The relationship of impending death and age category to treatment intensity in the elderly.

The purpose of this study was to isolate and quantify the age-related treatment intensity differential in elderly clients (n = 278) with functional disability in one managed care setting. For those who died during the study, treatment intensity changes for the last year and month of life were examined. The subjects were categorized into four age groups: 75-79 years; 80-84 years; 85-89 years and 90 + years, and a treatment intensity index was calculated for each group using a ratio of actual to expected costs. Indices of overall costs and cost per day for all clients, and also indices for the year and month prior to death for the deceased clients were calculated. The results clearly show that for all clients, the oldest age group was treated less intensively than the youngest age group. For the deceased clients, the older age group was treated less intensively than the youngest age group in the last year and month of life but, for all age groups, the intensity of treatment increased during the last month of life.

What price an additional day of life? A cost-effectiveness study of case management.

OBJECTIVE: To examine the costs and benefits of a case-management program for an elderly, functionally impaired population in a managed care setting. STUDY DESIGN: A post hoc, cost-effectiveness study of case management. SUBJECTS AND METHODS: As part of a larger study, 317 elderly, functionally impaired clients were randomly assigned to a case-managed or regular-care group. During the 2-year study period, 34 clients in the case-managed and 43 clients in the regular-care group died. A post hoc analysis of the difference in average total cost per person, death rates, and average number of days of exposure per person were assessed to determine the cost per life saved and cost per additional day of life. RESULTS: Although the average costs for the case-managed group were greater than the costs for the regular-care group, clients in the case-managed group lived an average of 106 days longer. The cost per additional day of life was $40. The difference in death rates was so small that, by extrapolation, the cost per life saved was over $42 million. CONCLUSION: Although the case-management program was more costly when viewed from a purely fiscal perspective, it may very well be considered a success when its benefits are evaluated. The case-management program improved quality and was associated with prolonged life at a cost of $40 per day of additional life. Additional research involving other patient populations, study settings, and case-management models is warranted.

Rat protein kinase c zeta gene contains alternative promoters for generation of dual transcripts with 5'-end heterogeneity.

Protein kinase C (PKC) zeta is a phospholipid-dependent serine/threonine kinase that appears to perform important cell signaling functions. Two forms of PKC zeta RNA, with different 5' ends, have been reported. The major form (zeta) is expressed in most, if not all tissues, while the minor form (zeta'), which encodes the catalytic domain of the enzyme without most of its regulatory domain, is predominant in normal brain and certain rat prostate tumors. We report here the structure of the 5' end of the rat PKC zeta gene, demonstrating that both forms of RNA can be transcribed from the same gene through the use of alternative promoters and splicing. In luciferase reporter constructs, progressive deletions of the PKC zeta and zeta' 5' flanking sequences yielded activities that were higher in the cell lines expressing endogenous PKC zeta and zeta' RNAs, respectively. Also, multiple PCRs across different introns of the PKC zeta gene indicate that recent duplication of the gene or the existence of a closely related pseudogene in the rat genome are unlikely.

The relationship between self-assessed health status, mortality, service use, and cost in a managed care setting.

This article explores the extent to which Self-Assessed Health Status (SAH) can contribute to the development of capitation and premium rates by predicting mortality, service use, and service cost in an elderly population in a managed care setting. Those who rated their health as poor were three times as likely to die, and service use and cost were positively associated with those who rated their health as poor. Performance indices based on the ratio of actual-to-expected cost within each SAH category suggest a more aggressive treatment of those who rated their health as poor.

Case management and the cost of care in the last month of life: evidence from one managed care setting.

Elderly, functionally disabled enrollees in a managed care organization were randomly assigned to case management or regular care. The service use and cost of care for the last month life for the case managed deceased is compared with that of the regular care group. The results suggest that contrary to general expectation, the managed care clients experienced greater use and costs of care in the last month of life.

Case management of the elderly in a health maintenance organization: the implications for program administration under managed care.

