Primary care networks: choose your physicians wisely

As hospitals and health care systems maneuver for a position in the integrated health care delivery system, no initiative is more important than building an effective and competitive primary care network. Yet this critical initiative is fraught with potential pitfalls. In their haste to develop primary care networks, hospitals and health care systems may fail to thoroughly evaluate network participants and in turn create large, inclusive, and inefficient primary care networks that don't come close to breaking even, much less repay practice acquisition costs. In an effort to become more efficient, practitioners often find themselves in the unenviable position of "de-selecting" peers retrospectively. The author presents criteria for evaluating and selecting network physicians.     

Re-forming the traditional organization medical staff

The traditional, two-bylaws-model organized medical staff was created in another age (1919) to serve a simple health care system, controlled by physicians, in which the only players were patients, doctors, nurses, and small hospitals. This medical staff model does not meet the needs of the U.S. health care system of the 1990s. The purpose of this article is to provide the physician executive with a resource to use when he or she is called on to help determine what, if any, changes are needed in his or her organization to make the role of physician leaders more effective. Finding the right answer to this question is part of discovering ways to reduce health care costs without reducing the funds available to pay for direct delivery of health care services. Maintaining traditional, bureaucratic, legalistic organized medical staff activities is a very expensive game that we can no longer afford to play.     

Medical practice in large-scale organizations.

The traditional role of the physician as the principle resource allocator in the health care system is rapidly giving way to a shared decision-making. As more and more physicians practice in large organizational settings, an adversarial relationship is developing that affects both the quality of care and the efficiency of medical practice.     

Models for medical practice integration

Decreased physician income, increased administrative burdens, and interference with the compassionate delivery of high-quality medical care are threatening the independent practice of medicine in solo and small group practices. Many established physicians, and the hospitals with which they relate, are searching for organizational models that, by integrating some or all aspects of their practices, will preserve incomes and reduce regulatory and administrative burdens. This article will describe several "practice integration models," pointing out advantages and disadvantages to physicians in established practices. (Many of the same arguments could be made for physicians new to practice, with different emphasis). The continuum of integration models is shown in figure 1, page 19. The group practice without walls and its two submodels, the independent group practice without walls (IGWW) and the affiliated medical practice corporation (AMPC) are more recent and more effective models and will be covered in depth in the article.     

The psychosocial work environment of district nurses in Sweden

Data were collected from a stratified sample of district nurses in the greater Stockholm area on four occasions during one year using questionnaire techniques (to assess psychosocial working conditions and social networks, and self-reported health sums); as well as physiological measurement techniques. Three groups of district nurses were compared: group A, those working independently in the 'traditional' role but outside primary health care centres; group B, those working independently in the 'traditional' role but in primary health care centres; and group C, those working in the model role as part of primary health care teams. The study focused on the effects of these different work environments on the district nurse's psychological and somatic health, and their physiological state.

The data suggested that district nurses in the primary care teams (group C) had a lower objective work load than those working in the more traditional role. Despite this, they reported a less favourable balance (ratio) of work demands to decision latitude. They reported more 'problems' and 'conflicts' at work than did the other district nurses. However, such 'problems' were diminishing during the study period, which could mean that successive adaptation to the 'new' situation was occurring. The 'conflicts', on the other hand, remained. This may indicate that despite this adaptation, the district nurses in the primary care teams were struggling with their new work roles. It points to the need for organizational support during this important change process. The district nurses in group B (traditional role but in a primary health care centre) had the highest objective work load and showed physiological reactions in terms of elevated plasma cortisol levels in the morning, high systolic blood pressure and sleep disturbances.     

How leader role identity influences the process of leader emergence: A social network analysis

Contemporary theories on leadership development emphasize the importance of having a leader identity in building leadership skills and functioning effectively as leaders. We build on this approach by unpacking the role leader identity plays in the leader emergence process. Taking the perspective that leadership is a dynamic social process between group members, we propose a social network-based process model whereby leader role identity predicts network centrality (i.e., betweenness and indegree), which then contributes to leader emergence. We test our model using a sample of 88 cadets participating in a leadership development training course. In support of our model, cadets who possess a stronger leader role identity at the beginning of the course were more likely to emerge as leaders. However this relationship was only mediated by one form of network centrality, indegree centrality, reflecting one's ability to build relationships within one's group. Implications for research and practice are discussed.     

