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The changing landscape of health care financing and delivery: How are rural communities and providers responding?

MILBANK QUARTERLY 1999年第4期77卷 485-+页

作者： Mueller, KJ Coburn, A Cordes, S Univ Nebraska Med Ctr Nebraska Med Ctr 984350 Coll Med Omaha NE 68198 USA Univ So Maine Portland ME 04103 USA Univ Washington Seattle WA 98195 USA Univ N Dakota Grand Forks ND 58201 USA Univ Missouri Columbia MO 65211 USA US Dept Hlth & Human Serv Washington DC 20201 USA

Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking;the creation of new strategies for managing patient care;and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices;a few were signing contracts fbr capitated fare, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health fare organization and financing reach the levels achieved by urban communities.

关键词：社区网络/经济学社区网络/组织和管理病人医护连续性/组织和管理合同业务财务管理/组织和管理卫生保健部门卫生服务研究医院乡村/经济学医院乡村/组织和管理医院乡村/发展趋势保险健康补偿管理医疗规划/组织和管理 Medicare/组织和管理明尼苏达纽约俄克拉何马组织状况研究组织改革乡村卫生服务/经济学乡村卫生服务/组织和管理乡村卫生服务/发展趋势南卡罗来纳田纳西美国华盛顿老年人人类

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Psychiatrists' views of managed care and the future of psychiatry

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GENERAL HOSPITAL PSYCHIATRY 2000年第2期22卷 97-106页

作者： Regestein, QR Brigham & Womens Hosp Dept Med Div Psychiat Boston MA 02115 USA

Managed care aims to insure the health of a population rather than that of an individual. This paper compiles opinions of psychiatrists and others on managed care and lists ways managed cave potentially affects psychiatry. Managed cave reverses the economic incentives indemnity insurance gave doctors to prolong treatment. It encourages psychiatrists to spend less rime on empathic discussion and to tl:je move standardized, less costly treatments. Many psychiatrists feel distressed about how managed care has changed their practices. Capitation care will change it further. Current trends suggest the U.S. will use and train fewer psychiatrists. Psychiatrists will spend less time with individual patients and more tin-re planning and guiding the treatment of severely impaired patients. Many more psychiatrists will likely have unprecedented changes imposed on their careers. (C) 2000 Elsevier Science Inc.

关键词：伦理学医学管理医疗规划/经济学管理医疗规划/组织和管理管理医疗规划/发展趋势精神卫生服务/经济学精神卫生服务/立法和法学精神卫生服务/组织和管理精神病学/经济学精神病学/教育精神病学/组织和管理精神病学/标准精神病学/发展趋势舆论美国人类

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Making a case for the CDE's role in outsourcing diabetes services to a freestanding outpatient diabetes disease state management center

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DIABETES EDUCATOR 1999年第5期25卷 766-+页

作者： Hendricks, LE Hendricks, RT LHCA Diabet Self Management Skills Training Ctr Wheaton MD 20906 USA

Outsourcing of diabetes disease state management services by MCOs is a good thing for enrollees with diabetes. It is a good mechanism for MCOs that are striving to cut the costs of diabetes care, and it is a trend that the authors expect to see continue in an accelerated way, given the new diagnostic guidelines released by the American Diabetes Association and the epidemic of diabetes among older persons. Through a partnership with a quality, freestanding, outpatient diabetes disease state management center staffed by CDEs, MCOs with a vision can expect to profit now and pay less later for devastating, expensive diabetes complications that lead to increased hospitalizations.

关键词：算法门诊医疗设施/组织和管理证明合同业务/组织和管理糖尿病/预防和控制疾病管理职务说明管理医疗规划/组织和管理临床护理医生/教育临床护理医生/组织和管理病人教育(主题)/组织和管理人类

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Perceptions of medical school seniors of the current changes in the US health care system

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EVALUATION & THE HEALTH PROFESSIONS 1999年第2期22卷 169-183页

作者： Hojat, M Veloski, JJ Louis, DZ Xu, G Ibarra, D Gottlieb, JE Erdmann, JB Jefferson Med Coll Philadelphia PA 19107 USA

Perceptions of medical school seniors about changes occurring in the health care environment were investigated A survey was completed by 196 Jefferson Medical College seniors in the class of 1997. Of the respondents, 79% believed that cost reduction rather than quality of care is the primary consideration behind recent changes, 78% felt that managed care organizations hamper physicians' abilities to render optimal care, 83% maintained that the control of health care by insurance companies would lead to lower quality of care, 69% agreed that patients should have the freedom to seek a specialist's care without being referred by a primary care physician, 82% recommended that mentally ill patients should be referred to a mental health professional, and 82% believed that learning to work in a managed care environment should be an essential component of medical education. Assessment of student perceptions can assist in the development and implementation of appropriate curricular changes.

