The insufficiency of evidence to establish the business case for quality.

PURPOSE: To determine whether a positive financial return on investment for quality-enhancing interventions is more likely for particular health conditions, in specific organizational settings, or with the use of particular interventions. DATA SOURCES: Electronic search of MEDLINE. DATA EXTRACTION: Search keywords included: business case, cost-effectiveness, cost-benefit, return on investment, costs, cost savings, quality, quality improvement, and program evaluation. RESULTS: Only 15 of 1968 articles identified contained sufficient information on both the costs of implementing quality-enhancing interventions and the resultant changes in costs of care or revenues to permit the calculation of a return on investment. CONCLUSIONS: Scant attention is currently paid in the quality-of-care literature to the cost of implementing quality-enhancing interventions. To understand which quality-enhancing interventions are likely to produce positive returns on investments, data collection and analysis must include tracking the investment and operating costs of implementing the intervention as well as the changes in revenues and costs that result from the intervention.     

Beyond principles: virtue ethics in hospice and palliative care

Living ethically in the face of death is a major challenge for the ill person, the family, and the hospice staff. Beyond the recognized need for ethical decision-making regarding medical principles, there are decisions about character for all involved: "What kind of person will I be?" "What kind of family will we be?" What kind of caregiver will I be?" "What kind of community will we be? This article is a discussion of virtues that are appropriate in hospice staff and volunteers: compassion/empathy, faithfulness, justice/advocacy and practical wisdom. The author calls for a wider sharing of their knowledge and experience.     

In the world but not of the world: going beyond a dilemma

Is the issue addressed in this volume a question like "What time is it?" or a quest-ion like "What is time?" I argue that it is a quest-ion that requires professional chaplaincy to quest for an answer although it will always have blurred edges that lack succinctness, clarity, and certainty. The challenge posed by the quest-ion means that we must transform the dilemma into a higher synthesis that respects the qualitative aspects inherent in the profession.     

Cancer program development: is your hospital ready?

According to a recent survey of 1,779 U.S. hospitals, nearly 50 percent intend to expand their oncology programs in the next two years (Sandrik 1990). Also, the membership of the Association of Community Cancer Centers (ACCC), an organization of community-based oncology programs, has quadrupled in the last decade (ACCC 1991). These facts indicate that a growing number of community hospitals are continuing to develop organized cancer programs. This two-part article answers the questions, "Why should a hospital consider expansion of oncology programs?" "When is a hospital ready for a major commitment to oncology?" "How does a hospital go about such a development?" "What components should be considered in the development process?" Part I will address the first three questions and part II will address the final one.     

Managing people: the breakfast menu

Discusses an exploratory study of the impact of NHS reforms on the management of staff. Argues that "management" has moved from a view that staff should be provided with a secure and comfortable working environment to "labour" being viewed simply as a factor of production. The result seems to be an unprecedented sense of alienation among significant numbers of NHS staff. Proposes possible ways forward. The first focuses on the "means", accepting that the "ends" of the NHS will, for the foreseeable future, be dominated by the market. The second examines more closely the market-driven, business "end" or purpose and challenges the unitary view of the NHS Trust as a coherent business entity. Beyond these short- to medium-term responses, concludes that a return to a somewhat more flexible and less hard-edged human resources philosophy is a longer-term investment as the labour market tightens and skilled staff become scarcer in the later 1990s.     

A practical reporting and evaluation system for intervention programs: guiding principles and potential uses.

The continued existence of intervention programs is contingent on the ability to answer basic questions such as "What is your program doing?" and "Why should we fund your program?" This paper outlines basic principles and describes a practical reporting and supplemental evaluation system that can be used by administrators of even the smallest intervention program.     

Value-chain analysis of a rural health program: toward understanding the cost benefit of telemedicine applications

While telemedicine's clinical effectiveness and educational benefits are accepted, its cost-effectiveness is controversial. This study focuses on telemedicine's cost-effectiveness from a provider's perspective. Reviews of the cost-effectiveness literature in telemedicine are critical of past studies' (a) methodological and analytical weaknesses; (b) focus on answering "Can we do this?" rather than "Should we do this?"; and (c) emphasis on patient benefits. Value chain analysis examines structural and executional cost drivers; a self-sustaining business model balances the cost and value associated with each telemedicine activity. We illustrate this analysis in a rural health program, examining teleradiography and telerehabilitation.     

