Douglas A. Conrad

Public–Private Collaboration in Health and Human Service Delivery: Evidence from Community Partnerships

The collaboration among public–private partnerships that applied to the Community Care Network (CCN) demonstration program of the Hospital Research and Educational Trust is examined. These partnerships link broad-based community coalitions with health and human service providers in efforts to improve community health and local service delivery. Although they willingly collaborated in identifying community health needs, coordinating services, and reporting to the community, partnership participants showed less alacrity in joining forces to reduce redundancy and increase efficiency. Such patterns suggest that organizations might best profit from working together on activities that maintain existing power relations and that have the potential to add prestige and attract new clients. Collaboration in these areas may be essential to building a foundation of trust that leads to future cooperation in more sensitive areas.

Integrated Health Systems: Promise and Performance

Summary Todays “virtually” and vertically integrated health systems increasingly are much better positioned than the multihospital systems of the 1980s to respond to the healthcare challenges of the twenty‐first century. The authors argue that the control of the health services “value chain” will devolve naturally to those market players who have the comparative advantage in coordinating the flows of information, human, and physical resources along the continuum of services required to improve and maintain the health of populations. Available evidence does not render a clear verdict on whether superior performance is generated by the virtual integration of strategic alliances and affiliations or the vertical integration represented by unified single ownership of all system components. While inertia, acute care‐based “mental models,” weak incentives, and insufficiently developed information systems represent important barriers to the creation and sustainability of integrated systems, the authors argue that system evolution is occurring and offers promise of enhanced efficiency and patient benefit. However, the full potential of these systems will only be realized as they accept explicit accountability for meeting the health needs of their local communities. The transition from “covered lives” to accountability for the community population is crucial.

Costing medical care: Using medicare administrative data

This paper describes how the PORTS are using data from the Medicare administrative records systems to study the medical care costs of specific conditions. The general strengths and weaknesses of the Medicare databases for studying cost related issues are discussed, and the relevant data elements are examined in detail. Changes in the nature of the data collected over time are noted. Information is provided on how the PORTS are using these data to estimate the cost to Medicare of treating Medicare beneficiaries with specific conditions and the social (opportunity) cost of treating these patients. Furthermore, information is provided on how data from the Medicare administrative records system can be used to determine the cost of services for patients who have been identified through other large databases (i.e., state hospital discharge tapes) or who have been enrolled in prospective cohort studies.

Penetrating the “Black Box”: Financial Incentives for Enhancing the Quality of Physician Services

This article addresses the impact of financial incentives on physician behavior, focusing on quality of care. Changing market conditions, evolving social forces, and continuing organizational evolution in health services have raised societal awareness and expectations concerning quality. This article proceeds in four parts. First, the authors place financial incentives in the context of broader forces shaping the quality of physician services. Second, the article reviews the literature on financial incentive effects on physician behavior. Third, a simple net income maximization model of physician choices is presented, from which are derived formal hypotheses regarding the effect of financial incentives on physician choices of quality per unit of physician service and the quantity of services per patient. The model is extended qualitatively to offer further hypotheses and research directions. Finally, gaps and limitations of the model and of the extant empirical research are articulated, and additional researchable questions are posed.

The cost and efficacy of home care for patients with chronic lung disease.

A randomized controlled trial was conducted to assess efficacy and cost of sustained home nursing care for patients with chronic lung disease. Three hundred one patients were randomly assigned to a respiratory home care group (RHC) that received care from respiratory home care nurses, a standard home care group (SHC) that received care from regular home care nurses, or an office care group (OC) that received whatever care they needed except for home care. Patients were followed for 1 year. At the end of the study year, there was no difference in survival, pulmonary function, or everyday functioning among the three groups. Average annual cost of care for all study patients was

Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It?

7,647 (1981–82 dollars). The average annual health care costs for patients in the RHC group was

Vertical integration in health services: theory and managerial implications.

9,768; for those in the SHC group,

ANALYSIS OF AUTOMATED ADMINISTRATIVE AND SURVEY DATABASES TO STUDY PATTERNS AND OUTCOMES OF CARE

8,058; and for those in the OC group,

Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care A Randomized Trial

5,051 (P = 6.45, df = 2/298, P = 0.02). These results suggest that the current policy of limited coverage of home nursing services by Medicare and other third-party payers may be appropriate.

Collaborative Initiatives: Where the Rubber Meets the Road in Community Partnerships

This article asks whether financial incentives can improve the quality of health care. A conceptual framework drawn from microeconomics, agency theory, behavioral economics, and cognitive psychology motivates a set of propositions about incentive effects on clinical quality. These propositions are evaluated through a synthesis of extant peer-reviewed empirical evidence. Comprehensive financial incentives--balancing rewards and penalties; blending structure, process, and outcome measures; emphasizing continuous, absolute performance standards; tailoring the size of incremental rewards to increasing marginal costs of quality improvement; and assuring certainty, frequency, and sustainability of incentive payoffs--offer the prospect of significantly enhancing quality beyond the modest impacts of prevailing pay-for-performance (P4P) programs. Such organizational innovations as the primary care medical home and accountable health care organizations are expected to catalyze more powerful quality incentive models: risk- and quality-adjusted capitation, episode of care payments, and enhanced fee-for-service payments for quality dimensions (e.g., prevention) most amenable to piece-rate delivery.