Hospital-based versus free-standing primary care costs

A survey of the literature supports the broad generalization that primary care delivered in this hospital outpatient department will be more expensive than care provided in a free-standing setting. Among the reasons discussed by the author are: (1) reimbursement policies of third party insurors which mask and inflate the distribution of the true costs of care within the hospital; (2) lack of control by outpatient department directors over their own costs; (3) the degree to which the availability of sophisticated and expensive technology within the hospital setting encourages its utilization; and (4) the differences in case mix: "sicker" patients are seen in outpatient departments. Gold recognizes that most studies to date contain serious limitations in their generalizability; she concludes that additional studies are necessary to explain why the costs vary to the extent they do. She also suggests studying other issues such as access, consumer preferences, provider preferences and training requirements, and quality of care before reaching any decisions about the future of hospital-based primary care.     

Marketing retail health clinics: challenges and controversies arising from a health care innovation

Since their founding in 2000, retail-based health care clinics, also called convenient care clinics, have flourished but continue to generate controversy. This article examines the literature with respect to the industry's background, establishment of industry standards, types of services offered, marketing of retail health clinics, industry growth with new target markets, and patient demographics. It also examines the growing relationship with insurers and third-party payers, quality-of-care concerns by medical associations, and legal regulations and their potential impact on industry growth nationwide.     

Relating personnel costs in special care units and in traditional care units to resident characteristics

BACKGROUND: There are over 16 000 nursing homes in the United States (US), among which approximately 70% of residents are cognitively impaired. Reflecting this, approximately 20% of US nursing homes maintain Special Dementia Care Units (SCUs). SCUs supposedly provide more staff time and more specialized staff assignments to residents than do traditional care units. AIMS OF THE STUDY: This paper addresses the issues of staff time and assignment: do the costs of personal care inputs differ according to whether they are provided by SCUs or in traditional care settings? Related to this, are differences associated with the different settings, or are they accounted for by resident characteristics within the settings? METHODS: Given the bias generally associated with collection of staff time data, the author developed (supported by the Health Care Financing Administration and the National Institute on Aging) and used in this study a barcode-based system ('InfoAide'). Using InfoAide, each provider automatically recorded task- and resident-specific time expenditure data which were subsequently monetized, using prevailing local wage rates. Individual resident personal characteristics and status data were provided by another simultaneous study of SCU impacts among the same residents. Regression analysis (MANCOVA for significantly correlated dependent variables) was used to examine the relationships between cost and SCU/traditional status, and individual resident characteristics, separately for each category of provider. RESULTS: Controlling for resident characteristics, the cost of aide care is significantly (positively) related (p <=0.01) to SCU status. Cognitive impairment, ADL impairment and being restrained are also related to higher aide care cost (p <=0.05, p <=0.01, and p <=0.05, respectively). The same is generally true of Speech Therapy, Social Service and care by licensed practical nurses, although the differences between SCU and traditional care units are essentially trivial - and there are no SCU/traditional care differences for registered nurses. DISCUSSION: SCU/traditional unit status, even when combined with the central resident covariates, explains very little variance in service costs, other than among nursing aides; in separate MR analyses in which monetized service time was the dependent variable, the cumulative adjusted R2 among aides was 0.37; for each of the other categories of service provider, the adjusted R2 was less than 0.10. There were differences (particularly in cognitive and ADL impairment) between SCU and non-SCU residents; these differences were related to differences in basic services which were, in turn, provided primarily by aides. The increased level of care provided in SCUs is attributable primarily to nursing aides. However, there is relatively little (albeit statistically significant) variation in more 'elective'services according to individual characteristics or to SCU versus traditional unit placement. This discussion is limited by the absence of analyses of possible interactions among variables, and by the cross-sectional nature of the data presented here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This absence of a substantial relationship between SCU/traditional status suggests that dichotomization between SCU and traditional care is misplaced, and that more attention should perhaps be given to the targeting and tailoring of services related to individual gradations of impairment and need. IMPLICATIONS FOR HEALTH POLICY FORMULATIONS: A very considerable literature has developed recently pertaining to Special versus Traditional care for persons with dementing illness. These data suggest that this is not a fruitful distinction, and that more effort should be devoted to defining and quantifying the elements and quality of care provided to nursing home residents. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the components of optimal quality care for demented nursing home residents, and into the interaction among these components as they relate to resident outcomes.     

Use marketing to reduce malpractice costs in health care

Marketing may have contributed to malpractice litigation by elevating public expectations. If all of the four basic functions of marketing--intelligence, strategy, operations, and communications--are applied well, then marketing may have a significant impact on malpractice risks and costs.     

