From Tele-ed to Telehealth: the need for IT ubiquity in nursing

Although numerous studies have shown that information technology (IT) improves care, makes the workplace better for clinicians, and reduces costs, healthcare-especially nursing-has been slow to adopt it for a variety of reasons. However, because of a worsening nursing shortage, couples with increasing healthcare costs and administrative overhead, nursing demands that IT become not only common, but pervasive, playing a role in every aspect of nursing, from recruitment and education, to patient care. This article will examine the several potential applications of IT to nursing and their benefits, challenges to widespread IT adoption, and the importance of IT ubiquity to the very viability of the profession.     

Single-payer,defined contribution or portable HRAs: will market-based models prevail?

Rising healthcare costs have created a crisis situation in employee health benefits. For the first time in a decade, the call for a single-payer healthcare system has been renewed. Although the single-payer system might help expand access to care and reduce administrative costs, the potential costs and bureaucracy make its implementation unrealistic. Consumer-centric health benefit models such as defined contribution and portable HRAs are the first attempts by the private sector to involve consumers in the healthcare decision process. Portable HRAs, which treat health benefits as portable assets to be managed and saved over a lifetime, have the potential to reduce employer costs while improving the quality and continuity of care, with equal access to care for all.     

Solution to patient access to specialist care lies in a balanced approach

Managed care economic and administrative measures designed to coerce "gatekeepers" to limit patients' access to specialist care need to be balanced by sound clinical protocols. Balance is maintained when appropriateness of care, not costs, guides care and referral decisions. This article explores how appropriateness can be achieved through the use of clinical decision support criteria or guidelines. Not only do the guidelines enable providers to deflect demand appropriately and prevent unnecessary interventions, they help mitigate the financial risk that providers assume under managed care.     

Nurse practitioners and managed care: patient satisfaction and intention to adhere to nurse practitioner plan of care

PURPOSE: To explore patient satisfaction, intention to adhere to nurse practitioner (NP) plan of care, and the impact of managed care on NPs' patients in multiple settings, the final phase of a three-part study of NPs and managed care. DATA SOURCES: Postvisit questionnaires and narrative comments about patient satisfaction with NP communication, overall satisfaction with visit, recall of plan of care, intention to adhere to NP's recommendations, and impact of managed care on ease of obtaining healthcare resources. CONCLUSIONS: Patients were very satisfied with NP communication and with their healthcare visit. They mostly intended to adhere to the NP-recommended plan of care but less so to recommended lifestyle changes. Patients trusted their NPs, valued their expertise, were confident in the NPs' care, and believed that the NPs considered their best interests. They appreciated that the NPs took time to listen to their concerns and helped them to obtain healthcare resources. Most patients were not greatly impacted by managed care and obtained needed healthcare resources with little difficulty. IMPLICATIONS FOR PRACTICE: Although the first two phases of this study found that many NPs had strong negative attitudes toward managed care, these attitudes were not conveyed toward patients in this sample. NPs, however, will continue to face new challenges as third-party payers attempt to reduce healthcare costs, further testing NP adaptability and resourcefulness.     

Cost of atrial fibrillation in United States managed care organizations

Introduction  

Atrial fibrillation (AF) has been shown to be associated with high healthcare costs; however, limited data are available from large-scale studies quantifying the overall cost burden of AF in the USA. We therefore aimed to provide an up to date estimate of the overall per-patient costs of AF in managed care organizations across the USA.     

Personal, organizational, and market level influences on physicians' practice patterns: results of a national survey of primary care physicians

BACKGROUND: One of the principal tenets of managed care is that physicians' clinical decisions can be influenced both to improve the quality and consistency of care and to decrease health care expenditures. Medical decision making, however, remains a complex phenomenon and the most important determinants of physicians' approaches to clinical decision making remain poorly understood. OBJECTIVES: To determine how clinical decisions are associated with individual characteristics, practice setting and organizational characteristics, attributes of the patient population under care, and the market environment. RESEARCH DESIGN: Cross-sectional, nationally representative survey of patient-care physicians. SUBJECTS: Primary care physicians who provide direct patient care at least 20 hours per week. MEASURES: Proportion of physicians who would order a referral, diagnostic test, or treatment for 5 clinical scenarios thought to be representative of discretionary medical decisions. RESULTS: Responses were received from 4,825 primary care physicians who cared for adult patients (Response Rate 65%). The distribution of results for each of the five clinical scenarios demonstrates significant variability both within and between physicians. No evidence was seen of a consistent practice style across the vignettes (eg, "aggressive" or "conservative"). The organizational setting of practice was the most consistent predictor of behavior across all the clinical scenarios, with the exception of back pain, which was minimally related to any of the environmental factors. When compared to physicians in solo practice, physicians in all other practice settings were less likely to order a test or referral or pursue treatment. Practice involvement with managed care and measures of financial influences and administrative strategies associated with managed care were minimally and inconsistently associated with reported physician behaviors. CONCLUSIONS: The ability of managed care to improve the quality and consistency of care while also controlling the costs of care depends on its ability to influence medical decisions. Our findings generally demonstrate that managed care has a weak influence on discretionary medical decisions and that the influence of managed care pales in comparison to personal and practice setting influences.     

