To investigate the effects of payor–provider integration on the operational performance of health service provision. The research explores whether integration governs…
To investigate the effects of payor–provider integration on the operational performance of health service provision. The research explores whether integration governs agency problems and tilts the incentives of diverse actors toward more systematic outcomes.
A two stage multimethod case study of occupational health services. A qualitative stage aimed to understand the reasons, mechanisms, and outcomes of payor–provider integration. A quantitative stage evaluated the performance of the integrated hospital against fee-for-service partner hospitals with a sample of 2,726 patients.
Payor–provider integration mitigates agency problems on multiple levels of the service system by complementing formal governance mechanisms with informal mechanisms. Compared to partner hospitals, the integrated hospital yielded 9% lower the total costs of occupational injuries achieved primarily by emphasizing conservative care and faster recovery.
Focuses on occupational health services in Finland. Provides initial evidence of the effects of payor–provider integration on the operational performance.
Vertical integration may provide systematic outcomes but requires mindful implementation of multiple mechanisms. Rigorous change management initiative is advised.
For patients, the research shows payor–provider integration of health services can be implemented in a manner that it reduces care costs while not compromising care quality and customer satisfaction.
This study provides a rare longitudinal analysis of payor–provider integration in health-care operations management. The study adds to the knowledge of operational performance improvement of health services.
Federal and state governments collaborate on state Medicaid nursing facility long-term care (SMNF-LTC) programs. These programs are increasingly expensive as the…
Federal and state governments collaborate on state Medicaid nursing facility long-term care (SMNF-LTC) programs. These programs are increasingly expensive as the baby-boomers retire. Yet serious resident outcome problems continue in spite of the Centers for Medicare and Medicaid Services’ (CMS) extensive process-focused regulatory efforts. This study identifies a promising and simpler auxiliary path for improving resident outcomes.
Drawing on a longitudinal (1997–2005), 48-state data set and panel-corrected, time-series regression, we compare the effects on resident outcomes of CMS process-focused surveys and four minimally regulated program structural features on which the states vary considerably.
We find that each of these four structural features exerts a greater effect on resident outcomes than process quality.
We suggest augmenting current process-focused regulation with a less arduous approach of more extensive regulation of these program features.
Originality/values of chapter
To date SMNF-LTC program regulation has focused largely on member facility processes. While regulating processes is appropriate, we show that regulating program structural features directly, an arguably easier task, might well produce considerable improvement in the quality of resident outcomes.
This investigation focuses on patients hospitalized with congestive heart failure (CHF) to evaluate the effects of insurance status on resource utilization (costs and…
This investigation focuses on patients hospitalized with congestive heart failure (CHF) to evaluate the effects of insurance status on resource utilization (costs and procedure intensity), and the process of inpatient care (length of stay). Data include hospital discharge claims from fourteen states across the U.S. for 88,000 primary and another 135,000 secondary CHF patients under age 65. Risk adjustment methods control for clinical, demographic, and risk selection factors in order to isolate the effects of insurance status on the variables of interest.Results indicate that insurance status significantly affects the type and intensity of care. Lengths of stay are shortest for privately managed patients and longest for patient in public programs. Nonetheless access to high intensity treatment procedures favors private payors, especially those covered by indemnity plans. Overall hospitalization and treatment costs are less sensitive to payor status than length of stay and appear to be driven by high intensity procedure utilization. The marginal effects of CHF are substantial, raising length of stay and treatment cost by up to 40% and reinforcing the insurance status effect on length of stay and utilization found in patients hospitalized with CHF as a primary diagnosis. Despite these process-of-care differences, no significant inpatient mortality/morbidity differences were ascertained in either the primary or secondary analyses.
