SEARCH FOR BETTER WAYS TO CARE FOR THE CHRONICALLY ILL ELDERLY HAS LED TO "ALTERNATIVES TO INSTITUTIONAL CARE." A STUDY OF GERIATRIC DAY CARE & HOMEMAKER SERVICES FINDS THEY WERE USED AS AN ADD-ON TO EXISTING CARE, FEW BENEFITED & ... COSTS SOARED. FOUR MORE STUDIES HAVE CONFIRMED THE LACK OF SUBSTITUTION EFFECTS. SERVICES SHOULD BE TARGETED ON THOSE WHO NEED THEM ALTHOUGH IT IS DIFFICULT TO DO SO.
Case management programs often designate a nurse or social worker to take responsibility for guiding care when patients are expected to be expensive or risk a major decline. We hypothesized that though an intuitively appealing idea, careful program design and faithful implementation are essential if case management programs are to succeed. We employed two theory perspectives, principal–agent framework and street-level bureaucratic theory to describe the relationship between program designers (principals) and case managers (agents/street-level bureaucrats) to review 65 case management studies. Most programs were successful in limited program-specific process and outcome goals. But there was much less success in cost-saving or cost-effectiveness—the original and overarching goal of case management. Cost results might be improved if additional ideas of agency and street-level theory were adopted, specifically, incentives, as well as "green tape," clear rules, guidelines, and algorithms relating to resource allocation among patients.
Nursing home quality threatens the well‐being of residents. Pay for performance pays organizations for meeting performance targets and is required in Medicare hospitals under the 2010 Patient Protection and Affordable Care Act, where it is called "value‐based purchasing." It is not yet required of nursing homes. This article asks whether pay for performance could mitigate nursing home quality problems. A total of 159 health care studies were reviewed. "Effect sizes" (the percentage improvement or decline in care) were gleaned from 22 selected studies measuring 150 health outcomes ranging from more frequent foot exams to a measure of heart function. The median improvement was a modest 2.9 percent. Nursing home studies were a minority of those reviewed. Yet one large randomized trial proved successful. Pay for performance may be well suited to nursing homes given their routine care, chronic population, and low wage rates. However, design and implementation lessons must be applied to avoid failure.
The Commonwealth Fund Survey of Long-Term Care of Specialists was administered via the World Wide Web from September 2007 through March 2008. The primary purpose was to characterize the views of those with known or demonstrable experience and expertise with at least one aspect of long-term care. Among 2,577 potential respondents, 1,147 completed the entire survey for an overall response rate of 44.5%. This special supplement of Medical Care Research and Review uses data collected from the survey to explore several issue areas, namely, reforming long-term care financing, improving government oversight, adopting nursing home culture change, and rebalancing long-term care away from institutions toward home- and community-based services. Analyses documenting the opinion networks of long-term care specialists and the relationship between network characteristics and attitudes toward reform are also reported. Two leading experts provide commentary as well. Details of the study's methodology and issue content are described.
Though the Obama health reform has become law and many think it revolutionizes our health care system, the reality is that it will do very little about our two biggest problems, costs and quality. Our costs are the highest in the world, and our quality is mediocre at best. We are getting coverage of three-fourths of our uninsured, but nothing in the bill will force physicians to follow protocols to move care more toward science and away from art, and the cuts promised in Medicare payments to hospitals and physicians are no more likely to occur in the future than they have been in the past. Not angering powerful interests meant not really cutting their earnings or telling them how to practice. New taxes and employer inducements to provide insurance or pay a fine were an inevitable product of lacking the political muscle to cut costs while having taken the bold step of reforming the insurance industry. That reform committed the president to an individual mandate to buy insurance, the only way of protecting insurance companies against adverse selection of sick patients once they give up refusal to cover pre-existing conditions. Our permeable political system, our health care history and ideological intransigencies make it hard to adopt truly comprehensive reform that controls costs and assures quality care.
Though the Obama health reform has become law and many think it revolutionizes our health care system, the reality is that it will do very little about our two biggest problems, costs and quality. Our costs are the highest in the world, and our quality is mediocre at best. We are getting coverage of three-fourths of our uninsured, but nothing in the bill will force physicians to follow protocols to move care more toward science and away from art, and the cuts promised in Medicare payments to hospitals and physicians are no more likely to occur in the future than they have been in the past. Not angering powerful interests meant not really cutting their earnings or telling them how to practice. New taxes and employer inducements to provide insurance or pay a fine were an inevitable product of lacking the political muscle to cut costs while having taken the bold step of reforming the insurance industry. That reform committed the president to an individual mandate to buy insurance, the only way of protecting insurance companies against adverse selection of sick patients once they give up refusal to cover pre-existing conditions. Our permeable political system, our health care history and ideological intransigencies make it hard to adopt truly comprehensive reform that controls costs and assures quality care. Adapted from the source document.