Predictors of high hospital care and medication costs and cost trajectories in community-dwellers with Alzheimer’s disease

Abstract

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer’s disease (AD), diagnosed during 2005–2011 in Finland (N?=?70,531).

Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis.

Results: Total healthcare costs were driven mainly by hospital care costs. The definition of “high-cost person” was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs.

Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context.

• Key messages

• Persons with AD had large individual fluctuation in hospital care costs and medication costs over time.

• Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors.

• Antidementia medication was associated with lower hospital care costs.

     

Managing in the "new" era of managed care

Are we at the end of an era of reasonable price increases in managed care? Many experts seem to think so. The growth in healthcare costs is occurring so quickly that unless health plans find new ways to hold down costs, many small- to mid-sized companies and individuals may not be able to afford insurance, adding to the already 40 million who are uninsured.     

Demographics and financial impact of home respiratory care

Healthcare policymakers, governmental and private alike, are now faced with an enormous challenge. Demands for improved access to cost-effective and high quality healthcare are emanating from all segments of our society. Clearly, the traditional model of admitting patients to an acute care hospital as a first-line intervention is losing favor. Although there will always be a role for acute hospital care, utilization of this high-cost setting must be better managed if runaway healthcare costs are to be brought under control. The concept of moving patients along the healthcare continuum as their response to treatment reduces the acuteness of their condition is rapidly gaining support, especially with third-party payors. Accordingly, home healthcare providers, including those offering respiratory home care services, can expect to see an increase in the number of referrals they receive. HME/RT providers must actively promote the benefits they can offer in terms of high quality, cost-effective outcome. It is not unrealistic to suggest that the savings realized by reducing an acute hospital stay by 1 day can easily cover the costs of providing respiratory home care for 4 to 6 weeks. One can only hope that such compelling arguments, occurring at a time when healthcare reform and restructuring is a national priority, will translate to more equitable reimbursement guidelines for respiratory home care providers. The past practice of only reimbursing for equipment and supplies fails to take into account the vital role played by the home respiratory therapist. Home respiratory equipment and supplies, while an important component of managing chronic respiratory disease, are only effective if used safely, properly, and in compliance with the prescribing physician's intentions. The use of skilled and dedicated home respiratory therapists to train patients, monitor and assess outcomes, and communicate with the prescribing physician ensures optimum results. It is time for reimbursement policies to recognize this vital role played by home respiratory therapists.     

Taking the "I" road: from nursing informatician to CEO, CIO, or CFO

Strategically and fiscally, information technology (IT) has become one of the most significant areas in today's health care organizations. As clinical systems begin to constitute the lion's share of IT budgets, the progression from nurse information to "C" level should be an increasingly logical one. But is it? This article addresses why and how nurses can move up the administrative ladder and the value of technological expertise to that advancement.     

The impact of market-based 'reform' on cultural values in health care

The many issues managed care poses for providers and health networks are crystallized in the moral problems occasioned by its shifting of the financial risks of care from insurer to provider. The issues occasioned by market-based reform include: the problems presented by clashes between public expectations and payer restrictions; the corporatization of health service delivery and the cultural shift from humanitarian endeavor to business enterprise the depersonalization of treatment as time and money constraints stretch resources, and the culture rewards efficient "business-like" behavior the underfunding of care for the poor and uninsured, even as these populations grow the restructuring of care and reengineering of healthcare roles as the emphasis shifts from quality of care to conservation of resources rapid mergers of both health plans and institutional providers with all the inherent turmoil as rules change, services are eliminated, and support services are minimized to save money the unhealthy competition inherent in market-based reform that posits profit taking and market share as the measures of successful performance the undermining of the professional ethic of advocacy the use of incentives that pander to greed and self-interest. The costs of sophisticated technologies and the ongoing care of increasingly fragile patients have pulled many other elements into what previously were considered "privileged" professional interactions. The fact that very few citizens indeed could pay out-of-pocket for the treatment and ongoing care they might need led to social involvement (few people remember that both widespread health insurance and public programs are relatively recent phenomena--only about 30 years old). However, whether in tax dollars or insurance premiums, other people's money is being spent on the patient's care. Clearly, those "other people" never intended to give either the patient or the professional open-ended access to their collective pocketbooks. Just what form their involvement ought to take is being tested as "managed care" attempts to control the costs. What limits are acceptable to providers?: lower profit margins? quality controls? acceptable risk levels? To patients?: restricted choice? restricted mobility? restricted access to high tech? And to the general public?: decreased access to high tech? higher taxes? underserved populations? Abandonment of the sick or poor? Which "techniques" are acceptable, and which are not?: risk-sharing with providers? financial incentives for decision makers? rationing access? imposing behavioral parameters? The issues posed by market-based managed care cannot be adequately addressed merely in terms of social resources, nor will answers be found in subordinating human rights to practical materialism. Negotiating ethical guidelines for the "safe" handling of such problems to the good of individuals and of society requires a revitalization of the "old" values: the old commitment to master craftsmanship and altruism, the old emphasis on patient advocacy and human rights. However, these old values must be applied with the "new" knowledge of lifestyle choices (and thus personal responsibility), likely outcomes (and thus reasonable options), and the limits of success (and thus fair redeployment of health resources).     

