Win/win with an improved appeals process

In the past, decisions on what services were appropriate and/or desirable were made between the patient and the physician. In most cases, the cost of services was ignored. Lately, concern for cost containment has introduced a new person into the health care decision-making process: the managed care monitor/planner. The appearance of this new person has produced ambivalent feelings among patients and physicians, from joyful approval for those concerned with rising costs to extreme anger for those whose services are denied, while perceived by them as absolutely necessary. Thus, appeal mechanisms have become a way of life. This article explores ways in which the appeals process may be used as a tool to improve satisfaction levels among providers and subscribers and still fulfill the cost containment and efficiency goals of case management.     

基于动态博弈的远程医疗政策与患者社会福利研究

为了研究远程医疗的有效政策以及政策对患者社会福利的影响,考虑一个由政府、医院和患者三个主要利益相关者构成的医疗系统,利用动态博弈等理论建立了三种博弈模型：完全竞争条件下的两阶段动态博弈模型、医保报销比例政策下的三阶段动态博弈模型、医保报销比例和医疗服务价格限制双重政策下的三阶段动态博弈模型。研究结果表明,患者社会福利在完全竞争博弈中最低,在医保报销比例政策下的博弈中次之,在医保报销比例和医疗服务价格限制双重政策规制的博弈中最高。将远程医疗纳入医保范围,并给予较高的医保报销比例,既有利于远程医疗市场占有量的增长,又有利于患者社会福利的增加。但较高的医保报销比例会使远程医疗和传统医疗服务价格都显著上涨,必须施加医疗服务价格限制,以控制价格的上涨,减少社会医疗成本。最后,算例和敏感性分析验证了模型的有效性和正确性。     

Self-directed health plans: alternatives to managed care enabled by new technologies

Few people believed the Internet would have much impact on the delivery of health care services. However, combined with technological advances in how computer systems are structured and implemented and knowing what doesn't work in managed care from bitter experience, the Internet is being used to create a new paradigm of alternative health insurance products. These products hold the potential to change for the better the face of health care as we know it. Self-directed health plans will be less expensive than managed care programs and offer greater predictability in health care spending. For health care providers, SDHPs' reliance upon episode allowances will create a new market for packaged or bundled services. Providers will be paid to provide solutions, not just treatment. This could represent a new model in which physicians accept a risk-adjusted payment and provide a warranty that they will do whatever necessary until the patient has reached the reasonably expected health status. This is a radical departure from the fee-for-service or capitation system.     

Patient care: past, present, and future

The 40 years since St Christopher's Hospice opened has witnessed a burgeoning international interest in palliative care. Its key characteristics comprise a focus on the whole-person (physical, psychological, social, and spiritual), patient-centeredness (partnership with and empowerment of the patient and family), openness and honesty in communication, an acceptance of the inevitability of death coupled with improvement in the quality of life, multi-professional teamwork integrated with community (volunteer) involvement. Although much has been achieved, much remains to be done. Both in resource-poor countries and in more wealthy ones, the scope of palliative care has changed. Initially in the United Kingdom, palliative care was mostly limited to cancer patients but now strenuous efforts are being made to extend coverage to other patient groups, e.g., those with end-stage heart disease or renal failure. In India, with a dearth of chronic care facilities, palliative care services increasingly embrace those with chronic disability as well as progressive end-stage disease. In Sub-Saharan Africa, the devastating impact of AIDS is having a major impact on the development and delivery of palliative care. To maximize the benefits of limited financial and other resources, a strategic approach is necessary. The World Health Organization emphasizes three essential foundation measures: health service policy, public awareness and professional education, and drug availability. However, at the end of the day, if we are truly to honor Cicely Saunders, palliative care must remain a movement with momentum, combining creative charisma with inevitable bureaucratic routinization.     