Adults with autism spectrum disorder (ASD) experience significant health-care disparities across physical and mental health domains resulting in poorer health and quality…
Adults with autism spectrum disorder (ASD) experience significant health-care disparities across physical and mental health domains resulting in poorer health and quality of life. Poor transitions to adult care negatively impact the health of adults with ASD. Current research focuses on personal factors in research samples that lack diversity. The purpose of this study is to examine the lived health-care experiences of geographically and ethnically diverse young adults with ASD in adult care settings in the USA to understand provider and system-level factors affecting their health.
Nine caregivers of young adults with ASD participated in key informant interviews describing their experiences in navigating the health-care system. Data were analyzed using a grounded theory approach.
The data indicated that limited quantity of services, poor quality of services, and high cost of services had a negative effect on the health of adults with ASD. Issues cascaded to become more complex.
Practical implications for payors, providers, persons with ASD and their families are discussed in this paper.
To the best of the authors’ knowledge, this study answers the call to better understand system-level factors affecting the health of geographically and ethnically diverse people with ASD.
The assignment is to design a plan that aligns patient satisfaction scores with quality care metrics. The instructor’s manual (IM) introduces models for designing and…
The assignment is to design a plan that aligns patient satisfaction scores with quality care metrics. The instructor’s manual (IM) introduces models for designing and implementing a strategic plan to approach the quality improvement process.
This is a field research case. The author(s) had access to the Chief Operating Officer (COO) and other members of the management team, meeting with them on numerous occasions. Cleveland Clinic Florida (CCF) provided the data included in the appendices. Additionally, relevant hospital data, also included in the appendices, is required to be made public on Centers for Medicare and Medicaid Services (CMS) databases. Accordingly, all data and information are provided by original sources.
Osmel “Ozzie” Delgado, MBA and COO of CCF was faced with a dilemma. Under the new CMS reimbursement formula, patient satisfaction survey scores directly impacted hospital reimbursement. However, the CCF patient satisfaction surveys revealed some very unhappy patients. Delgado pondered these results that really made no sense to him because CCF received the highest national and state rankings for its clinical quality at the same time. Clearly, patients were receiving the best medical care, but they were still unhappy. Leaning back in his chair, Delgado shook his head and wondered incredulously how one of the most famous hospitals in the world could deliver such great care but receive negative patient feedback on CMS surveys. What was going wrong and how was the hospital going to fix it?
Complexity academic level
This case is designed for graduate Master’s in Business Administration (MBA), Master’s in Health Sciences Administration (MHSA) and/or Public Health (PA) audiences. While a healthcare concentration is useful, the case raises the generic business problems of satisfying the customer to increase brand recognition in the marketplace and displacing competition to increase annual revenues. Indeed, the same analysis can be applied in other heavily regulated industries also suffering from a change in liquidity and growth occasioned by regulatory change.
This paper aims to investigate organizational factors to explain why a corporate data warehouse (CDW) was not used by marketing to the extent that it was expected to be…
This paper aims to investigate organizational factors to explain why a corporate data warehouse (CDW) was not used by marketing to the extent that it was expected to be used for CRM and other marketing purposes.
A case study of a single health‐care payor organization is used in this study.
Reveals the three primary implementation factors related to marketing's lack of trust in the data, low perceived data quality and perception of marketing needs not being met. Practically, the unique data needs of marketing should be considered in the implementation of a CDW and its interface.
This is the first study of its kind to take the needs of marketing users into consideration.
The Commission on Accreditation of Rehabilitation Facilities (CARF) has experienced considerable market growth in recent years. Growth has occurred in the health care industry with exceptional growth occurring in the fields of persons with disabilities and children’s services. Expansion of their services beyond the American boarders has resulted in CARF accrediting organizations in Canada, Ireland and Sweden with active work occurring in Denmark, Finland, France, Scotland, Italy, England and Australia. In Canada, policy makers at all levels of government began demanding greater community involvement in consumer service delivery. Policy makers and consumers made it clear that a system of accountability needed to be incorporated to ensure quality of service. In order to address the resulting growth in Canada and listen to the needs of consumers it became apparent that a separate office was required to meet the unique needs of Canadians. CARF Canada was established to meet the needs.
