Aligning public health spending and priorities in Oklahoma.

UNLABELLED: All-state fiscal year 2005 public health-related spending in the state of Oklahoma was investigated including funds from federal, state, and local sources expended through the state health department and the two autonomous metropolitan health departments. METHODOLOGY: The cost finding and allocation methodology used a series of structured resource worksheets developed for this project that segregate public health department expenditures into six primary groups: disease and prevention; family health; community health; protective health; support and administrative services; and other. The six primary groups were further divided into 59 units and subunits. All financial data were provided directly by staff in the public health agencies working closely with project staff. The data were analyzed along three lines: (1) level of health department (state, metro, other local); (2) revenue source (federal, state, local); and (3) public health function (behaviors, health conditions, direct services, population health). RESULTS AND CONCLUSIONS: Public health officials may not have necessary information on the multiple sources and applications of revenue, categories of expense, operational control of resources, and the inherent restrictions upon the use of those resources. The study gave the city-county and state health officials a new and more complete picture of public health spending in Oklahoma, which catalyzed a dialogue between the commissioner and the directors to explore ways for local priorities to be incorporated into the direct state spending.

Impact of state tort reforms on physician malpractice payments.

State and federal initiatives to enact medical malpractice tort reforms lack an empirical basis for understanding how reforms might affect malpractice premiums and costs. This paper ranks each state's tort provisions, uses multivariate analysis to measure the effects of strong versus weak enactments on paid claims, and identifies tort law patterns associated with high and low claims frequency and payment levels. Our results suggest that (1) the size and number of medical malpractice payments are affected by only some tort reforms; and (2) the pattern of reforms differs between states with high versus low levels of claims or payments.

The role of the national practitioner data bank in the credentialing process.

Federal law requires hospitals and permits other entities to seek information from the National Practitioner Data Bank (NPDB) but places no requirements on how that information should be used. Our survey of NPDB users demonstrates that although the NPDB has generated substantial controversy and its information is nominally available from other sources, it still plays an important role in the credentialing process. Most institutions make timely NPDB inquiries that facilitate widespread use of the information in credentialing activities (4-5 individuals or committees). However, in 3% to 7% of cases, a decision was reached before the institution had the NPDB report. Between 5% and 30% of privileging and licensure applications involving an NPDB report were not granted "as requested," suggesting the NPDB data are important to the process. Unfortunately, underreporting was also evident: 60% to 75% of reportable actions were not reported, limiting the information to which health care entities have access.

10 years beyond the Health Security Act failure: subsequent developments and persistent problems.

Ten years after the failure of President Clinton's Health Security Act (HSA), the United States continues to face multiple stresses in health care, including large numbers of uninsured individuals, increasing costs, questions about quality, and dissatisfaction with managed care. Using the framework of the HSA-particularly universal coverage, spending and managed competition, insurance for low-income persons, and patients' rights-the post-HSA evolution and current status of the US health care system is traced and lessons to guide future actions are outlined. Neither incremental legislation nor private sector changes in health care organization and financing during the past decade have ameliorated the problems addressed by the HSA, and new troubles have emerged. These problems affect every group in the country and continue to deteriorate health care, yet there has been no political support for large-scale reform. The core components of a vision for future action-universal coverage, quality improvement, cost containment, and subsidies for the economically vulnerable-are essential. There is a pressing need to construct a clear vision that would tie together incremental steps into a rational approach to comprehensive reform and to actually move toward the realization of that vision.

Impact of the National Practitioner Data Bank on resolution of malpractice claims.

Policymakers and commentators are concerned that the National Practitioner Data Bank (NPDB) has influenced malpractice litigation dynamics. This study examines whether the introduction of the NPDB changed the outcomes, process, and equity of malpractice litigation. Using pre- and post-NPDB analyses, we examine rates of unpaid claims, trials, resolution time, physician defense costs, and payments on claims with a low/high probability of negligence. We find that physicians and their insurers have been less likely to settle claims since introduction of the NPDB, especially for payments less than dollars 50,000. Because this disruption appears to have decreased the proportion of questionable claims receiving compensation, the NPDB actually may have increased overall tort system specificity.

How useful is the information provided by the National Practitioner Data Bank?

BACKGROUND: The National Practitioner Data Bank (NPDB) serves as a federal information clearinghouse on malpractice payments for and disciplinary sanctions against health care practitioners. Hospitals are required to query the NPDB biannually for practitioners with clinical privileges, and other health care entities with significant peer review are encouraged to query the NPDB. A study was conducted to determine whether health care organizations find the NPDB useful. METHODS: A survey was conducted of 1,038 organizations that queried the NPDB between March 1998 and February 1999; 653 of those respondents also answered questions regarding 1,639 specific matched responses (feedback from the NPDB when the practitioner in question had one or more reports). RESULTS: Overall, the entities rated querying the NPDB as very useful (6.16 on a 7-point scale). More than 21% of matched responses contained new information, and this information altered institutional credentialing decisions in more than 5% of the cases. DISCUSSION: Many of the results from this study are consistent with findings in Office of Inspector General reports. The fact that 5% of credentialing decisions were altered because of NPDB information suggests that practitioner self-report is an inadequate mechanism for soliciting credentialing information. SUMMARY AND CONCLUSIONS: NPDB reports provide accurate and complete information that is useful to providers in their credentialing process.

Physician and health system integration.

Incentives for vertical integration in the health care industry have led many hospitals to consolidate into health systems and profess a desire for closer alignment with affiliated physicians. In this study of fourteen organized delivery systems and their 11,000 physicians in sixty-nine medical groups, we found that many health systems did not align well with physicians. Even systems ostensibly committed to alignment emphasized structural relationships that did not enhance physician-system alignment and paid inadequate attention to issues of importance to physicians. This gap between the goal and reality of physician-system alignment appears to be the result of systems' responding to a changing mix of policies, not all of which foster integration.