A Model for Planning Resource Requirements in Health Care Organizations

In this paper we present a general model and solution methodology for planning resource requirements (i.e., capacity) in health care organizations. To illustrate the general model, we consider two specific applications: a blood bank and a health maintenance organization (HMO). The blood bank capacity planning problem involves determining the number of donor beds required and determining the size of the nursing and support staff necessary. Capacity must be sufficient to handle the expected number of blood donors without causing excessive donor waiting times. Similar staff, equipment, and service level decisions arise in the HMO capacity planning problem. To determine resource requirements, we develop an optimization/queueing network model that minimizes capacity costs while controlling customer service by enforcing a set of performance constraints, such as setting an upper limit on the expected time a patient spends in the system. The queueing network model allows us to capture the stochastic behavior of health care systems and to measure customer service levels within the optimization framework.     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

Design requirements for health care production control systems

This paper addresses the issue of determining design requirements for production control in health care organizations, with a restriction to the internal production control of hospitals. Hospital management has limited possibilities to control hospital production, as hospital production processes are driven by medical specialists who, however, do not manage that process. We consider therefore the hospital as a virtual organization, consisting of a number of relatively independent businesses in a common framework. Each business unit functions as a focused factory for a range of more or less homogeneous products. Production control principles can be applied to each of these businesses, but not to the system as a whole. A number of elements from classical production control theory can be also applied to health care, i.e. the use of decoupling points, the bottleneck-oriented approach, and the operational control between production and market. However, important factors that need to be considered in health production control are that often specifications on quality are not available at the start of the process, and that there is strong interaction between the patient and the process. Our conclusion is that a dedicated framework for approaching hospital production control is necessary. The specific characteristics of hospital care and its state of production control development are the main arguments for this dedicated framework.     

SOLUTION OF THE SHORTEST ROUTE PROBLEM USING THE ASSIGNMENT TECHNIQUE

A solution to the shortest route problem of going from city i to city j with p necessary intermediate stops (0 p n - 2) is given using the assignment algorithm, with a simple modification of the initial matrix. A branch and bound algorithm is necessary in all but the simplest case (p = 0).     

Ethics and Choosing Appropriate Means to an End: Problems with Coal Mine and Nuclear Workplace Safety

A common problem in ethics is that people often desire an end but fail to take the means necessary to achieve it. Employers and employees may desire the safety end mandated by performance standards for pollution control, but they may fail to employ the means, specification standards, necessary to achieve this end. This article argues that current (de jure) performance standards, for lowering employee exposures to ionizing radiation, fail to promote de facto worker welfare, in part because employers and employees do not follow the necessary means (practices known as specification standards) to achieve the end (performance standards) of workplace safety. To support this conclusion, the article argues that (1) safety requires attention to specification, as well as performance, standards; (2) coal-mine specification standards may fail to promote performance standards; (3) nuclear workplace standards may do the same; (4) choosing appropriate means to the end of safety requires attention to the ways uncertainties and variations in exposure may mask violations of standards; and (5) correcting regulatory inattention to differences between de jure and de facto is necessary for achievement of ethical goals for safety.     

Beyond Patient Classification: Using Individual Patient Characteristics in Appointment Scheduling

Scheduling patients involves a trade‐off between the productivity of the service provider and customer service. This study considers how outpatient medical facilities can improve their appointment scheduling by incorporating individual patient information in the scheduling process. Specifically, we obtain data on patient characteristics and examination durations from a health clinic, describe how that data can be used to predict patient examination durations in the clinic's appointment scheduling system, and evaluate the benefit of using individual patient characteristics over a conventional classification method. Computational results illustrate this method of patient scheduling reduces an overall cost function comprised of patient wait time, physician idle time, and over time by up to 24.2%, particularly when patients are sequenced with short duration patients being scheduled first. Several environmental characteristics are found to play critical roles in determining the magnitude of the benefit, including patient punctuality, no‐show probability, the clinic duration, the appointment rule used for scheduling, and the ratio of the physician's idle time cost to the patient wait cost. We also detail and evaluate a practical procedure for using heterogeneous scheduling under a fixed schedule.     