Kaiser Permanente initiated a two-year demonstration ambulatory case management program in its Ohio region to evaluate five outcomes: perceived health status, functional status, and satisfaction with care, service use, and service costs. Expected results were not consistently obtained for the five outcome measures. Treatment group members did not, however, experience the functional status impairments or decline in health status perceptions reported by the control group during the study period. The unexpected finding that costs were not affected may be attributed to the type of case management intervention used in the demonstration program. This study is broadly applicable to managed care settings facing the challenge of developing programs to minimize the risk for bearing the costs of the Medicare beneficiaries' overall health when all services are not covered. Managed care administrators should be favorably disposed to implementing a case management model with the potential for affecting functional status, the most significant predictor of expensive continuing care for this cohort of Medicare beneficiaries, while working to develop more effective protocols and resource control strategies.

Happy employees lead to loyal patients. Survey of nurses and patients shows a strong link between employee satisfaction and patient loyalty.

A strong relationship exists between employee satisfaction and patients' perceptions of the quality of their care, measured in terms of their intent to return and to recommend the hospital to others. Employee dissatisfaction can negatively affect quality of care and have an adverse effect on patient loyalty and, thus hospital profitability. Therefore, health care marketers should regularly measure employee satisfaction as one way to monitor service quality. Health care marketers must work more closely with their human-resource departments to understand and influence employees' work environment and maintain a high level of job satisfaction. Marketers also should place an increased emphasis on both employee and patient perceptions of satisfaction when developing internal and external strategic marketing plans and formulating future research.

Managing financial risk with options on futures.

With the rise of managed care and capitation, more providers will be sharing in the financial risk of providing care. To help protect their organizations from the risk of unexpectedly high utilization under such a fixed-payment system, healthcare financial managers soon will be able to use options on futures contracts. These contracts provide wide profit potential but limited loss potential. Before investing in options on futures, however, healthcare financial managers should consider issues such as basis risk and trading costs.

Providing services to obstetrical patients: an overview and implications.

Obstetrics is one of the few hospital services with the potential for developing favorable client relationships resulting in increased market share, repeat purchase behavior, and referral of other patients in a direct marketing environment. To determine what qualities women find appealing in an obstetrics service and if women's preferences for a specific type of birthing arrangement had been examined and reported, a review of the literature was carried out. After reviewing the extant literature, the article provides strategic implications for health care marketers.

Offsetting unexpected healthcare costs with futures contracts.

Group health insurance futures contracts will be traded at the Chicago Board of Trade in the near future. These contracts may be useful devices for capitated systems, such as health maintenance organizations (HMOs), to hedge unanticipated increases in the costs of providing health care. This article discusses how futures contracts may be used by an HMO to prevent financial losses that arise from unexpected increases in inpatient utilization.

The effect of PPS on hospital product and productivity.

The results suggest that Prospective Payment System (PPS) prompted a reduction in the proportion of Medicare patients that were discharged, for whom the hospital considered the episode of care to be completed. The results also show a reduction in the proportion of patients discharged dead. When controlling for patient type, the results support the findings, but the magnitude of the change that might be attributed to PPS is somewhat smaller. Proportional changes in the input measures for all patients were next considered. The results indicate that fewer diagnostic tests, fewer laboratory tests, and fewer x-rays were used in 1984. Laboratory tests showed the most dramatic decrease. LOS decreased, but the drug input remained fairly constant. A productivity index that reflects the change in the input measure while controlling for patient type was developed. The results provide strong evidence of a productivity increase in all products for Medicare patients. The drug input did not contribute to the productivity increase. The 50 most frequent DRGs for Medicare patients were examined separately for productivity changes by product. The results further support the findings of an increase in productivity.

Growth status and the risk of contracting primary tuberculosis.

A case of open tuberculous infection in a member of staff at a primary school resulted in an outbreak in which nearly a quarter of the children in the school contracted a primary infection. The growth status of these children was compared with that in the non-infected children before the outbreak and on two occasions after the outbreak. The children with tuberculous infection were taller and fatter than the controls before and after the outbreak but differences were not always statistically significant. Among children with a good nutritional status the thin and small child is at no greater risk of contracting primary tuberculous infection than other children.