The benefits divide: health care purchasing in retail versus other sectors

This paper is the first to compare health care purchasing in the retail versus other sectors of the Fortune 500. Employing millions of low-wage workers, the retail sector is the largest employer of uninsured workers in the economy. We found that retail companies are using the same competitive bidding process that other companies use to obtain a given level of coverage for the lowest possible cost. However, they are more price oriented than other Fortune 500 companies are. The most striking disparity lies in the nearly fivefold difference in offer rates for health care coverage. This shows that the economy's bifurcation in health benefits extends even to the nation's largest companies.     

Hospital-affiliated and hospital-owned retail clinics: strategic opportunities and operational challenges

Retail clinics have experienced an exponential growth in the last few years. While the majority of retail clinics are freestanding, venture-backed companies affiliated with retail hosts, an increasing number of hospital systems have decided to develop their own retail clinics or partner with existing national companies. Using a stakeholder approach, the purpose of this article is to assess the strategic considerations behind these decisions and the operational challenges associated with them and to use the results to develop a questionnaire that can be applied in future research in a national sample of healthcare executives. We conducted eight in-depth interviews with administrative and clinical leaders in seven hospital systems across the United States that have or had a relationship with retail clinics in the last three years. Our findings show that the hospital systems' association with retail clinics involves two main models: an affiliation with retail chains that operate the clinics and ownership of the clinics with an arms-length relationship with the retail chain. Hospital systems are engaging in these relationships for several strategic reasons: to increase market share through enhanced referrals to physician offices and hospitals, to become closer to consumers, and to experiment with nontraditional ways of delivering health care. Operational challenges included physician resistance and skepticism, poor financial performance, people's perception of retail clinics, staffing issues, and the newness of the business model. Six out of eight respondents thought that hospital affiliation with/ownership of retail clinics is a trend that is here to stay, although many provided caveats and stipulations. Further research is needed to provide more evidence about this emerging way of healthcare delivery.     

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics)

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change.     

Effectiveness and costs of omeprazole vs ranitidine for treatment of symptomatic gastroesophageal reflux disease in primary care clinics in West Virginia

OBJECTIVE: To compare clinical, health-related quality of life (HRQL), and medical cost outcomes in patients with symptomatic gastroesophageal reflux disease (GERD) receiving omeprazole sodium or ranitidine hydrochloride treatment. METHODS: A multicenter, randomized, open-label, medical effectiveness trial conducted in 5 university-based family medicine clinics. Two hundred sixty-eight patients with GERD were recruited and randomly assigned to omeprazole sodium, 20 mg once daily, or ranitidine hydrochloride, 150 mg twice daily, for up to 6 months. Main outcome assessments included the Gastrointestinal Symptom Rating Scale (GSRS) Reflux score, Psychological General Well-Being Index, and Short-Form-36 Health Survey administered at baseline and 2, 4, 12, and 24 weeks. Medical resource use and cost data were collected. RESULTS: More omeprazole-treated patients reported improved heartburn resolution at 2 weeks (49.0% vs 33.3%; P=.007) and 4 weeks (58.6% vs 35.0%; P<.001) compared with ranitidine-treated patients. The GSRS Reflux scores across 3 months showed overall differences between omeprazole (mean, 2.67) and ranitidine (mean, 2.95) groups (P=.04). Mean total 6-month medical costs were $915 lower ($8371 vs $9286; P=.64), and no difference in mean outpatient medical costs ($1198 vs $1158; P=.76) were observed in the omeprazole group compared with the ranitidine group. A post hoc secondary analysis showed that, at 12 and 24 weeks, patients treated with omeprazole for 8 weeks or more reported greater heartburn resolution (ie, 24 [43%] of 56 patients at both intervals) than patients treated with ranitidine for 8 weeks or more (12 [24%] and 13 [26%] of 50 patients, respectively; P=.001). CONCLUSIONS: Ranitidine and omeprazole were both effective at improving heartburn symptoms; however, omeprazole provided greater resolution of heartburn symptoms at 2 and 4 weeks. Despite omeprazole's higher acquisition cost, there were no significant differences in total or outpatient costs between groups.     

Early return visits by primary care patients: a retail nurse practitioner clinic versus standard medical office care

The purpose of this study was to compare return visits made by patients within 2 weeks after using retail nurse practitioner clinics to return visits made by similar patients after using standard medical office clinics. Retail medicine clinics have become widely available. However, their impact on return visit rates compared to standard medical office visits for similar patients has not been extensively studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2009 were analyzed for this study. Patients who were treated for sinusitis were selected. Two groups of patients were studied: those who used one of 2 retail walk-in clinics staffed by nurse practitioners and a comparison group who used one of 4 regular office clinics. The dependent variable was a return office visit to any site within 2 weeks. Multiple logistic regression analysis was used to adjust for case-mix differences between groups. Unadjusted odds of return visits were lower for retail clinic patients than for standard office care patients. After adjustment for case mix, patients with more outpatient visits in the previous 6 months had higher odds of return visits within 2 weeks (2-6 prior visits: odds ratio [OR]=1.99, P=0.00; 6 or more prior visits: OR=6.80, P=0.00). The odds of a return visit within 2 weeks were not different by clinic type after adjusting for propensity to use services (OR=1.17, P=0.28). After adjusting for case mix differences, return visit rates did not differ by clinic type.     