This chapter describes the results of an exploratory study that examined parents’ experiences with the law as they obtained funding for speech generating devices for their…
This chapter describes the results of an exploratory study that examined parents’ experiences with the law as they obtained funding for speech generating devices for their children with communication disabilities, either through public health insurance, private health insurance, or a public school. Exploring legal consciousness: Experiences of families seeking funding for assistive technologies for children with disabilities. Law, Policy, and Society Dissertations. Paper 17. Retrieved from http://hdl.handle.net/2047/d20000265). The study explored how parents engaged with the law and how their experiences and perceptions about the law compared to the formal law. This research was based on sociolegal theory, particularly the concept of legal consciousness, which examines how people think and act in relation to the law as a consequence of social interactions, and analyzes how law in action compares with the formal law. Sociolegal theory broadens the definition of law to include “the meanings, sources of authority, and cultural practices” (Ewick & Silbey, 1998, p. 22) as well as the formal law.
Similar to other sociolegal research, this study collected personal narratives of law using grounded theory methods to identify themes within those narratives. The narratives revealed that while parents expressed varieties of legal consciousness, there was one overarching theme: the law provided a framework for parents to envision rights, discuss rights, and claim rights. While few parents invoked formal legal mechanisms to solve grievances, the law created a rights consciousness among parents which empowered them to acknowledge and validate the notion of rights and entitlements.
Pharmaceuticals are essential for the management of many chronic conditions. As a result, it is important to examine how the administration of pharmaceutical benefits…
Pharmaceuticals are essential for the management of many chronic conditions. As a result, it is important to examine how the administration of pharmaceutical benefits affects physicians and pharmacists providing chronic care services. In the 1990s, HMOs and PPOs began to more aggressively manage outpatient pharmaceutical benefits, leading to the growth of pharmaceutical benefit management companies (PBMs).
In this exploratory study, 10 primary care physicians and 12 pharmacists in the San Francisco area were interviewed in 1999, and 11 more pharmacists in 2004, on how they worked with PBMs and their controls on prescribing and dispensing. Responses indicated major problems for both health professionals in negotiating with the PBM as a third party payor, in coping with switches and multiple formularies, and in added work for the health care professional. Increased risk to chronically ill patients for poorer outcomes is an important related problem with PBMs.
The Medicare drug benefit law passed in 2003 will likely result in similar problems for many beneficiaries, including those with chronic care needs. The paper proposes some policy solutions to reduce PBM problems for physicians, pharmacists and the Medicare population.
Brand-name pharmaceutical companies have engaged in a variety of business conduct that has increased price. One of these activities involves “product hopping,” or brand…
Brand-name pharmaceutical companies have engaged in a variety of business conduct that has increased price. One of these activities involves “product hopping,” or brand switches from one version of a drug to another. The antitrust analysis of product hopping implicates antitrust law, patent law, the Hatch–Waxman Act, and state drug product selection laws, as well as uniquely complicated markets characterized by buyers different from decision makers. As a result, courts have offered inconsistent approaches to product hopping.
In this chapter, we offer a framework that courts and government enforcers can employ to analyze product hopping. The framework is the first to incorporate the characteristics of the pharmaceutical industry. It defines a “product hop” to include instances in which the manufacturer (1) reformulates the product to make the generic nonsubstitutable and (2) encourages doctors to write prescriptions for the reformulated rather than the original product.
When the conduct meets both requirements, our framework offers two stages of analysis. First, we propose two safe harbors to ensure that the vast majority of reformulations will not face antitrust review. Second, the framework examines whether the hop passes the “no-economic-sense” test, determining if the behavior would make economic sense if the hop did not have the effect of impairing generic competition. Showing just how far the courts have veered from justified economic analysis, the test would recommend a different analysis than that used in each of the five product-hopping cases that have been litigated to date, and a different outcome in two of them.