Standardizing medical data

Congress passed The Health Insurance Portability and Accountability Act of 1996 in the doldrums of last Summer, and promptly charged the National Committee on Vital and Health Statistics to begin working on the regulations that will help providers, payers, and all members of the public adhere to the spirit of the law. What does this legislation portend for the health care industry? Standardization of information systems will play a large role in assuring the portability of health care insurance from one employer and payer to another in this legislation. Accountability, too, will depend on those same data standards to allow comparisons of processes and outcomes of care across health plans, providers, communities, states, and regions. In fact, without standardized data describing patients and their treatments, there can be no comparisons of their outcomes of care, or the processes used to treat them.     

Health reform for small population areas

There has been criticism of the managed competition model in terms of its impact on rural areas. It is suggested that the approach simply won't work for providers in rural areas and that an adjustment will be necessary. The author, acknowledging the flaw, proposes changes that will make competition work better for all providers. This column is jointly edited by Kevin M. Fickenscher, MD, and David A. Kindig, MD, PhD, chair and member, respectively, of the College's Forum on National Health Policy. Dr. Fickenscher is participating in various advisory capacities on health care in the Clinton Administration, and Dr. Kindig is Senior Advisor to HHS Secretary Donna Shalala.     

The shift from vertical to networked integration, Part 1

Lessons, dangers, and difficulties for health care integrators from the world of mergers, acquisitions, and alliances. The authors examine why there needs to be a shift from vertical integration, with its command and control hierarchical structure, to the more fluid and flexible networked enterprise in health care. By sharing the integration experiences of other industries, the authors make a compelling case for rethinking the integrated delivery system that so many have embraced and explain why the emergence of the extended health care enterprise will be the next stage in the progression. Making the journey into networked enterprises--how to start, what to do, and case studies from St. Vincent's, Cascade Healthcare Alliance, and Mullikin Medical Centers--will be presented in the second article in the June 1996 issue of Physician Executive.     

Modern health care depends on technology, Part 2

The first article in this series presented the principles and vocabulary of technology assessment and described the process used at St. Luke's, a tertiary care hospital in Bethlehem, Pennsylvania. This second article will describe the resources needed to support a technology assessment program. Technology planning, acquisition, and management will also be discussed. Historically, the health care marketplace has welcomed new technologies. In a future in which providers will be accountable for the outcomes of the care they provide, the ability to evaluate new and existing technologies will be essential for success.     

The HIPAAcratic oath: do no harm to patient data

Physician executives need to prepare their organizations for the next great system-wide challenge--HIPAA, the Health Insurance Portability and Accountability Act of 1996. Organizations will have to plan for and execute a compliance program with the same vigor and system-wide participation as they did for Y2K. This article provides a brief overview of HIPAA, emphasizing the privacy and security components that will be the biggest challenge for physician executives. Physician leaders must become actively involved in the policymaking process to ensure a balanced approach to protecting the confidentiality of health information, while giving providers optimal access to data to make informed decisions on patient care and management. Ignoring HIPAA is simply not an option.     

Hospitals' newest challenge: designing in quality

The job of producing high-quality products is even more difficult for health care providers than it is for those in manufacturing, where the quality movement began. As a part of the service industry, health care providers are in the position of producing products and delivering services at the moment of sale. Our task is to improve the quality of all of these simultaneous and interrelated processes. Traditionally, health care providers have made efforts to improve their products and services without realizing the impact that could be made by also improving resources, processes, and outcomes. This article is an overview of the new direction we have been taking: Retrospective review. Critical pathways. Building quality into all areas (resources, processes, products and services, and outcomes). Focused study of outcomes). We foresee a further evolution that will lead to exciting new methods for understanding and delivering high-quality care.     

Benefits and barriers to consumer choice

Any successful health care reform effort must increase the market power of individual consumers. If consumers act in the medical marketplace as they do in other segments of the economy they will make sensible decisions about the allocation of resources (rationing) without the intrusion of third parties and will select providers and medical interventions that meet their needs. This article asserts the importance of consumer influence, focuses on the barriers that prevent consumers from exerting the same muscle in health care that they manifest in other areas of the economy, and suggests ways to remove these barriers.     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.     

Important considerations in using indicators to profile providers

The demand is accelerating for information about the clinical performance of providers. In the more competitive and value-sensitive marketplace that is already developing, purchasers (consumers, employers, and insurers) of health care services will require more information to better assess the relative value of providers' (professional and hospital) services. The cornerstone of a wise, value-based strategy in selecting health care services is careful assessment of each provider's performance based on detailed, quantitative data in the form of clinical indicators. The use of indicators to profile the comparative performances of providers allows purchasers to compare as well as to influence provider performance.     

Preparing for managed competition

Without the demands of managed competition or economic incentives to control costs, providers have little reason to invest in systematic data analysis about their patients. Information technologies in the hands of health care managers and physician executives primarily are tools for cost control, and, if cost control is not an important issue for them, they do not learn how to do it. The rules of the game have already changed for providers where managed care dominates the medical community and will change for the entire nation under managed competition. Managed competition gives providers strong incentives to identify the costs of care and unnecessary variations in those costs, to introduce new processes of care to reduce unnecessary administrative and clinical costs, to implement practice guidelines to reduce variations in outcomes of care, and to document statistics indicating excellent quality.     