Prepaid versus traditional Medicaid plans: effects on preventive health care

Prepaid, case managed systems have been proposed as a method of controlling costs in Medicaid populations. We investigated the utilization of preventive services in two prepaid Medicaid Competition Demonstration programs in Santa Barbara County, Calif., and Jackson County, Mo. (containing the city of Kansas City). Care in the demonstration sites was compared with care given in similar counties functioning under a traditional fee-for-service Medicaid system--Ventura County, Calif., and St Louis, Mo. We tested the hypothesis that preventive care would be less in the capitated demonstrations. 2735 Children's and 3389 adult's charts were abstracted for care received during the calendar year 1985, after the prepaid demonstration had been in place for more than 1 year. No significant differences were found between the demonstration and comparison counties in the proportion of children with complete DPT or OPV immunizations at 1 year of age, with 56% complete in both California counties and 69 and 65% complete in Jackson County and St Louis, respectively. Regression analysis demonstrated a slight, but statistically significant trend towards more immunizations in the demonstration counties. Pap smear use in women of 15-44 years of age was little different in the California counties, but significantly greater in the Jackson County demonstration in Missouri (64 vs 45%). Physician breast examinations were somewhat more likely to occur in the prepaid, case managed demonstration counties. Capitated, case managed systems for the AFDC Medicaid population appear to result in no diminution of preventive services. Substantial problems exist in this, as in other poor populations, in childhood immunizations.     

Alcohol or traditional methods versus natural drying for newborn's cord care

This is a quasi-experimental study that aimed to compare the use of alcohol and traditional methods for newborn's cord care with a no-treatment approach, natural drying. The study also aimed to identify the factors associated with the occurrence of cord infection and time of cord separation. A convenient sample of 70 women with vaginal delivery, full-term and healthy babies was selected from postpartum departments of two university hospitals in Alexandria and Minia. A specially designed interview schedule was developed and utilized to collect data. Swabs were taken from the newborns' umbilical stumps on zero and 3rd day of birth to detect bacterial colonization. Follow-up was carried-out at home to assess methods used for cord care, babies' hygiene, cord infection and time of cord separation. The study revealed that traditional methods of cord care were used by women with higher mean age (30.8 +/- 7.8 years), from Minia (100%) or rural areas (71.4%), while alcohol and natural drying were used by women with lower mean age (27.7 +/- 4.8 and 24.8 +/- 6.5 years) respectively, from Alexandria (76% and 100%) respectively or urban areas (56% and 64.7%) respectively. Alcohol was used for male babies (76%), while traditional methods and natural drying were used for female babies (71.4% & 64.7%) respectively. Incidence of cord infection was significantly lower among natural drying group (35.3%), and no signs of systemic infection were observed among them. Rate of increase of bacterial colonization (from 0-3rd day of birth) was significantly higher in alcohol group (44%). It was relatively similar with presence or absence of cord infection (33.3 & 32.1) respectively. Mean time of cord separation was longer among alcohol group (6.4 +/- 2.4 days), as compared with natural drying group (4.7 +/- 1.9 days) and traditional methods group (3.4 +/- 0.7 days). Bathing baby while cord was attached was carried-out by all women of alcohol and natural drying groups, compared to only 28.6% of traditional methods group. Breast-feeding was significantly related to less incidence of cord infection (P= 0.008) and shorter time of cord separation (P= 0.002). Incidence of cord infection was significantly related to using cloth diaper (P= 0.015), using dry method for skin care (X(2) 2= 7.2917), giving tub bath (X(1)2 = 4.1788) and delaying the bath to the 7th day of birth (P= 0.050). Time of cord separation was significantly shorter with closed cord dressing (X(2)2= 20.4028), in Minia, during spring, among male babies (X(2)2= 15.0352), and in rural areas (X(2)2 = 9.7608). It was significantly longer with bathing the baby while cord was attached (X(2)2 = 27.9354), giving 2-3 baths/week or delaying the bath to the 7th day of birth (P= 0.049) and with using cloth diaper (P= 0.0467). So, moving from an intervention to a non- intervention, particularly in a healthy population should be applied to the healthy naturalistic approach to care advocated in nursing. Also, only through continuing efforts done to examine our assumptions about historic health care routines, will we be able to demonstrate evidence-based practice and to advance nursing care.