The impact of rationing of health resources on capacity of Australian public sector nurses to deliver nursing care after‐hours: a qualitative study

Australia, along with other countries, has introduced New Public Management (NPM) into public sector hospitals in an effort to contain healthcare costs. NPM is associated with outsourcing of service provision, the meeting of government performance indicators, workforce flexibility and rationing of resources. This study explores the impact of rationing of staffing and other resources upon delivery of care outside of business hours. Data was collected through semistructured interviews conducted with 21 nurses working in 2 large Australian metropolitan hospitals. Participants identified four strategies associated with NPM which add to workload after‐hours and impacted on the capacity to deliver nursing care. These were functional flexibility, vertical substitution of staff, meeting externally established performance indicators and outsourcing. We conclude that c ost containment alongside of the meeting of performance indicators has extended work traditionally performed during business hours beyond those hours when less staffing and material resources are available. This adds to nursing workload and potentially contributes to incomplete nursing care.     

Comparing traditional Medicare and managed care Medicare.

The current healthcare environment presents multiple challenges and opportunities. Patients need in-home health services and managed care companies require prior approvals for these services. There are many demands on the time of home healthcare nurses and supervisors. The following suggestions are offered with the goal of saving time and energy while getting the task accomplished so that patients receive the care they need: Cultivate an ideal relationship with your insurers' case managers. Be flexible. Communicate pertinent information to whomever is responsible for seeking approvals. Provide high-quality patient care that is reflected in the documentation. Inform patients of the prior authorization process as it relates to their home healthcare services (Harris, Lynch, 1996). Fischer and Hurst (1997, p. 16) state that home care providers should adopt a managed care mentality. Linda Pulliam (1989) shared a list of survival skills during a presentation. One of these is "make friends with this changing world" (p. 1). This is excellent advice for all healthcare nurses as we meet the current challenges and anticipate the new ones in the 21st century.     

Integrated patient data for optimal patient management: the value of laboratory data in quality improvement

Managed care organizations are shifting from traditional utilization management programs to focus on initiatives that improve the health of an insured population. This strategy requires sophisticated data integration to identify at-risk individuals and track outcomes. Laboratory data are becoming increasingly valuable tools for managed care organizations and healthcare providers. The HEDIS Effectiveness of Care measures have incorporated laboratory data into several key performance indicators. By building a comprehensive repository of laboratory data that includes both procedure codes and laboratory values, managed care organizations can realize substantial savings by avoiding the costly medical record reviews required when administrative data are incomplete. In addition to tracking clinical outcomes, laboratory data provide the ability to risk-stratify a population to target high-risk individuals for case management and disease management interventions. Healthcare organizations face several challenges in the integration of laboratory data into medical databases and practice management software. Confidentiality is a key consideration in view of recent healthcare regulations. Providers of laboratory services should work collaboratively with organizations setting standards for healthcare informatics to facilitate the pooling of data for quality improvement and outcomes research. Health Level Seven, Inc. (HL7), Logical Observation Identifier Names and Codes (LOINC), and Systematized Nomenclature of Medicine (SNOMED) will likely play a key role in this process.     

Use of more than one electronic medical record system within a single health care organization

Healthcare organizations vary in the number of electronic medical record (EMR) systems they use. Some use a single EMR for nearly all care they provide, while others use EMRs from more than one vendor. These strategies create a mixture of advantages, risks and costs. Based on our experience in two organizations over a decade, we analyzed use of more than one EMR within our two health care organizations to identify advantages, risks and costs that use of more than one EMR presents. We identified the data and functionality types that pose the greatest challenge to patient safety and efficiency. We present a model to classify patterns of use of more than one EMR within a single healthcare organization, and identified the most important 28 data types and 4 areas of functionality that in our experience present special challenges and safety risks with use of more than one EMR within a single healthcare organization. The use of more than one EMR in a single organization may be the chosen approach for many reasons, but in our organizations the limitations of this approach have also become clear. Those who use and support EMRs realize that to safely and efficiently use more than one EMR, a considerable amount of IT work is necessary. Thorough understanding of the challenges in using more than one EMR is an important prerequisite to minimizing the risks of using more than one EMR to care for patients in a single healthcare organization.     