关键词：医务工作者的态度费用控制课程教育医学本科卫生保健部门/发展趋势管理医疗规划/组织和管理卫生保健质量问卷调查转诊和会诊学生医科美国人类

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The emergency department on-call backup crisis: Finding remedies for a serious public health problem

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 495-499页

作者： Johnson, LA Taylor, TB Lev, R Sutter Davis Hosp Emergency Dept Davis CA 95617 USA Good Samaritan Reg Med Ctr Dept Emergency Med Phoenix AZ USA Arizona Coll Osteopath Med Div Clin Educ Phoenix AZ USA Scripps Mercy Med Ctr Dept Emergency Med San Diego CA USA Univ San Diego San Diego CA 92110 USA

[Johnson LA, Taylor TB, Lev R. The emergency department on-call backup crisis: finding remedies for a serious public health problem. Ann Emerg Med. May 2001;37:495-499.]

关键词：伦理学医学设施的规章和管理/组织和管理预测卫生政策卫生服务研究管理医疗规划/组织和管理医务人员医院/立法和法学医务人员医院/供应和分配需求估价人员配备和时间安排/组织和管理公共卫生医生拒绝医治/立法和法学美国人类

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Heart failure: A case for subspecialized care management

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AMERICAN HEART JOURNAL 1999年第1期138卷 14-16页

作者： Smith, JJ Konstam, MA New England Med Ctr Div Cardiol Heart Failure & Cardiac Transplantat Ctr Boston MA 02111 USA Tufts Univ Sch Med Dept Med Div Cardiol Medford MA 02155 USA Tufts Univ Sch Med Dept Pharmacol & Expt Therapeut Div Cardiol Medford MA 02155 USA

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Optimizing treatment of dyslipidemia in patients with coronary artery disease in the managed-care environment (The Rocky Mountain Kaiser Permanente experience)

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第3A期85卷 36A-42A页

作者： Merenich, JA Lousberg, TR Brennan, SH Calonge, NB Rocky Mt Kaiser Permanente Dept Endocrinol Denver CO USA Rocky Mt Kaiser Permanente Dept Cardiol Denver CO USA Rocky Mt Kaiser Permanente Dept Pharm Denver CO USA Rocky Mt Kaiser Permanente Dept Prevent Med Denver CO USA

Rocky Mountain Kaiser Permanente has taken aggressive steps to ensure optimal treatment of all modifiable cardiac risk factors, especially low-density lipoprotein (LDL) cholesterol, in patients with coronary artery disease. In this article, we are presenting (1) the basic rationale for our approach, (2) the critical steps translating philosophy into practice, and (3) justification for all health plans to pursue a similar course. The continuum of physician-directed disease management systems that have evolved in our region-one administered by cardiology nurses in the perihospitalization period and the other by pharmacists in the long-term, outpatient setting-is then detailed. Although the relatively short duration that our comprehensive systems have been in place precludes any assessment of their impact on cardiac death, coronary artery disease events, or coronary artery disease procedure rates, the improvements in intermediate surrogate outcomes are promising. Virtually all surveyed patients participating in our manage-ment systems have been "very" or "extremely" satisfied with their experience. The LDL-cholesterol screening rate in the approximately 2,500 participants in the programs to date has reached 97%. Of these patients, 84% have LDL cholesterol <130 mg/dL and 48% <100 mg/dL, and only 15% of those few with LDL cholesterol >130 mg/dL (2.5% overall) are currently not receiving lipid-lowering therapy. The proportions of patients on aspirin/antiplatelet and beta-blocker therapy after myocardial infarction are 97% and 92%, respectively. The lipid-screening and treatment rates, especially, represent significant improvement from our own baseline, and compare favorably with outcomes from other practice settings. In conclusion, health maintenance organizations have tremendous incentive and the unique opportunity and ability to develop systems to better manage large numbers of individuals with coronary artery disease. (C) 2000 by Excerpta Medica, Inc.

