Qui tam claims: threat to voluntary compliance programs in health care organizations.

The Department of Justice (DOJ) reports that after violent crime, health care fraud is the department's top priority. The number of health care fraud investigations pending at the DOJ increased from 270 cases in 1992 to more than 4,000 in 1997. The DOJ's primary weapon in prosecuting health care fraud is the federal False Claims Act (FCA) of 1863 (31 U.S.C. secs. 3729-3733). Almost unique among federal antifraud provisions, the FCA may also be used by "private prosecutors" to file lawsuits on behalf of the federal government charging organizations with submitting false claims to the government. The FCA rewards such whistle-blowers with a share of any resulting recoveries as a bounty and protects them from discharge for filing false claims lawsuits against their employers. It also requires defendants to pay the costs and attorneys fees of successful claimants. Although the private "bounty hunter" features of the FCA data back to the Civil War, these so-called qui tam claims were nearly dormant until 1986, when Congress amended the FCA to revive their use. Following the 1986 amendments, and paralleling the rapid increase in federal reimbursements for health care costs, private qui tam claims have far expanded beyond their traditional purview of defense contracts into the field of health care. By 1997, health care providers were the targets of 54 percent of the 530 private qui tam lawsuits field that year.

The Socratic Method: analyzing ethical issues in health administration.

The Socratic Method has long been recognized by the legal profession as an effective tool for promoting critical thinking and analysis in the law. This article describes ways the technique can be used in health administration education to help future administrators develop the "ethical rudder" they will need for effective leadership. An illustrative dialogue is provided.

The delicate balance of law and ethics: a model for health administration educators.

The purpose of this paper is to provide a model for educators involved in teaching interrelated ethical, moral and legal dilemmas confronting health care delivery. For purposes of discussion, the AIDS epidemic is used as an example. Similarly complex issues, such as invitro fertilization, transplantation policy, etc. could also be analyzed using this model. A review of federal law, including a number of relevant cases, and their relationship of fundamental ethics issues is provided.

Implementation of total quality management: conventional wisdom versus reality.

Hospitals nationwide are beginning to implement continuous quality improvement (CQI) (Barsness et al. 1993; Kosta 1992). In large part this is due to the belief that the implementation of CQI will lead to higher quality patient care, improved patient satisfaction, better employee morale, and lower cost service delivery. However, to date there have been few empirical studies of CQI implementation efforts in healthcare (Shortell et al. 1994).

Keys for successful implementation of total quality management in hospitals.

This article reports the findings of an analysis of the implementation of continuous quality improvement (CQI) or total quality management (TQM) programs in 10 hospitals. This analysis is the result of a 2-year study designed to identify and assess the ingredients that lead to the successful implementation of CQI programs in acute care hospitals.

Assessing the impact of continuous quality improvement/total quality management: concept versus implementation.

OBJECTIVE: This study examines the relationships among organizational culture, quality improvement processes and selected outcomes for a sample of up to 61 U. S. hospitals. DATA SOURCES AND STUDY SETTING: Primary data were collected from 61 U. S. hospitals (located primarily in the midwest and the west) on measures related to continuous quality improvement/total quality management (CQI/TQM), organizational culture, implementation approaches, and degree of quality improvement implementation based on the Baldrige Award criteria. These data were combined with independently collected data on perceived impact and objective measures of clinical efficiency (i.e., charges and length of stay) for six clinical conditions. STUDY DESIGN: The study involved cross-sectional examination of the named relationships. DATA COLLECTION/EXTRACTION METHODS: Reliable and valid scales for the organizational culture and quality improvement implementation measures were developed based on responses from over 7,000 individuals across the 61 hospitals with an overall completion rate of 72 percent. Independent data on perceived impact were collected from a national survey and independent data on clinical efficiency from a companion study of managed care. PRINCIPAL FINDINGS: A participative, flexible, risk-taking organizational culture was significantly related to quality improvement implementation. Quality improvement implementation, in turn, was positively associated with greater perceived patient outcomes and human resource development. Larger-size hospitals experienced lower clinical efficiency with regard to higher charges and higher length of stay, due in part to having more bureaucratic and hierarchical cultures that serve as a barrier to quality improvement implementation. CONCLUSIONS: What really matters is whether or not a hospital has a culture that supports quality improvement work and an approach that encourages flexible implementation. Larger-size hospitals face more difficult challenges in this regard.

An integrative model for organization-wide quality improvement: lessons from the field.

This article describes a model of CQI that is designed to characterize the elements necessary for successfully improving quality at an organization-wide level; describe and understand the organizational dynamics in implementing an organization-wide effort; and aid in diagnosing and solving common implementation challenges. Three cases illustrate the model and how it can be used.

Conditions not attributable to a mental disorder: an epidemiological study of family problems.