Information technology: the next wave. Clinician acceptance of information technology

Information systems have yet to make a significant inroad at the interface between clinicians and patients. The obstacles to implementing information systems at the clinical level are formidable. As these systems have begun to mature and marketplace pressures have created changing needs for clinicians and the integrated delivery systems they are working in, the need for these systems has increased. Understanding the pressures that managed care brings to bear on clinical processes will facilitate clinicians' acceptance of these technologies.     

Formatting and presenting quality data to medical staffs and hospital boards

A host of historical and practical precedents have made hospitals responsible for the quality of care rendered within their facilities. The medical staff and the board of trustees share in this responsibility. Increasing demands for demonstrative evidence of the quality of care in an institution have made the process data-based. There is no substitute for specific data on the performance of both the hospital and its providers in the delivery of care. The trick, however, is in presenting this information to the medical staff and the board in a fashion that will be understandable and that will still maintain confidentiality of provider and patient. The authors offer a presentation system that has met with success in their community hospital.     

Health care's power brokers in the 21st Century. Interview by Donna Vavala

Health care has undergone turbulent change in the 20th Century. In addition to dramatic pharmaceutical and technological advances, the entire health care delivery system has been significantly improved. Through all the turmoil, hospitals have been at the center of the health care universe. But, as the 21st Century approaches, that may change, too. What will become of hospitals, which for most of this century have played a commanding role? Will managed care organizations and group practices come out on top? And, once the new power broker takes over, what will be the impact on providers, insurers, and the government, and how will their relationships to each other change? Jeff Goldsmith, PhD, President of Health Futures, Inc., Bannockburn, Ill., and health care futurist, examines tomorrow's health care delivery system and makes some eye-opening predictions.     

Hiding your criteria will never work

In this era of managed care, the message has been that the health care industry has provided inappropriate or inefficient care, causing the ruination of medicine and ultimately of the U.S. economy. Published research data on small area analysis have demonstrated marked differences in utilization rates for the same surgical procedure in various locations. Researchers and others have logically surmised that criteria used by providers in recommending these procedures have also varied from location to location. Correction, therefore, will require attention to the establishment of logical and defensible criteria.     

The theory of S-curve discontinuity in the medical care field

Confusion reigns supreme in the health are field today. In a previous paper, I described my thoughts about the reasons for this chaos. This article reviews the gradual escalation of health care costs and many of the unsuccessful methods to control them, reiterates the theory of S-Curve discontinuity in health care and develops a "tool" that will enable physician executives to determine whether or not a product or process in health care will succeed in the near and distant future. This new tool can be of value to all health care providers, investors, health planners, politicians involved in evolving health care legislation, and any others who have an investment in the future of health care.     

Defined contribution--the future for health care

Employers are seeing breathtaking health care premium increases. As action-oriented people, they are not going to cough up additional money to pay for these rate increases. The real question is what solution might employers move to? The most logical answer is defined contribution--a way that employers could give employees health benefit funding that resembles what they have already done in pension funding. Today, facing massive cost pressures from their health care premiums, many employers are wishing that they could create or use the equivalent of a defined contribution plan for health care. The next major evolution of defined benefit health financing needs the full-scope functional equivalent of a 401 (k) administrator to make the concept work--someone to give employers the tools needed for employees to make meaningful choices. Up until now, no one has been able to give consumers meaningful data about health care and health benefit alternatives. A viable 401 (k) health administrator will need to offer an array of choices that will work for all players.     

Cost shifting: the final straw in federalization of health care

While cost controls applied by Medicare and indemnity insurance programs initially helped curtail abusive medical billing practices, creative billing techniques have since resulted in runaway medical costs and rising insurance premiums. Employers have been forced to increase employee's contributions to health care by increasing deductibles, copayments, and coinsurance or by simply dropping health care benefits. If National Health Insurance comes to pass, and that is a cry now coming from major employers, it will be followed in time by federalization of all health care delivery systems, including Workers' Compensation. It is the providers who shift their fees into Workers' Compensation, which pays from the first dollar, who will cause the business community to petition Washington for relief. It will claim the need for cost controls in Workers' Compensation to keep American business competitive in world markets.     

Credentialing in managed care

Through the use of managed care techniques in recent years, the insurance industry has tried to bring the runaway costs of medical care under control. The result of this control effort is system access limitations, compared to the full choice indemnity plans of the past. This limited system access has now clearly moved HMOs and other managed care organizations into the category of "potentially liable health care entities," based on patient steerage, economic disincentives, and limited choices of the plan's participating providers and facilities. Just as hospitals have had to exercise rigorous care in the credentialing of members of their medical staffs, managed care organizations will have to ensure that the providers they use meet acceptable standards of competence.     

Demand rising for medicine's rarest birds

The prognosis from most quarters is that the U.S. health care delivery system is moving inexorably toward managed care. The final form that managed care takes under whatever health reform measure finally takes shape in Washington is still in doubt, but it is clear that care will be managed in the future. It also seems increasingly clear that the system evolving will require more primary care providers, and that they will occupy some very key decision-making roles in the clinical firmament. In this article, staff writer Donna Vavala brings together the thoughts and predictions of several health care leaders on this critical topic in medical management.