Promising, and delivering, health care value

It came as no surprise a year or so ago to read in Physician Executive that "Clinical decision-making is no longer the exclusive domain of the health care practitioner." The authors pointed out that consumers, as patients and as business-payers, are insisting on provider accountability, both in quality and in appropriate cost. They used the phrase "health care value" to show a balance between cost containment and quality. One managed care operation has decided to operate on the premise of health care value.     

A historic, geographic, cultural, and economic guide to Australian health care

This is the first in a series of articles that will explore the health care systems of countries around the world. To begin the series, the President of the Royal Australian College of Medical Administrators describes the current status of the health of his country's people, its health care delivery system, and how it has responded to historic, geographic, cultural, and economic factors that characterize the growth and development of Australia.     

25 Health care trends. What's hot,what's not,and what does the future hold

As we usher in 2003, America's health care system remains in a chaotic state. Will managed care live or die? Will quality improvement efforts pay off? Are we ready for the next bioterrorism attack? Will the shortage of physician soon rival the shortage of nurses? To help gauge where health care stands today and what the future holds, The Physician Executive asked doctors who serve on ACPE's peer review panel to list the hottest health care trends in the U.S right now. Then, we took the list to three respected health care futurists -- Leland Kaiser, PhD, Jeff Goldsmith, PhD, and Russel Coile, MBA -- and asked them for their insights on the trends. Yes, Kaiser, Goldsmith and Coile are opinionated. Yes, they're controversial. But no matter whether you agree or disagree with their views, the three health care futurists' comments could spark discussions that will help shape U.S. health care this year and beyond. The trends are presented in no particular order.     

Customized clinical case management for chronically ill patients. Health system sees remarkable results with teams of case managers,physicians, patients

Securing excellent care and positive outcomes for seriously ill, high-risk patients requires extraordinary measures. A health system in Georgia is experiencing strong results by taking a team approach to health care with case managers, physicians and patients working together.     

The rudiments of an Internet-based health plan for consumers: an interview with John Danaher, MD, MBA. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed John Danaher, MD, MBA, on August 16, 2000, to discuss how his new company is preparing for the perfect storm--the looming convergence of demanding consumers, defined contributions, and Internet-based health plans. He describes how his firm is putting financial and clinical tools in the hands of consumers and physicians, so consumers can be more enlightened in their health care choices. Danaher says, "We're not about buying goods and services online. We are transforming the way consumers buy health care and seek insurance. We're trying to be a 401 k where people get on, knowing their risk profile and return horizons. We aim to motivate consumers to be proactive in making health care choices. How do we make consumers responsible and motivated enough to take control of managing their health care costs? How well we articulate this call to consumer action will be the key to our success."     

Physician executives: managers first, clinicians second

The literature is replete, many would say depressingly so, with accounts of the changes that are rocking the health care delivery system. The demands on the system's leadership increases with every change. And the future holds even more changes, with a level of uncertainty that will makes today's demands seem childplay. Physicians, especially physician executives, will surely be key factors in helping the system maintain its fundamental charge of high-quality patient care provided at reasonable cost, but what exactly is expected of them? One point is clear: While their clinical backgrounds will continue to arm them well for reaching the executive suites of health care organizations, physicians who hope to fully succeed in management will have to acquire and master a widening range of management skills. An indication of just how demanding the health care management job will be is provided in this report, based on interviews with physician executives and the people who seek and sell their services.     

Merging, de-merging, and emerging at Deaconess Billings Clinic

Complexity theory offers a powerful model for effective mergers of health care organizations that differs substantially from customary approaches. Exploring how Deaconess Billings Clinic in Montana evolved from two separate and very different cultures provides insight into how organizations can apply a complex adaptive system (CAS) model of mergers to create more truly integrated health care systems. DBC's merger illustrates the phenomenon of emergence in complex systems, whereby structures arise that are not a synthesis of the pre-existing cultures or the result of a new culture being imposed. Instead, the merger is understood as an ongoing, self-organizing process appropriately characterized by fits and starts, feelings of uncertainty, and other natural challenges of change and growth. By squarely surfacing the distinct cultures of the organizations through abundant interaction, relationship building, and information flow, differences can be creatively transformed, resulting in deep-seated change and the emergence of a genuine, shared health care system culture.     

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.     

Integrated planning for health care organizations, especially hospitals

Planning in health care organizations is of considerable current interest in this country. Furthermore, effective planning processes require, as a necessary condition for that effectiveness, development within a framework which considers the organizational, managerial and service delivery environment.This paper examines the concept of planning in relation to health care organizations. Through an examination of the effects which proper planning can have upon industrial organizations the authors analyze the possible impacts of planning procedures upon health care institutions. Their analysis leads to certain tentative conclusions as to appropriate organizational structure which could support effective planning. Whilst the authors have yet to test their hypothesis the conclusion they draw from their initial analysis are worthy of further investigation.     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.     

