How prevalent are hospital-based palliative care programs? Status report and future directions.

In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.

Tracking the changing provider landscape: implications for health policy and practice.

Throughout the 1990s health care providers were interested in developing organized delivery systems. However, industry observers have increasingly questioned the sense of these efforts. Using an established taxonomy of health networks and systems, we examined whether there was a nationwide trend away from the vertical and horizontal arrangements that serve as the backbone to organized delivery systems. Studying 1994-1998, we found that both health networks and systems became less centralized in their hospital services, physician arrangements, and insurance product development. We did not find a general pathway to disintegration but instead found considerable experimentation in organizational form.

Classifying health networks and systems: managerial and policy implications.

This article illustrates how a new approach to classifying health networks and systems can be used to evaluate the readiness of health care organizations to accept risk. Examples are provided from the Harris-Methodist, Henry Ford, and SSM Health Care Systems. The classification system can also be used to assist executives and physician leaders in making decisions involving the centralization of services, the number of different services to offer, and decisions to enter into various strategic alliances. The classification system can be updated to help track the evolution of the U.S. health care system over time.

A taxonomy of health networks and systems: bringing order out of chaos.

OBJECTIVE: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features. DATA SOURCES: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems. STUDY DESIGN: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations. These dimensions were applied to three components of the health service/product continuum: hospital services, physician arrangements, and provider-based insurance activities. DATA EXTRACTION METHODS: We identified 295 health systems and 274 health networks across the United States in 1994, and 297 health systems and 306 health networks in 1995 using AHA data. Empirical measures aggregated individual hospital data to the health network and system level. PRINCIPAL FINDINGS: We identified a reliable, internally valid, and stable four-cluster solution for health networks and a five-cluster solution for health systems. We found that differentiation and centralization were particularly important in distinguishing unique clusters of organizations. High differentiation typically occurred with low centralization, which suggests that a broader scope of activity is more difficult to centrally coordinate. Integration was also important, but we found that health networks and systems typically engaged in both ownership-based and contractual-based integration or they were not integrated at all. CONCLUSIONS: Overall, we were able to classify approximately 70 percent of hospital-led health networks and 90 percent of hospital-led health systems into well-defined organizational clusters. Given the widespread perception that organizational change in healthcare has been chaotic, our research suggests that important and meaningful similarities exist across many evolving organizations. The resulting taxonomy provides a new lexicon for researchers, policymakers, and healthcare executives for characterizing key strategic and structural features of evolving organizations. The taxonomy also provides a framework for future inquiry about the relationships between organizational strategy, structure, and performance, and for assessing policy issues, such as Medicare Provider Sponsored Organizations, antitrust, and insurance regulation.

Medicaid shortfalls and total unreimbursed hospital care for the poor, 1980-1989.

This article examines the relationship between Medicaid payments and hospital costs from 1980 through 1989, using data from the American Hospital Association's Annual Survey of Hospitals. It finds that payments covered about 90% of Medicaid hospital costs until 1985, then declined to 78% in 1989. Together, Medicaid shortfalls ($4.2 billion) and unsponsored care ($8.9 billion) accounted for $13.1 billion in unreimbursed hospital costs in 1989. Most of the recent growth in unreimbursed hospital cost incurred in care for the poor is now caused by rising Medicaid shortfalls rather than increases in unsponsored care. While Medicaid shortfalls accounted for about one-fifth of unreimbursed care for the poor in 1980, they accounted for a third in 1989.

Data on U.S. hospitals: a comparison of the two principal sources.

Rapid changes in the nation's health-care requirements and systems of health-care delivery are making detailed and reliable information about the nation's hospitals increasingly important to researchers. This article compares the two principal sources of regular data about the utilization, finances, and staffing of U.S. hospitals--the American Hospital Association's Annual Survey of Hospitals and the National Hospital Panel Survey. It describes the kinds of data collected by the surveys and the methods by which they are processed and verified; and it shows how the surveys complement one another in providing a picture of the nation's hospital industry. The Annual, a yearly survey of all U.S. hospitals, obtains a data set suitable for detailed cross-sectional analyses. The Panel, a monthly survey of a sample of U.S. community hospitals, obtains a data set from which estimated projections suitable for broad longitudinal analysis are derived.

Survey shows increase in hospital training programs.

A 1976 AHA survey has determined that the extent of hospital-based training programs for the allied professions has increased since 1973, when the previous survey was conducted. Both surveys depict the wide range of types of such programs offered by hospitals.