmental organizations (NGOs) for district health systems management ('contracting-in') may improve health care access and utilization. Contracting-in increased use of antenatal care by 28% and use of public facilities by 14%. However, contracting-in was not found to have an effect on population health outcomes. The findings of the other study provide low quality evidence that intermittent training courses over 18 months may improve district health system managers' performance. In three countries in Latin America, managers who did not receive the intermittent training courses had between 2.4 and 8.3 times more management deficiencies than managers who received the training courses. No studies that aimed to investigate interventions for retaining district health systems managers met our study selection criteria for inclusion in this review. AUTHORS' CONCLUSIONS: There is low quality evidence that contracting-in may improve health care accessibility and utilization and that intermittent training courses may improve district health systems managers' performance. More evidence is required before firm conclusions can be drawn regarding the effectiveness of these interventions in diverse settings. Other interventions that might be promising candidates for hiring and retaining (e.g., government regulations, professional support programs) as well as training district health systems managers (e.g., in-service workshops with on-site support) have not been adequately investigated.

Current situation of clinical trials in Beijing and Shanghai, China.

OBJECTIVE: Global clinical trials are important because they facilitate rapid delivery of new and effective drugs to patients Assessment of the current situation of clinical trials conducted in Asia is critical for improving performance of global clinical trials. However, review reports from China or other Asian countries are not yet available. Therefore, the purpose of this research was to investigate the current quality of clinical trials conducted in Shanghai, as well as Beijing. METHODS: Questionnaires were distributed to medical doctors attending institutes in Beijing and Shanghai in which clinical trials have been conducted. These questionnaires were delivered and collected from both areas by the Peking University research team of Beijing and the Fudan University research team of Shanghai respectively. Analysis and evaluation were conducted by research teams from both China and Japan. RESULTS: Subjects were randomly selected by the respective research team. A total of 145 questionnaires in Beijing and 162 in Shanghai were administered: all 307 questionnaires were completed. In total, 57.2% and 74.5% of respondents from Beijing and Shanghai, respectively, reported participation in audits and inspections on an annual basis conducted by their own institute. A total of 49.2% and 56.0% of respondents from Beijing and Shanghai, respectively, reported that they received reports after the audits and inspections by an institute. 23.5% and 37.7% of respondents from Beijing and Shanghai, respectively, reported participation in audits conducted annually by external authorities. A total of 18.9% and 29.5% of respondents from Beijing and Shanghai, respectively, reported that they received reports after the audits and inspections by an external authority. CONCLUSIONS: Our research suggests that clinical trials in Shanghai, as well as in Beijing, are conducted vigorously and appropriately monitored by audits and inspections conducted by concerned institutes and/or by an external authority.

How can clients improve the quality of transport infrastructure projects? The role of knowledge management and incentives.

The aim of this paper is to argue for a number of statements about what is important for a client to do in order to improve quality in new infrastructure projects, with a focus on procurement and organizational issues. The paper synthesizes theoretical and empirical results concerning organizational performance, especially the role of the client for the quality of a project. The theoretical framework used is contract theory and transaction cost theory, where assumptions about rationality and self-interest are made and where incentive problems, asymmetric information, and moral hazard are central concepts. It is argued that choice of procurement type will not be a crucial factor. There is no procurement method that guarantees a better quality than another. We argue that given the right conditions all procurement methods can give good results, and given the wrong conditions, all of them can lead to low quality. What is crucial is how the client organization manages knowledge and the incentives for the members of the organization. This can be summarized as "organizational culture." One way to improve knowledge and create incentives is to use independent second opinions in a systematic way.

Reduction of construction wastes by improving construction contract management: a multinational evaluation.