Strategic resource management

No one in healthcare can challenge the fact that expense reduction is and will continue to be one of the primary concerns of the industry. Everyone also knows that these cost pressures are merely beginning. All indications point to a future environment of intense competition, managed care based on cost-per-covered-life reimbursement, reduced reimbursement from Medicare and Medicaid, and further reconfiguration of the industry to shift patients from in- to out-patient settings. When we focus on the future, the $64,000 question is: "What is the healthcare industry doing to control non-labor expenses, and who is responsible for this ambitious undertaking within each hospital or network?" With nearly 30% of every hospital dollar consumed by non-labor expenses, are current efforts adequate to meet future demands? This article focuses on a strategic plan for reducing non-labor expenses.     

Recruiting physicians for established clinics

A member physician, for whatever reason, decides to leave the group. The clinic which has long-range recruitment goals and plans for implementing them will be ahead of one which must hastily convene its governing body, asking, "What do we do now?"     

Group/hospital affiliation: possible barriers to medical staff integration

Group practice administrators are understandably concerned about the drawbacks and the benefits of formal affiliation of their groups with hospitals or other healthcare institutions. An administrator may wonder: "Should we align ourselves with this particular institution at this time?" or "What kinds of formal arrangements should we enter into?" A good administrator is also a good negotiator, and as such, will try to consider and include the opinions of the other participants in actions involving his group. When considering affiliation with an organization, the administrator will try to understand the drawbacks and the benefits as seen from the other side of the fence.     

Financial impact of population health management programs: reevaluating the literature

Although many employers offer some components of worksite-based population health management (PHM), most do not yet invest in comprehensive programs. This hesitation to invest in comprehensive programs may be attributed to numerous factors, such as other more pressing business priorities, reluctance to intervene in the personal health choices of employees, or insufficient funds for employee health. Many decision makers also remain skeptical about whether investment in comprehensive programs will produce a financial return on investment (ROI). Most peer-reviewed studies assessing the financial impact of PHM were published before 2000 and include a broad array of program and study designs. Many of these studies have also included indirect productivity savings in their assessment of financial outcomes. In contrast, this review includes only peer-reviewed studies of the direct health care cost impact of comprehensive PHM programs that meet rigorous methodological criteria. A systematic search of health sciences databases identified only 5 studies with program designs and study methods meeting these selection criteria published after 2007. This focused review found that comprehensive PHM programs can yield a positive ROI based on their impact on direct health care costs, but the level of ROI achieved was lower than that reported by literature reviews with less focused and restrictive qualifying criteria. To yield substantial short-term health care cost savings, the longer term financial return that can credibly be associated with a comprehensive, prevention-oriented population health program must be augmented by other financial impact strategies.     

Marketing Medicaid drugs: an analysis of cost factors.

The cost of drugs dispensed through the Medicaid program is the focus of this article. The research question addressed is, "What variables raise or lower the expense of marketing drugs to Medicaid recipients?" Medicaid drug programs are dichotomized into high- and low-cost groups and variables are identified that are linked with either the more or less expensive programs. Three groups should be interested in identifying factors that increase or decrease the cost of marketing drugs to Medicaid patients--pharmacy managers, Medicaid administrators at the state and federal levels, and public aid recipients.     

Why do professionals disagree? The case of hormone replacement therapy and coronary heart disease prevention

Why have professionals disagreed about whether midlife women should be advised to use hormone replacement therapy (HRT) for prevention of coronary heart disease (CHD)? Because the evidence has been incomplete and could be interpreted differently by different professionals, the question with regard to HRT and CHD prevention thus is not "What does the evidence prove?" but rather is "What are the decision rules by which research can be evaluated and made sense of?" The present article attempts to clarify the problem by cataloging dimensions along which professionals differ. These dimensions include the weight to be given to epidemiological vs. clinical trial data; whether a conclusion has already been drawn based on available evidence; whether a theoretical rationale exists; whether a professional is oriented to clinical work or research; and whether data is distorted.     