OBJECTIVE: The objective of this research was to identify and measure the differences among three groups of psychiatric outpatients: those with family problems but without mental disorders, those with both family problems and mental disorders, and those with a mental disorder but without family problems. DSM-III V code conditions (conditions not attributable to a mental disorder) other than family problems do occur, but family problems were chosen because of their importance. METHOD: All patients admitted to an outpatient psychiatric clinic during a 2-year period were studied (N = 382). Of these, 92 had V code conditions unrelated to family problems and were excluded. Data are presented on the remaining 290 patients. Sociodemographic variables, DSM-III diagnoses, source of referral, previous and subsequent use of outpatient services, and type of family problem were examined. Patients were from a low-income population and came from three ethnic groups (white, black, and Hispanic). RESULTS: Among whites, more men than women had family problems without mental disorders; among blacks, more women than men had family problems with and without mental disorders. Marital problems occurred most frequently in the group with family problems without mental disorders, and married subjects were more likely to have a V code condition. Professional referrals were more common than other referral sources in all three groups. However, family problems without mental disorders were more likely to occur among those who were referred by their families and had never had psychiatric treatment; patients with family problems and mental disorders were more likely to be self-referred and to have been previously treated; those with a mental disorder but without family problems were usually referred by professionals and almost always had been previously treated. There appeared to be underreporting of family problems among those with family problems and mental disorders and among black men with family problems with and without mental disorders. CONCLUSIONS: More research is needed on the patterns of use of outpatient psychiatric services by individuals with family problems and other V code conditions.

Administrative and policy issues in reimbursement for nursing home capital investment.

The way in which states reimburse for nursing home capital costs can create incentives for nursing home owners to use the home primarily as a vehicle for real estate speculation, with potentially adverse consequences for patient care. In order to help promote and control the stability, adequacy, and quality of capital investment in long-term care, an increasing number of states are using a fair-rental approach for calculating capital reimbursement. In this article we compare the fair-rental approach with traditional cost-based capital reimbursement in terms of administration and policy. We discuss issues of concern to the state (cost and reimbursement design options) and the investor (after-tax cash flows, rate of return, etc.). Our analysis suggests that fair-rental systems may be superior to traditional cost-based reimbursement in promoting and controlling industry stability, while at the same time providing an adequate return to investors, without incurring long-term increases in the costs of administering programs.

Prediction of use of psychiatric services: application of the CART (classification and regression trees) algorithm.

A computerized recursive partitioning program called Classification and Regression Trees (CART) was used to identify potential high users of services among low-income psychiatric outpatients. Sociodemographic variables, clinical variables (e.g., psychiatric diagnosis and type of presenting complaint), source of referral and the most recent psychiatric treatment setting used were studied. Discharge from inpatient psychiatric treatment right before admission to outpatient psychiatric treatment was found to be the most consistent, the most powerful and the only necessary predictor of high use of outpatient psychiatric services.

Analysis of nursing home capital reimbursement systems.

An increasing number of States are using a fair-rental approach for reimbursement of nursing home capital costs. In this study, two variants of the fair-rental capital-reimbursement approach are compared with the traditional cost-based approach in terms of after-tax cash flow to the investor, cost to the State, and rate of return to investor. Simulation models were developed to examine the effects of each capital-reimbursement approach both at specific points in time and over various periods of time. Results indicate that although long-term costs were similar for the three systems, both fair-rental approaches may be superior to the traditional cost-based approach in promoting and controlling industry stability and, at the same time, in providing an adequate return to investors.

Integration of nursing and business. Issues in curriculum development.

Foster and Boerstler look at the challenge of bringing integration into nursing service programs that combine nursing and business content. They examine capstone courses and internships among other strategies. They also give an interesting criterion of comparative advantage to judge where various content should be acquired.

Utilization of medical resources in persons with DSM-III personality disorders in a community sample.

A community survey of 401 randomly selected subjects yielded 249 responders, of which twenty-six had DSM-III criteria personality disorders (PDs), and 167 had no personality disorder traits (controls). More PDs than controls were medically hospitalized during the last year (38% vs 17%, p = .006). A number of significant associations was found between the number of DSM-III personality trait questions answered in a positive fashion and medical utilization. These associations varied by gender. Most striking was the .50 correlation for females between flamboyant personality disorder scores and visits to the family doctor for mental health reasons.

Management preparation for nurse executives: the dual degree option.

Nurses have the clinical expertise that enables them to better understand the complex issues inherent in management of the delivery of health care. Yet without adequate preparation in management, as well as training of higher levels of nursing theory and research, nurses will be less prepared to compete at higher levels as the system continues to change. The University of Colorado offers a program designed to meet these needs, which serves as a national model for other schools of nursing considering such a curricular change. Further research needs to be conducted to identify the specific components of a graduate program that will enable the nurse executive to develop advanced nursing practice skills while developing the management skills necessary to achieve effectiveness in the practice setting. Because the long-term outcome of the dual degree model is still unknown, the effectiveness of the program in the health care system over time will be evaluated in relation to three outcomes: first, the effectiveness of program goals and objectives for producing successful nurse executives; second, the effectiveness of the curriculum design in preparing successful nurse executives; and third, satisfaction of graduates with the program and with their preparation. Participants in the dual degree program look forward to meeting this challenge.

The relationship of presenting complaints to the use of psychiatric services in a low-income group.

The presenting complaints of 503 subjects who contacted a mental health clinic serving an inner-city, low-income group were classified into mental state, physical functioning, social relations, and social performance. The authors examined the relationship between type of presenting complaint and race ethnicity, gender, age, marital status, DSM-III diagnosis, source of referral, and previous use of psychiatric services. Diagnostic group, source of referral, previous use of services, and type of presenting complaint were the four best predictors of number of outpatient visits. The increment in prediction produced by type of presenting complaint, however, was relatively modest.