Assessment of Patient Classification in Appointment System Design

This paper investigates two approaches to patient classification: using patient classification only for sequencing patient appointments at the time of booking and using patient classification for both sequencing and appointment interval adjustment. In the latter approach, appointment intervals are adjusted to match the consultation time characteristics of different patient classes. Our simulation results indicate that new appointment systems that utilize interval adjustment for patient class are successful in improving doctors' idle time, doctors' overtime and patients' waiting times without any trade‐offs. Best performing appointment systems are identified for different clinic environments characterized by walk‐ins, no‐shows, the percentage of new patients, and the ratio of the mean consultation time of new patients to the mean consultation time of return patients. As a result, practical guidelines are developed for managers who are responsible for designing appointment systems.     

Medically necessary?

Coverage decisions can ultimately be traced back to three words in the original health policy contract: medically necessary and investigational. Investigational as a coverage exclusion applies to the minority of cases, in which there is inadequate data to validate the effectiveness of the intervention. In contrast, the majority of coverage decisions are based on medical necessity. Over the years the concept of medical necessity has evolved to encompass a multitude of medical management strategies. This discussion highlights the variable uses of the concept of medical necessity in terms of: (1) Determining the most appropriate intensity of service and place of service; (2) determining whether the proposed therapy is medically appropriate for the patient's condition; (3) distinguishing between medically necessary services and those that are performance enhancing or discretionary in nature; (4) making a distinction between medically necessary, cosmetic, and reconstructive services; and (5) defining medical necessity in accordance with generally accepted principles of good medical practice.     

Modeling patient arrivals in community clinics

We develop improved methods for modeling and simulating the streams of patients arriving at a community clinic. In previous practice, random (unscheduled) patient arrivals were often assumed to follow an ordinary Poisson process (so the corresponding patient interarrival times were randomly sampled from an exponential distribution); and for scheduled arrivals, each patient's tardiness (i.e., the deviation from the scheduled appointment time) was often assumed to be randomly sampled from a normal distribution. A thorough analysis of patient arrival times, obtained from detailed workflow observations in nine community clinics, indicates these assumptions are not generally valid, and the tardiness data sets for this study are best modeled by unbounded Johnson distributions. We also propose a nonhomogeneous Poisson process to model the random patient arrivals; we review a nonparametric approach to estimating the associated mean-value function; and we describe an algorithm for generating random patient arrivals from the estimated model. The adequacy of this model of random patient arrivals can be assessed by standard goodness-of-fit tests. These findings are important since testable scheduling optimization strategies must be based upon accurate models for both random and scheduled patient arrivals. The impacts on modeling, as well as implications for practice management, are discussed.     

Externe Organisationsberatung und Schulentwicklung

External organization counseling and school development Modernizing schools by internal school development is an important issue in Germany. This article discusses the conditions for successful processes in school development from the view of organization counseling. Which conditions for external counseling are necessary, how does a professional process steering function, and which tasks external counselors have to fulfil in the development process? Because of the very high demands on external counselors and coaches, an competence profile is presented and the necessary frame conditions for the setup of a counseling system are discussed.     

供应链协同与信息共享的关联研究

将协同分成管理协同、技术协同与人机协同3类。据此定义了供应链协同,分析了信息共享在不同条件下存在的价值差异,探讨了供应链协同与信息共享的内在关联。研究结果表明,信息共享是供应链协同实现的必要但不充分条件。在某些条件下,信息共享并不能解决供应链中的协同问题,相反还可能增大协同工作量。要避免这种情况发生,提前进行合理的信息共享设计是必须的。     

The Impact of Variability and Patient Information on Health Care System Performance