Health care futures, Part 1. The emergence of the new health care consumer. Panel discussion

In Part 1 of this second annual panel discussion, six experts examine the new health care consumer. The whole concept of the patient as consumer still makes people uneasy when it's applied to health care. Whether you prefer consumer, customer, purchaser, end-user, ultimate buyer, or beneficiary, one thing's for sure: Many of us are as different from the bygone patient as an HMO is from the general practitioner who made house calls. One of the reasons for many Americans' new interest, knowledge, attitudes, and expectations about health and health care is the Internet, the second topic in this discussion. In Part 2, physician executives from the three leading physician practice management companies (PPMCs) join Jeff Goldsmith, Barbara LeTourneau, and Uwe Reinhardt for a spirited exchange about this burgeoning new industry in the American health care sector. They will tackle questions such as: Are PPMCs delivering what they promise? What will separate successful PPMCs from the rest? Can PPMCs meet Wall Street's earnings expectations and also help physicians deliver better care? When PPMCs win, who loses? And, what roles will physician executives play in PPMCs?     

A case of wrongful use of quality management. Summit Health, Ltd., v. Pinhas

Summit Health, Ltd., v. Pinhas liberalized the jurisdiction of the Sherman Antitrust Act to include cases of intrastate hospital credentialing. The U.S. Supreme Court decision eased the requirements for plaintiffs to sue when they perceived that health care organizations were acting as monopolies. The court removed the defense that a plaintiff had to prove that the decision of a health care organization affected interstate commerce for the case to be heard in court. Important as the case is in antitrust law, however, greater lessons can be gained by health care organizations from analyzing the events that led to the lawsuit.     

The eternal triangle: cost, access, and quality

No matter who is in charge of health policy, no matter what his or her ideological bent, no matter whether the economy is in boom or bust, three concerns stubbornly dominate the discussion: the cost of care, access to care, and the quality of care. The main variation among them is that normally each in turn receives the most attention from policy makers, payers, and the public, over time.     

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.     

Greening the health care supply chain: Triggers of change,models for success

A historic agreement signed in July 1998 between the American Hospital Association (AHA) and the U.S. Environmental Protection Agency (EPA) signals changes in waste management in the health care industry. The agreement, which calls for a fifty percent reduction of hospital waste by 2010, will not only have an impact on hospital facility managers, but throughout the entire healthcare supply chain. As this article argues, improving the environmental impact of the health care industry should start with the health care delivery institutions themselves. The health care industry has a long way to go in addressing its environmental impacts, compared to the energy and chemical industries, for example. One reason is that these industries are raising their suppliers' environmental performance. Health care delivery institutions can effectively pull environmental performance requirements through the entire supply chain as well. This can be accomplished by examining supply chain strategies of leading industries and firms and considering the role of environmental management systems such as a ISO 14001 throughout the entire chain.     

Study tour examines health care systems in Germany, Holland--Part I: A comparison of three health care systems

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and onsite visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. Beginning in this issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. This first report compares the health care delivery systems of the United States, Germany, and Holland. In subsequent reports, the German and Dutch health care systems will be described in greater detail and the ability of the United States to adopt European health care systems will be assessed.     

An emergency department perspective--Part III, Outcomes

The outcome of care has traditionally been defined as a "change in the patient's current and future health status that can be attributed to antecedent health care." However, this definition provides a "unidimensional view of quality." It fails to take into account the customer's attributes and the many small steps or process variances that can contribute to an unexpected outcome. This failure can be especially pronounced in the emergency department.     

Management,Competition and Professional Practice: Medicine and the Marketplace

Within the context of the creation of the internal market for health care, the paper examines the role of clinical directors, that is doctors who have retained their professional clinical positions whilst at the same time assumed roles as managers within increasingly well-defined corporate organizations providing health care. This represents considerable change from previous contexts in which doctors could always contract out of difficult managerial decisions. The role of clinical director is examined in terms of its own directorate and its involvement in contracting, co-operation and competition both within its own corporate organization and within the wider market place for health. Key issues are raised for the individuals and organization by these changes, they are discussed in terms of time, succession, managing colleagues, financial and human resources, market behaviour, support and terms of reference. These changes occasion wider discussion in terms of the challenge of coping with future demands for innovation, changes in the distribution of power within an emerging market for health care and the relationship among health care organizations, professionals and lay clients.     

Leading beyond the bottom line, Part 4. The questions it has raised

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.