Health plans target advanced imaging services: cost, quality and safety concerns prompt renewed oversight.
Issue brief (Center for Studying Health System Change)
Faced with double-digit annual increases in the use of advanced imaging services, health plans are stepping up efforts to manage imaging utilization, maintain imaging quality and ensure patient safety, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Plan strategies range from informing physicians about evidence-based imaging guidelines to requiring prior authorization of services to credentialing physicians and imaging equipment. Mindful of the physician backlash against managed care in the 1990s, plans are instituting requirements they perceive to be less intrusive and burdensome for physicians. Some physicians, however, view the requirements as administratively onerous and obstacles to patient care. Depending on the experience with imaging, plans may expand utilization management to other services with rapid volume increases.
Available from: rwjf.org
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ABSTRACT: Physician self-referral ranges from suggesting a follow-up appointment, to sending a patient to a facility in which the doctor has an ownership interest or financial relationship. Physician referral to facilities in which the physicians have an ownership interest is becoming increasingly common and not always medically appropriate. This Synthesis reviews the evidence on physician self-referral arrangements, their effect on costs and utilization, and their effect on general hospitals. Key findings include: the rise in self-referral is sparked by financial, regulatory and clinical incentives, including patient convenience and doctors trying to preserve their income in the changing health care landscape. Strong evidence suggests self-referral leads to increased usage of health care services; but there is insufficient evidence to determine whether this increased usage reflects doctors meeting an unmet need or ordering clinically inappropriate care. The more significant a physician's financial interest in a facility, the more likely the doctor is to refer patients there. Arrangements through which doctors receive fees for patient referrals to third-party centers, such as "pay-per-click," time-share, and leasing arrangements, do not seem to offer benefits beyond increasing physician income. So far, the profit margins of general hospitals have not been harmed by the rise in doctor-owned facilities.
The Synthesis project. Research synthesis report 06/2008;
Available from: amcp.org
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ABSTRACT: This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism.
Health Affairs 09/2008; 27(5):1362-70. DOI:10.1377/hlthaff.27.5.1362 · 4.97 Impact Factor
Available from: Kenneth R Kaufman
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ABSTRACT: Cultural competence advances global healthcare by promoting greater understanding of individual patients, combined interventions, and maximum adherence. However, the healthcare professional's culture and the culture of medicine itself must also be considered. In westernized medicine, especially America, improved technology and therapeutics profoundly impact medical culture; but medical economics is as significant. Managed care and Medicare Diagnosis-Related Groups (DRGs) strongly affect American medical economics with resultant decreased physicians' incomes, increased patient volumes, decreased time spent with each patient, and decreased subjective/objective quality of care. Physicians' roles blur with duties delegated to lesser qualified healthcare professionals to maximize patients seen and generated incomes. In psychiatry, performing multiple psychopharmacology visits hourly is economically more productive than an hour therapy session. Doctors need to understand that in entering medicine they enter a life's career of nobility in which they serve others, do not expect to become wealthy, but at life's end are able to state "a job well done with caring for all." Perhaps then, less harm will be done to patients in doctors' haste to earn more money by seeing too many patients too briefly. Groups of doctors jammed into elevators maddeningly looking at their lists, checking off those seen and yet to be seen and occasionally looking up toward a colleague and bemoaning how many more consults to be done before the end of the day. When did doctoring stop being a noble profession of caring for others, of having time to care for others, and change so dramatically into making sure that all those who could be billed in a given day were seen and then billed for maximum charges? In retrospect, one could argue that we as physicians sold our souls to the insurance companies and that over the years the insurance companies realized their power, and having done such also realized that they controlled how much doctors were paid and even if services should be authorized . Managed care companies now manage not only the health of patients but also physicians' lives. With decreased professional autonomy, managed care is associa-ted with decreased physician career satisfaction . Authorization must be obtained not simply for admission to a hospital, but for outpatient procedures, for specific medications, and even for dosage of medications [1, 3-5]. Often these authorizations are obtained from individuals with no knowledge of the procedure or medication but reading from a handbook stating what should or should not be approved and taking valuable time from patient care for administrative tasks.
The Open Social Science Journal 10/2008; 1(1). DOI:10.2174/1874945300801010001
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