Schmidt C, Mohr A, Möller J, Levin-Scherz J, Heller M
Klinik für Allgemeine Chirurgie und Thoraxchirurgie, der Universität Kiel.
Rofo. 2003 Sep;175(9):1198-206. doi: 10.1055/s-2003-41935.
A large regional health plan in the Northeastern United States noted that its radiology costs were increasing more than it anticipated in its pricing, and noted further that other similar health plans in markets with high managed care penetration had significantly lower expenses for radiology services. This study describes the potential areas of improvement and managed care techniques that were implemented to reduce costs and reform processes.
We performed an in-depth analysis of financial data, claims logic, contracting with provider units and conducted interviews with employees, to identify potential areas of improvement and cost reduction. A detailed market analysis of the environment, competitors and vendors was accompanied by extensive literature, Internet and Medline search for comparable projects. All data were docu-mented in Microsoft Excel(R) and analyzed by non-parametric tests using SPSS(R) 8.0 (Statistical Package for the Social Sciences) for Windows(R).
The main factors driving the cost increases in radiology were divided into those internal or external to the HMO. Among the internal factors, the claims logic was allowing overpayment due to limitations of the IT system. Risk arrangements between insurer and provider units (PU) as well as the extent of provider unit management and administration showed a significant correlation with financial performance in terms of variance from budget. Among the external factors, shared risk arrangements between HMO and provider unit were associated with more efficient radiology utilization and overall improvement in financial performance. PU with full-time management had significantly less variance from their budget than those without. Finally, physicians with imaging equipment in their offices ordered up to 4 to 5 times more imaging procedures than physicians who did not perform imaging studies themselves.
We identified initiatives with estimated potential savings of approximately $ 5.5 million. Some of these initiatives are similar to the reforms to reduce cost and improve quality that are already implemented or proposed within the German healthcare system.
美国东北部一个大型区域健康计划指出，其放射学成本增长超过了定价预期，还进一步指出，在管理式医疗渗透率高的市场中，其他类似健康计划的放射学服务费用显著更低。本研究描述了为降低成本和改革流程而实施的潜在改进领域和管理式医疗技术。
我们对财务数据、理赔逻辑、与供应商单位的合同进行了深入分析，并对员工进行了访谈，以确定潜在的改进领域和成本降低点。对环境、竞争对手和供应商进行了详细的市场分析，并通过广泛查阅文献、互联网搜索和医学文献数据库搜索类似项目。所有数据都记录在Microsoft Excel(R)中，并使用适用于Windows(R)的SPSS(R) 8.0（社会科学统计软件包）通过非参数检验进行分析。
导致放射学成本增加的主要因素分为健康维护组织内部或外部因素。在内部因素中，由于信息技术系统的局限性，理赔逻辑导致多付款。保险公司与供应商单位（PU）之间的风险安排以及供应商单位管理和行政的程度与预算差异方面的财务绩效显著相关。在外部因素中，健康维护组织与供应商单位之间的共享风险安排与更有效的放射学利用以及财务绩效的整体改善相关。有全职管理的PU与没有全职管理的PU相比，预算差异显著更小。最后，办公室配备影像设备的医生开出的影像检查程序比自己不进行影像研究的医生多4至5倍。
我们确定了预计可节省约550万美元的举措。其中一些举措类似于德国医疗保健系统内已经实施或提议的降低成本和提高质量的改革。