Physician payment in Canada, Germany, and the United States

As the debate about reforming the U.S. health care system intensifies, interest has focused on three alternative delivery systems: the predominantly private-sector model in the United States, the provincial-government health insurance model of Canada, and the social insurance model of Germany. The organization of physician payment is an important part of all these health care systems. To maintain an affordable system that delivers high-quality care, payment to physicians must be sufficient to attract and maintain an able group of doctors, while not exceeding an amount that the country can afford. In this article, these three systems will be examined, and an attempt will be made to apply the lessons learned from Germany and Canada to the direction of physician payment reform in the United States.     

考虑空间随机需求的急救站点选址规划

随着人民生活水平的提高和人口老龄化加剧，公众对急救医疗服务的要求越来越高。为保证急救需求的响应及时性，急救站点的选址规划问题受到广泛关注。急救站点选址的依据是需求的分布，然而现有研究未能充分考虑急救需求在空间分布上的随机性影响，通常将其空间分布简化为若干个集中需求点，或将规划空间划分为若干矩形网格，然而这种需求刻画过于粗略，导致需求覆盖水平的计算不够准确，影响配置方案的有效性。针对该问题，本研究应用高斯混合模型解决了急救需求的空间分布刻画问题，创新性地提出基于高斯混合聚类的站点选址规划方法，考虑急救需求时空随机性，建立了相应的机会约束规划模型。实际数据的验证分析表明，该选址方法能够显著减少服务延误时间和次数，保证急救服务的响应及时性。     

Optimal Designs for Estimating the Effective Dose in Developmental Toxicity Experiments

Recent advances in risk assessment have led to the development of joint dose-response models to describe prenatal death and fetal malformation rates in developmental toxicity experiments. These models can be used to estimate the effective dose corresponding to a 5% excess risk for both these toxicological endpoints, as well as for overall toxicity. In this article, we develop optimal experimental designs for the estimation of the effective dose for developmental toxicity using joint Weibull dose-response models for prenatal death and fetal malformation. Based on an extended series of developmental studies, near-optimal designs for prenatal death, malformation, and overall toxicity were found to involve three dose groups: an unexposed control group, a high dose equal to the maximum tolerated dose, and a low dose above or comparable to the effective dose. The effect on the optimal designs of changing the number of implants and the degree of intra-litter correlation is also investigated. Although the optimal design has only three dose groups in most cases, practical considerations involving model lack of fit and estimation of the shape of the dose-response curve suggest that, in practice, suboptimal designs with more than three doses will often be preferred.     

Providing health care to human beings trapped in the poverty culture

The culture of poverty impacts everything patients in this socioeconomic group think and do. If what poor patients say does not sit well with the way we think, that doesn't mean they are wrong. Physicians have to adjust their mental model and think in different cultural terms. The author recently completed his thirtieth year of a career dedicated to providing health care to people living in poverty. He shares seven concepts important in building a mental model that will enable physicians to successfully provide health care to this patient population: (1) Poverty is the number one health problem; (2) we see same diseases as everyone else; (3) patients are trapped in the poverty culture; (4) patients' behavior is often manipulative; (5) compliance is a unique challenge; (6) patients have limited resources; and (7) the ultimate contributors to poverty are unwanted adolescent pregnancy and substance abuse. These concepts can help physicians to be more effective in providing health care to patients living in poverty. They can help them understand what is happening, so that their experience might be fulfilling rather than demoralizing.     

Attitude adjustment

How can you motivate physicians so that their decisions and behavior reflect what is best for the group practice, instead of themselves or their department? By clearly stating expectations and goals, physicians can learn that the priority must be the success of the group practice. Presented here is an example of how the Orlando Health Care Group (OHCG), a primary care medical group with 85 physicians in four specialties, addressed this challenge and the physicians' positive response to the change. To survive as a group, the OHCG had to abandon old ways of managing conflict and agree upon a list of core values around which it could evaluate all future physician behavior. The list became known as the "10 Commandments." They were meant to give every individual a sense of place and purpose within the group, knowing that the best way for an individual to prosper was to be part of a successful group.     

Economic feasibility of a primary care practice

To make informed career decisions, the new physician must acquire basic skills in medical management and health care economics and learn how to evaluate the potential survival and growth of a primary care practice. The authors have developed a model designed to aid physicians in determining the economic feasibility of establishing a practice in a specific community or joining an established practice.     