Ethics of case management: implications for advanced practice nursing

The healthcare system is under pressure to provide quality care with less money for a growing and aging populace, and the resulting changes in the system could pose ethical problems for advanced practice nurses. Expanding healthcare needs, the increased use of technology, and dwindling resources all place burdens on advanced practice nurses, who have taken on the role of case manager in an attempt to reduce costs, meet patient outcomes, and provide improved, personalized, high-quality care. This paper explores the ethical concerns that can arise from managed care delivery systems and discusses the role of advanced practice nurses as case managers and the possible implications for nursing practice and research.     

From past paradigms to future frontiers: unique care delivery models to facilitate nursing work and quality outcomes

As healthcare processes were reengineered in response to managed care, traditional care delivery models were abandoned, resulting in nursing staff dissatisfaction, increased healthcare error, and eroding clinical outcomes. An aging patient population, chronicity of illness, the proliferation of new medical information and technology, severity of illness, and the focus of acute care to "stabilization and transition" necessitate the creation of systems that address changes in nursing work expectations while maximizing available resources. By evaluating unit-specific structure and process criteria and allocation of provider roles, unique, setting-specific care delivery models can be created to facilitate direct and nondirect patient care functions, resulting in improved financial and clinical outcomes.     

Impact of formulary restrictions on the cost-effectiveness of antidepressant treatment

Newer antidepressants are associated with higher costs of treatment of anxiety and depression. Managed care organizations are challenged to control treatment costs by implementing restricted formularies based on price and perceived medical value. Despite unfavorable side effects of efficacious tricyclic antidepressants, the low acquisition cost rationalizes the inclusion of this older class of agents on a formulary. On the other hand, cost-containment approaches have been taken toward more expensive drug classes (e.g., selective serotonin reuptake inhibitors) despite a superior safety profile of these drug classes over tricyclics. There is compelling evidence that dual reuptake inhibitors (e.g., venlafaxine extended-release), which have acquisition costs similar to serotonin reuptake inhibitors, have a broad spectrum of efficacy and thus added value, contributing to the cost-effectiveness of including this agent in the managed care formulary. Assessment of overall cost-effectiveness should not be limited by acquisition costs but should take total healthcare costs into consideration.     

Current status of integrating information technologies into the clinical research enterprise within US academic health centers: strategic value and opportunities for investment.

Little information exists about the incorporation of information technologies (ITs) into clinical research processes within US academic health centers (AHCs). Therefore, we queried a group of 37 leading AHCs regarding their current status and future plans in clinical research IT. The survey specifically inquired about the presence or absence of basic infrastructure and IT support requirements; individual applications needed to support study preparation, study conduct, and its administrative support; and integration of data from basic research, clinical trials, and the clinical information systems increasingly used in health care delivery. Of the 37 AHCs, 78% responded. All strongly agreed that a "state-of-the-art" clinical research IT program would be ideal today and will be essential tomorrow. Nonetheless, no AHC currently has an IT solution that even approached this ideal. No AHC reported having all of the essential management foundations (ie, a coherent vision, an overall strategy, a governance structure, and a dedicated budget) necessary to launch and sustain a truly successful implementation of a cohesive clinical research IT platform. Many had achieved breakthroughs in individual aspects of clinical research IT, for example, adverse event reporting systems or consent form templates. However, overall implementation of IT to support clinical research is uneven and insufficient. These data document a substantial gap in clinical research IT investments in leading US AHCs. Linking the clinical research IT enterprise with its clinical operations in a meaningful fashion remains a crucial strategic goal of AHCs. If they are to continue to serve as the "translational research engines" that our society expects, AHCs must recognize this gap and allocate substantial resource deployment to remedying this situation.     

Towers Perrin's outlook: what employers (and providers) need to know about defined contribution health plans

In the face of spiraling healthcare costs, administrative burdens and pent-up demand by employees for more control over their healthcare, a growing number of employers are taking a fresh look at defined contribution health plans with consumer-driven components. In fact, the use of defined contribution health plans and other techniques to shift responsibility and cost to employees is the number one cost-control technique employers are currently considering, according to "Navigating the Healthcare System," a Towers Perrin survey of health benefit managers that was completed in early 2002.