The Canadian construction industry generates 30% of the total municipal solid waste deposited in landfills. Ample evidence can be found in the published literature about rework and waste generation due to ambiguity and errors in contract documents. Also, the literature quotes that disclaimer clauses in contract documents are included in the contractual agreements to prevent contractor claims, which often cause rework. Our professional practice has also noted that there are several disclaimer clauses in standard contract documents which have the potential to cause rework (and associated waste). This article illustrates a comparative study of standard contractual documents and their potential to create rework (and associated waste) in different regions of the world. The objectives of this study are (1) to analyse standard contractual documents in Canada, the USA and Australia in terms of their potential to generate rework and waste, and (2) to propose changes/amendments to the existing standard contract documents to minimise/avoid rework. In terms of construction waste management, all the reviewed standard contract documents have deficiencies. The parties that produce the contract documents include exculpatory clauses to avoid the other party's claims. This approach tends to result in rework and construction waste. The contractual agreements/contract documents should be free from errors, deficiencies, ambiguity and unfair risk transfers to minimise/avoid potential to generate rework and waste.

Staffing patterns of scheduled unit staff nurses vs. float pool nurses: a pilot study.

In this study, the differences in patient assignments between float pool nurses versus scheduled unit staff nurses were examined. Although there was a tendency for float pool nurses to receive more difficult patient assignments, this was not statistically significant (at alpha=0.05).

Industry-contract research organization pathology interactions: a perspective of contract research organizations in producing the best quality pathology report.

This article provides observations on the features of sponsor-contract research organization communication that will achieve the best quality pathology report based on our collective experience. Information on the test article and any anticipated findings should be provided, and initial slide examination should be done with knowledge of treatment group (but may be followed by blinded review of target tissues to determine no-effect levels). Only a pathologist should write or revise the pathology report or the pathology section of the overall study report. To address concerns related to undue sponsor influence, comments by sponsors should be presented as suggestions rather than directives. Adversity should be defined for each finding by the study pathologist, but the no-observed adverse effect level should not be discussed in the pathology report. Board-certified pathologists are recommended, but are not essential. Sponsors that have a particular format or report preferences should make them known well in advance. Histologic processing "to glass" of protocol-specified tissues from all dosage groups is recommended for rapid evaluation of target tissues. Telepathology is beneficial in certain situations, but it is usually more efficient for the study pathologist and reviewing pathologist to be in the same physical location to review differences of opinion and reach a consensus.

Implementation of a competency assessment tool for agency nurses working in an acute paediatric setting.

AIM: This paper reports on the implementation of a competency assessment tool for registered general agency nurses working in an acute paediatric setting, using a change management framework. BACKGROUND: The increased number of registered general agency nurses working in an acute children's hospital alerted concerns around their competency in working with children. These concerns were initially raised via informal complaints about 'near misses', parental dissatisfaction, perceived competency weaknesses and rising cost associated with their use. METHOD: [Young's (2009) Journal of Organisational Change, 22, 524-548] nine-stage change framework was used to guide the implementation of the competency assessment tool within a paediatric acute care setting. IMPLICATIONS FOR NURSING MANAGEMENT: The ongoing success of the initiative, from a nurse manager's perspective, relies on structured communication with the agency provider before employing competent agency nurses. Sustainability of the change will depend on nurse managers' persistence in attending the concerns of those resisting the change while simultaneously supporting those championing the change. These key communication and supporting roles highlight the pivotal role held by nurse managers, as gate keepers, in safe-guarding children while in hospital. Leadership qualities of nurse managers will also be challenged in continuing to manage and drive the change where resistance might prevail.

Are temporary ward staff cost effective?

BACKGROUND: Temporary staff cost the NHS a significant amount, which is unlikely to fall in the near future. What is their effect on care and cost? AIM: To compare staff activity, cost and service quality in wards with and without temporary staff, and highlight issues that ward managers need to monitor. METHOD: Data on patient dependency, nursing activity, workload, staffing and quality was collected for 959 NHS wards; 659 wards had permanent staff only, while 300 had permanent, bank and agency staff. RESULTS: Workloads and absence on wards with temporary staff were greater than on those with permanent staff only. Staffing levels on the former were lower, and working styles and quality scores differed. CONCLUSION: Ward managers should monitor temporary staffing, and its effect on ward staff activity and nursing quality.