Pharmaceutical Portfolio Management: Global Disease Burden and Corporate Performance Metrics

BackgroundBiopharmaceutical companies face multiple external pressures. Shareholders demand a profitable company while governments, nongovernmental third parties, and the public at large expect a commitment to improving health in developed and, in particular, emerging economies. Current industry commercial models are inadequate for assessing opportunities in emerging economies where disease and market data are highly limited.ObjectiveThe purpose of this article was to define a conceptual framework and build an analytic decision-making tool to assess and enhance a company’s global portfolio while balancing its business needs with broader social expectations.MethodsThrough a case-study methodology, we explore the relationship between business and social parameters associated with pharmaceutical innovation in three distinct disease areas. The global burden of disease–based theoretical framework using disability-adjusted life-years provides an overview of the burden associated with particular diseases. The social return on investment is expressed as disability-adjusted life-years averted as a result of the particular pharmaceutical innovation. Simultaneously, the business return on investment captures the research and development costs and projects revenues in terms of a profitability index.ConclusionsThe proposed framework can assist companies as they strive to meet the medical needs of populations around the world for decades to come.     

Mirtazepine: heir apparent to amitriptyline?

"What's new in therapeutics?" will examine and evaluate drugs that may have a place in hospice, palliative, and long-term care. Mirtazepine will be examined and evaluated. Mirtazepine is a potential alternative anti-depressant with multiple additional benefits. It is an atypical anti-depressant, which has both noradrenergic and specific serotonergic receptor antagonism (NaSSa), and a unique pharmacological profile. Mirtazepine appears to be a "designer drug" for palliative medicine with a number of benefits, but cost may be a drawback.     

Achieving breakthrough outcomes: measurable ROI

You're a case manager. Your boss is talking return on investment (ROI). Your patients don't want to be numbers on a spreadsheet. What does it take to be a hero to both the boss and the patient? Case managers frequently try to argue that great gains in quality of life for the patient are so valuable that management ought to ease up on case managers when talking about budget and returns. An experienced quality professional might respond, "Good luck."     

Performing Well on Nursing Home Report Cards: Does It Pay Off?

Objective. To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting. Data Sources. Data from 6,286 freestanding Medicare‐certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System. Study Design. Using a facility‐level fixed‐effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999–2002) to after (2003–2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time. Principal Findings. Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High‐scoring facilities showed similar patterns, though differences were not statistically significant. Conclusions. Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting.     

Time for a change in how new antibiotics are reimbursed: Development of an insurance framework for funding new antibiotics based on a policy of risk mitigation

Healthcare systems depend on the availability of new antibiotics. However, there is a lack of treatments for infections caused by multidrug resistant (MDR) pathogens and a weak development pipeline of new therapies. One core challenge to the development of new antibiotics targeting MDR pathogens is that expected revenues are insufficient to drive long-term investment. In the USA and Europe, financial incentives have focussed on supporting R&D, reducing regulatory burden, and extending market exclusivity. Using resistance data to estimate global revenues, we demonstrate that the combined effects of these incentives are unlikely to rekindle investment in antibiotics. We analyse two supplemental approaches: a commercial incentive (a premium price model) and a new business model (an insurance model). A premium price model is familiar and readily implemented but the required price and local budget impact is highly uncertain and sensitive to cross-sectional and longitudinal variation in prevalence of antibiotic resistance. An insurance model delivering risk mitigation for payers, providers and manufacturers would provide an incentive to drive investment in the development of new antibiotics while also facilitating antibiotic conservation. We suggest significant efforts should be made to test the insurance model as one route to stimulate investment in novel antibiotics.     

Managed care: quality management differentiates the product

Comprehensive quality management is a goal that requires major corporate commitment to implement and maintain. The best results in a quality management program will be achieved when all components are tied together in a comprehensive program. To do that, a significant investment in personnel and equipment is required. As the benefits of having a program such as the one as described above become more widely known and accepted, more and more managed care insurers and providers will adopt these or similar standards. The question, "How do you know that patients are getting high-quality and sufficient care?" cannot be answered today by insurers who do not have such a program.