关键词：降血脂药/治疗应用胆固醇 LDL/血液科罗拉多冠心病/血液冠心病/并发症冠心病/治疗健康维护组织/组织和管理高脂血症/血液高脂血症/并发症高脂血症/药物疗法管理医疗规划/组织和管理病人满意度人类

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Academic practice groups: Strategy for survival

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SURGERY 2000年第4期128卷 505-510页

作者： Rodriguez, JL Jacobs, DM Zera, RT Van Camp, JM Muehlstedt, SG West, MA Bubrick, MP Univ Minnesota Sch Med Hennepin Cty Med Ctr Dept Surg Minneapolis MN 55455 USA

Background. The mission of public academic health centers (puAHC) and their affiliated practice groups (APG) focuses on teaching, research, and the clinical care of at-risk populations. Resources to accomplish this mission, however, are becoming scarce. For puAHC to survive and remain competitive, innovative strategies will need to be developed by the APG. We hypothesized that the integration of a surgical academic practice of the APG with a nonacademic integrated health care delivery system (NAIDS) in a managed care environment would benefit all involved. Methods. A surgical academic practice was integrated with a NAIDS in a 95% managed care market. Faculty alone provided care the first year and third-year residents were added the following year. To assess outcome, we collected benefit and cost data for the 1-year period before integration and compared them with the two, 1-year periods after integration. Results. In the second year of integration 1-revenues from the NAIDS referrals to the puAHC and APG increased 89% and 150%, respectively. The NAIDS' general surgical and endoscopy caseload increased by 25%. Additionally, there was a 92% reduction in operating room technician cost with no increase in operating time per case. Finally, the third-year resident experienced a caseload increase of 163%. Conclusions. In an environment where resources are diminishing and managed care consists of many large NAIDS that drive referrals and revenue, the integration of a surgical academic practice with a NAIDS benefits all shareholders. Academic practice groups that develop strategies that leverage their competitive advantage will have the best chance of surviving in today's turbulent health care market.

关键词：医学科学研究中心/组织和管理卫生保健提供联合/组织和管理全体教工医学院校/组织和管理联合开业/组织和管理医院县/组织和管理实习医师和住院医师职务/组织和管理管理医疗规划/组织和管理卫生服务使用研究组织隶属关系结果评价(卫生保健) 外科学/组织和管理人类

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Reducing the risk of malpractice claims

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HOSPITAL PRACTICE 1999年第7期34卷 69-+页

作者： Lichtstein, DM Materson, BJ Spicer, DW Univ Miami Sch Med Dept Med Coral Gables FL 33124 USA

Many physicians will be sued for malpractice at some time during their careers. Risk of litigation can be reduced by adopting practices that include keeping thorough medical records, educating office personnel, and fostering good patient-physician relationships. The last is important because patients who view their physicians as caring tend not to sue even if an adverse outcome occurs.

关键词：防御医学/方法佛罗里达卫生人员/教育医疗事故/立法和法学医疗事故/统计学和数值数据管理医疗规划/组织和管理病案医生病人关系卫生保健质量危险因素危险处理/方法人类

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Examining specialty care

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AMERICAN JOURNAL OF MEDICINE 2000年第1期108卷 89-90页

作者： Yelin, E Univ Calif San Francisco Dept Med San Francisco CA 94143 USA Univ Calif San Francisco Rosalind Russell Med Res Ctr Arthrit San Francisco CA 94143 USA

The managed care revolution was not supposed to turn out this way. As outlined in Alain Enthoven□s influential, if immodestly titled, book, Health Plan: The Only Practical Solution to the Soaring Cost of Medical Care(1), the medical marketplace under managed competition would operate much like a deist□s vision of the way the world works: a basic, minimal set of regulations would ensure that the playing field was leveled among competing health plans so that they could not succeed by selecting low-risk patients. Then the invisible hand of the marketplace would result in a more efficient provision of health care.

关键词：内科学关节疾病/诊断关节疾病/治疗膝关节管理医疗规划/经济学管理医疗规划/组织和管理管理医疗规划/发展趋势矫形外科学病人满意度医师诊疗模式转诊和会诊风湿病学肩关节专业医学美国人类

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