Each week, you must make at least 3 posts to the Discussion Board. One post will be your response to the week’s topic or question, and the other two posts will be responses to your classmates or the Instructor. To earn full credit, all posts must be substantive and well written and the posts must be on at least three separate days of the week. Please see the Discussion Board Rubric for specific expectations for the Discussion Boards. You must use a citation and reference, APA 6th ed. style, in your initial post and in at least one of your response posts. It is important to review the Discussion Board Rubric to fully understand the grading and expectations.To begin discussing in this forum, click the forum title. Then, click Create Thread on the Action Bar to post your initial reply. To reply to a fellow participant, click the title of the initial post, then click Reply. Thank you.Topic: Managed Care and Health Care Settings
Select “Student Resources” on the left navigation on this course, and then select “Writing and Library“. The library orientation video is included here for help with accessing the library and finding materials.You must use a citation and reference in your initial post and in at least one of your response posts.
For Help Finding Articles in the Keiser Online Library: Video URL: https://youtu.be/_WVHquPOPEY (Keiser Library Orientation)Once you have logged in, this video shows a quick example of finding an article: https://youtu.be/4NEFt74Z5UQ (HSA1117 Library)
**See article below**
Related Article: Health Policy Report: , N Engl J Med 1992:327;742-747.
To the Editor: In his article on managed care (Sept. 3 issue),* Iglehart discusses the challenge of identifying cost-effective physicians. Whereas many debate the appropriateness of selecting physicians on the basis of the numbers, managed-care entities, out of necessity, are using such criteria to refine their provider networks.
Selecting cost-efficient providers requires data from which payers can make informed decisions. There are two sources of data that would make the compilation of statistically significant averages possible: statewide discharge data on hospital inpatients and data on claims history from payers. Although the latter can include extensive data about inpatient and outpatient activities, most payers cannot use this information for analyses of physicians because they do not collect the necessary data elements.
We have found that statewide data bases on inpatients are rich in information with which to profile and compare physicians’ practice patterns. In addition, averages can be established that are regionally based, reflecting the practice patterns unique to various areas of the country.
There are approximately 36 states with legislative mandates that require the collection of hospital data. Very few states record physician identifiers, although many are now debating the addition of this critical element. In the states that collect such identifiers, the practice patterns of individual physicians can be compared with statewide measures of efficiency. Apart from its value to payers, this information is valuable to physicians, who have had little comparative information with which to measure their own practice patterns against those of their peers. For such analyses to be beneficial, however, users must clearly understand the limitations of the data.
Data must be adjusted for severity of illness and outliers. There should be a recognition that the analyses are usually based on inpatient care and that there are few statewide data on outpatient care. Thus, specialties that are oriented toward inpatients are more appropriate for profiling than specialties with few inpatient admissions. Finally, safeguards must be developed to ensure that an individual physician’s profile portrays his or her practice patterns accurately, instead of showing statistical anomalies.
Physician profiles should be only one tool in the evaluation of a physician’s efficiency and use of resources, since a physician who appears not to provide cost-effective care according to inpatient data may be quite cost effective in providing outpatient care and in office practice. Perhaps more important, such analyses measure only the efficient use of resources and have few, if any, indicators of quality.
To the Editor: Iglehart has aptly, succinctly, and comprehensively summed up the current state of managed care in America. . . .
One physician-driven organization that Iglehart did not mention is the physician–hospital organization (PHO). This type of organization is rapidly emerging as a powerful force in managed care across the country. PHOs are sprouting like weeds in more conservative regions, regions so far only lightly touched by health maintenance organizations or preferred-provider organizations. Physicians and hospitals are forming PHOs to position themselves for a future of managed care.
These organizations offer a mechanism for physicians and hospitals to act as partners in creating their own form of managed care, to interact directly with local businesses, to offer “bundled” sets of medical and surgical services, to bill for those services with a single unified bill, and to deal directly, constructively, and efficiently with other managed-care entities.
Mr. Iglehart replies:
To the Editor: Contrary to the assertion of Bennett and Twiss, my discussions suggest that payers already collect the “necessary data elements” but lack the capacity to analyze them or process them into valid and reliable form. From my understanding of Pro/File and the willingness of several Blue Cross and Blue Shield plans to invest substantial sums in its development or purchase, this computer-based system seems to offer this capacity, although it is a new form of technology the implementation of which will bear watching, particularly by physicians who are evaluated by it. In any event, I regard as wholly inadequate the use of hospital data alone to evaluate physicians’ practice patterns. Statewide data bases on inpatients, including the one mandated by law in Washington, contain data elements abstracted entirely from hospitals’ UB-82 claims. Thus, they do not include any of the financial data for services provided by physicians during a hospital stay or any of the data on diagnostic and procedural coding from each physician’s claim — necessary information, it would seem, to understand and categorize these episodes of care. Furthermore, data on outpatient care, which are currently available only to payers, are essential, since outpatient care accounts for about three quarters of physicians’ total billings and half their patients’ total care. Rather than focus on hospital data, various organizations now promote uniform coding, reporting, and the sharing of claims data by payers to facilitate the development of practice guidelines and medical outcomes research, along with profiling of physicians.
Dr. Reece cites a new variation on the managed care theme — a “physician-driven organization” called a PHO. A key characteristic is for these parties “to act as partners in creating their own form of managed care.” His choice of words reflects the ambivalence that many physicians have long felt toward the hospitals in which they practice. As the American hospital evolved, on the basis of a nonsectarian British model in which authority was divided between the administration and the medical staff, with physicians acquiring the power in this relationship, an uneasy alliance took shape that must change, given current circumstances. If the organization Dr. Reece briefly describes represents a reordering of roles that will lead to a more rational allocation of resources and better service to the patient, I applaud its development. If, on the other hand, it is an effort to consolidate control for physicians under the guise of partnership, I would question its long-term viability in the coming era of tougher allocational trade-offs.
*. Iglehart JK. The American health care system — managed care. N Engl J Med 1992;327:742 -7.
Gregg D. Bennett M.H.A., M.B.A.
Amanda S. Twiss M.B.A.
Richard L. Reece M.D.
John K. Iglehart
Healthcare Business Services, Bellevue, WA 98004
Deaconess Clinical Associates, Oklahoma City, of 73112
The american health care system — managed care: [letter]. (1992). The New England Journal of Medicine, 327(27), 1956. doi:http://dx.doi.org/10.1056/NEJM199212313272717
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