In the delivery of health care services, variability in the patient arrival and service processes can cause excessive patient waiting times and poor utilization of facility resources. Based on data collected at a large primary care facility, this paper investigates how several sources of variability affect facility performance. These sources include ancillary tasks performed by the physician, patient punctuality, unscheduled visits to the facility's laboratory or X‐ray services, momentary interruptions of a patient's examination, and examination time variation by patient class. Our results indicate that unscheduled visits to the facility's laboratory or X‐ray services have the largest impact on a physician's idle time. The average patient wait is most affected by how the physician prioritizes completing ancillary tasks, such as telephone calls, relative to examining patients. We also investigate the improvement in system performance offered by using increasing levels of patient information when creating the appointment schedule. We find that the use of policies that sequence patients based on their classification improves system performance by up to 25.5%.     

Hippocrates,Maimonides and the doctor's responsibility

Jack Kevorkian criticizes the Hippocratic tradition in Greek medicine, which bans the physician from giving his patient a lethal medication. He sees this prohibition as potentially bringing harm to a suffering patient and not reflective of the larger Greek society which was tolerant and even approving of suicide. However, Kevorkian's advocacy of doctor-assisted suicide can be seen as the polarity of doctor abandonment of the suffering patient rather than as an antidote to it. Both positions involve an outcome of physician removal from the suffering patient, which can be contrasted with Maimonides' command to the physician to watch over the life and death of his patients.     

Conflicting strategic objectives in hospital design

This paper presents a multigoal linear programming model designed to analyse the impact of different strategic objectives in the planning of hospitals. The paper argues that it is necessary to adopt an overall point-of-view in planning; that it is necessary to consider the interactions between the hospital, other social and health institutions and the community at large in order to attain an efficient plan. A simplified cost-benefit analysis is suggested, and it is demonstrated that the opportunity costs of lost working days may be more important than both capital and operating costs from a social point of view.     

The problem of the last bed: Contextualization and a new simulation framework for analyzing physician decisions

Faced with a full Intensive Care Unit (ICU), physicians need to decide between turning away a new patient in need of critical care and creating a vacancy by prematurely discharging a current occupant. This dilemma is widely discussed in the medical literature, where the influencing factors are identified, the patient discharge process described and the patient health consequences analyzed. Nevertheless, the existing mathematical models of ICU management practices overlook many of the factors considered by physicians in real-world triage decisions.This paper offers a review of the medical and mathematical literature on patient discharge decisions, and a proposal for a new simulation framework to enable more realistic mathematical modeling of the real-world patient discharge process. Our model includes a) the times at which discharge decisions are made and setup times for patient transfer from the ICU to a general ward and preparation of an ICU bed for an incoming patient, in order to capture the impossibility of an immediate switch of patients; b) advance notice of the number of patients due to arrive from elective surgery requiring intensive postoperative care and potentially triggering the need for early discharges to avoid surgery cancelations; and c) patient health status (to reflect the dependency of physicians’ discharge decisions on health indicators) by modeling length of stay with a phase-type distribution in which a medical meaning is assigned to each state.A simulation-based optimization method is also proposed as a means to obtain optimal discharge decisions as a function of the health status of current patients, the bed occupancy level and the number of planned arrivals from elective surgery over the following days. Optimal decisions should strike a balance between patient rejection and LoS reduction.This new simulation framework generates an optimal discharge policy, which closely resembles real decision-making under a cautious discharge policy, where the frequency of early discharge increases with the ICU occupancy level. This is a contrast with previous simulation models, which consider only the triage of the last bed, disregarding the pressures on physicians faced with high bed occupancy levels.     

True patient safety begins at the top. Leaders at one large health system rally around safety,avoid blame game

Making patient safety the No. 1 priority at a hospital or clinic sounds like a easy task. It isn't. At one Oklahoma health system, an improved patient safety program is a massive effort requiring input and participation from every member of the staff. Figuring out how to convince employees that patient safety is their first priority means developing an extensive communication and education program.