Merging medical groups

One of the trends of the past 10 years that has marked the way physicians practice medicine is growth in the size and complexity of group practice. The reasons for these changes (better patient coverage, within-the-group referral, a larger financial base, a collegial environment, shared overhead, professional management, and packaged negotiation) are clear and are certainly valid. This trend shows few signs of slowing and may be accelerating. Indeed, most of the proposals for national health care reform seem likely to put larger groups at a competitive advantage. We have developed a highly effective procedure that helps improve the efficiency and the success of the merger process.     

Is leadership born or made?

Is leadership born or made? By profiling three colleagues who made the transition from clinician to top-flight executive in a health care organization, the author provides case studies from which to discuss leadership issues. An evolutionary pattern has developed with respect to physicians changing careers: The first model was the medical director, followed by the vice president for medical affairs, and finally the move to managing the health care system, group practice, or managed care organization. Are physician executives fundamentally different from clinicians in terms of leadership characteristics? What are the essential qualities needed to lead health care organizations? These questions are explored in-depth.     

Primary care: the driver in health care reform

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.     

服务业员工工匠精神的结构维度探索与测量量表开发

采用定性和定量研究方法相结合的方式,借助扎根理论对服务业员工工匠精神的结构维度进行了探索性研究,并在此基础上开发并检验了测量量表。研究结果表明,服务业员工的工匠精神是一个具有丰富内涵的多维度构念,包含职业承诺、服务追求、持续创新、能力素养、履职信念、传承关怀6个维度,其测量量表由6个因子、24个题项构成。因子分析的结果表明,所开发量表的信度和效度检验均达到理想水平。     

The physician executive "arrives"--a new generation prepares for the future

The recent rise in the number of physician executives in the health care industry vividly demonstrates that a genuinely new generation of physician executives is seeking to combine the sensitivity of their clinical skills with the business acumen that today's health care organizations need to prosper and grow. But physicians who are preparing themselves to be selected one day as chief executive officers by hospitals, integrated systems, and managed care organizations should understand that the CEO role is radically different from that of the CEO of a physician practice. The corporate CEO role requires the management of managers and responsiveness to the organization's board. Those who imagine that the corporate CEO role bears any resemblance to the autonomous, independent existence of the practitioner are certain to have a rough time.     

Assess your quality of care quotient

The upsurge of large, single/multi-specialty group practices in contemporary health care has precipitated a corresponding surge in marketing strategies aimed at promoting group speed, efficiency, and/or productivity. Subsequently, the quality of care is often overlooked or redefined in financial terms. However, assessing quality of care--above and beyond strictly economic factors--can provide crucial information for executives concerned with making informed managerial decisions. This article explores one prototypical physician group's quest to assess their "quality care quotient," and explicates the process by which they obtained important data from patients, as well as how they used the assessment to improve their practice. The process may serve as an exemplar to physician groups concerned with conducting such analyses.     

An evolving medical leadership position. Tomorrow's Vice President for Medical Affairs

The role of medical leadership in hospitals and health systems is under constant scrutiny and change. The nature of the Vice President for Medical Affairs (VPMA) position and its relationship to leadership in the health care system is explored through a national panel survey conducted recently. The effective VPMA will: be an aggressive manager able to implement change, address strategic planning and quality of care issues; have a high level of integrity; and be a good communicator and problem solver. The results of the research are presented in three sections. The first section describes the background characteristics and compensation of the VPMAs who participated in the survey. The second section focuses on the current role of the VPMA, including duties and responsibilities, job performance barriers and required skills. The final section addresses respondents' perceptions regarding areas for improvement in the role of the VPMA, as well as projections for future changes in this position.     

Twenty steps to survive managed care.

The health care industry is in the midst of discounted, price-driven, managed care. Many older physicians, not wanting to practice in this environment, are opting for early retirement. Others sell their clinical practices to management companies or hospitals to avoid the economic reality of day-to-day financial management. Most of these private practices are losing money every year. However, there still are a large number of physicians who have not sold their practice. As capitation continues to grow, these physicians will experience severe cash flow problems unless their financial plight is addressed rapidly. If it is not, the resultant cash flow problems will cause accounts payable to grow. Twenty steps are outlined that a physician or group should take right away to maintain a healthy cash flow. These include: Instituting a nurse triage system, setting up an after-hours clinic, getting the co-pay at the time of service, implementing a patient satisfaction questionnaire, monitoring the capitation reports, and checking capitation lists.