Cooperation and competition: balanced scorecard and hospital privatization.

PURPOSE: In 2000 the Skåne Region (a public authority) and a private contractor made a five-year agreement for the provision of both in-patient care and out-patient medical services to about 30,000 inhabitants in the south-east part of the region. The Skåne Region is the main provider of health care to about one million inhabitants in the south of Sweden and is responsible for all health care (private and public), including ten hospitals. This paper seeks to answer the question of how the Skåne Region can control and cooperate with a private contractor, entering into competition with the public health care providers in the region. DESIGN/METHODOLOGY/APPROACH: This is a longitudinal study conducted between 2001-2006. It is based on 28 taped interviews with employees responsible for the contracting process, participating observations and comprehensive secondary material. The study presents experiences made by the contractor and the public authority on how to work out and follow-up assignments within the health care sector regarding patient interest, public interest and professional medical interest. FINDINGS: Measurement within the frames of the balanced scorecard (BSC) made it possible to control both volumes and health care quality delivered by the private competing contractor. The political purchaser claims that the Skåne Region has established a cost-effective and successful control system based on trust and measurement. ORIGINALITY/VALUE: This paper reports on a control system, between public purchaser and a private provider within health care, that focuses on and follow-up not only health care production but also health care quality.

Contracting of primary health care services in Pakistan: is up-scaling a pragmatic thinking?

Quite often, public health care systems in developing countries are struggling because of incompetence and a lack of provider responsiveness to the needs of consumers. On the contrary, the private sector dominates the system of health provision. In recent years, contracting has been experimented as an approach to ensure delivery of comprehensive public health services in an efficient, effective, superior and fair manner and has generally thrived well. The state's healthcare system in Pakistan has suffered a lot, owing to structural fragmentation, resource scarcity, inefficiency and lack of functional specificity, gender insensitivity and inaccessibility. However, partnering with the private sector has shown some exceptional accomplishments. Though challenging but structural reforms, involving private health sector have become indispensable. The overall experience shows that up-scaling of such initiatives in the country would require lot of cautions to be taken by the government.

Leveraging Health Department Capacities, Partnerships, and Health Insurance for Infectious Disease Response in Massachusetts, 2014-2018.

Policies facilitating integration of public health programs can improve the public health response, but the literature on approaches to integration across multiple system levels is limited. We describe the efforts of the Massachusetts Department of Public Health to integrate its HIV, viral hepatitis, sexually transmitted infection (STI), and tuberculosis response through policies that mandated contracted organizations to submit specimens for testing to the Massachusetts State Public Health Laboratory; co-test blood specimens for HIV, hepatitis C virus (HCV), and syphilis; integrate HIV, viral hepatitis, and STI disease surveillance and case management in a single data system; and implement an integrated infectious disease drug assistance program. From 2014 through 2018, the number of tests performed by the Massachusetts State Public Health Laboratory increased from 16 321 to 33 674 for HIV, from 11 054 to 33 670 for HCV, and from 19 169 to 30 830 for syphilis. Service contracts enabled rapid response to outbreaks of HIV, hepatitis A, and hepatitis B. Key challenges included lack of a billing infrastructure at the Massachusetts State Public Health Laboratory; the need to complete negotiations with insurers and to establish a retained revenue account to receive health insurance reimbursements for testing services; and time to train testing providers in phlebotomy for required testing. Investing in laboratory infrastructure; creating billing mechanisms to maximize health insurance reimbursement; proactively engaging providers, community members, and other stakeholders; and building capacity to transform practices are needed. Using multilevel policy approaches to integrate the public health response to HIV, STI, viral hepatitis, and tuberculosis is feasible and adaptable to other public health programs.