The future of American health care in the "post-reform" era

"As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems.     

PAs/NPs: forging effective partnerships in managed care systems

Three issues have dominated national health policy discussions over the past three decades--how to control health expenditures, how to improve access to care, and how to ensure delivery of high-quality health services. Cost remains the principal societal concern today. An important new dimension in this debate, however, is a critical examination of the impact of the structure of the nation's health workforce on health expenditures. Within this examination, policy makers are giving specific attention to the supply of health professionals, the role of primary care, and the identification of the most appropriate professionals to deliver primary care. In particular, a renewed interest is being shown in the potential of physician assistants (PAs) and nurse practitioners (NPs) to address all three issues. This article will examine the factors that prompted this focus on health workforce issues and the implications of the use of PAs and NPs for the structure and management of the health workforce in the future.     

Self-directed health plans: alternatives to managed care enabled by new technologies

Few people believed the Internet would have much impact on the delivery of health care services. However, combined with technological advances in how computer systems are structured and implemented and knowing what doesn't work in managed care from bitter experience, the Internet is being used to create a new paradigm of alternative health insurance products. These products hold the potential to change for the better the face of health care as we know it. Self-directed health plans will be less expensive than managed care programs and offer greater predictability in health care spending. For health care providers, SDHPs' reliance upon episode allowances will create a new market for packaged or bundled services. Providers will be paid to provide solutions, not just treatment. This could represent a new model in which physicians accept a risk-adjusted payment and provide a warranty that they will do whatever necessary until the patient has reached the reasonably expected health status. This is a radical departure from the fee-for-service or capitation system.     

The role of the coordinator of care

Regardless of the specific outcome of the current health reform debate in Washington, it is likely that major changes to the health care system are in the offering. These changes, many of which are already in place or imminent in some locations, will have a major impact on the evolving relationships between physicians and hospitals. Most expect that these changes will accelerate the development of integrated health care delivery systems that will compete in the marketplace for a mixture of public and private health insurance dollars. In this system of "managed competition," health care dollars will flow to those systems that can ensure the best clinical outcomes while using the least economic resources. In this scenario, competing collaborative health networks that can manage the continuum of care will be central to the health care delivery system. The economic and political ties between physicians and hospitals will become more closely linked as government and private payers of health care services foster the development of these integrated, value-based health care delivery systems.     

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.     

Lessons from the Soviet health care system

The United States and the former Soviet Union have historically organized health care delivery systems according to totally different paradigms. These two divergent approaches have constituted a kind of natural experiment. At the present time, our systems may be becoming more alike, with the former Soviet system decentralizing and even experimenting with forms of medical insurance. Our system, on the other hand, has become much more regulated and, if some have their way, would become increasingly monopsonistic. At this critical point, it may be useful to learn from each other's experiences as we plan for the future.     

Important points in managed care contracts

Health care is increasingly managed through some contractual relationship. Such contracts vary and the contracting entities may be clinics, universities, health maintenance organizations, individual practitioner organizations, preferred provider organizations, corporate health plans, or other structures. It is estimated that within 10 years more than 70 percent of all health care will be provided through some type of managed care plan.     

Constitutional guarantees to health care in Spain

This analysis of the Spanish health care system is one in a series of such studies undertaken by the author, following a grid of factors that influence the delivery and financing of health care. The purpose of the national analyses is to facilitate a comparison of the United States' and other health care systems in terms of anticipated reform of the U.S. system. Analyses of the U.S. and nine other national systems are included in a book that has just been published by the College. Spain and nine additional countries will be studied in a book due for publication later this year. A final book with ten additional national analyses will appear in 1996.     

Purchasers and the impact of managed care on physicians

In much the same way that demands by managed care organizations are shaping the way physicians practice, health care purchasers impact how managed care organizations operate. Corporations purchase managed health care through their employee benefits programs, and understanding the language, objectives, and limitations of these purchasers is essential to grasping the forces influencing managed care organizations and the modern practice of medicine. The emergence of value-based purchasing as a strategic corporate approach to health benefits programs will dictate the forces on physicians, hospitals, and managed care organizations for years to come. These forces have already led to price reductions, health plan accreditation, employee-directed report cards, outcomes management, and organized systems of care, and they will determine the broad outlines of the emerging U.S. health care system.     

Success in managed care: improving clinical quality

What are the economic elements for success in managed care? Although they are quite simple, achieving them can be difficult. The criteria for success in the fee-for-service medical delivery system, generally characterized as "see more--do more--get more," are no longer valid for delivering care in a managed care system. This article identifies the economic elements for success in managed care, and offers a disciplined approach to achieving them, combining both actuarial and clinical expertise.     

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.     

Practicing managed care in the academic medical center

The purpose of this article is to outline the contrasts between the traditional AMC and an organization oriented toward the delivery of population-based managed care. Academic medical centers differ from one another considerably in the extent to which they serve as quaternary care community resources, the degree to which they emphasize primary care in training and care delivery, and the amount of research undertaken. Nor is there a single organizational structure for managed care; successful managed care is practices in IPAs, multispecialty groups, PHOs, and staff-model HMOs. Nonetheless, the contrasts outlined here between AMCs and managed care organizations (MCOs) are valid in most cases.     

Strategic positioning. Part 1: The sources of value under managed care

Part 1 of this series organizes and discusses the sources of value against a background of an evolving managed care market. Part 2 will present, in more detail, the marketing and financial challenges to organizational positioning and performance across the four stages of managed care. What are the basic principles or tenets of value and how do they apply to the health care industry? Why is strategic positioning so important to health care organizations struggling in a managed care environment and what are the sources of value? Service motivated employees and the systems that educate them represent a stronger competitive advantage than having assets and technology that are available to anyone. As the health care marketplace evolves, organizations must develop a strategic position that will provide such value and for which the customer will be willing to pay.     

What's ahead on quality: the managed care perspective

Without question, the most important processes occurring in managed care that can be expected to affect quality are accreditation and the effort to obtain and compare uniform information on quality of care across health care organizations, in short, to create "report cards." For both processes, 1993 was an extremely productive year, and 1994 promises to be even more so. These two processes fit hand-in-glove--one is designed to determine that managed care organizations are equipped to serve the public and to implement better health care programs, while the other is designed to help them understand and improve their own performance. Although, in the short run, managed care organizations may view both these efforts as additional costs, in the long run, both should lead to a better industry and to better care for the public.     

Does managed care need to be replaced? "Father" of managed care unveils new plan.

In a recent speech at the Graduate School of Management, University of California, Irvine, managed care architect Paul M. Ellwood, Jr., MD, outlined an ambitious vision for a dramatic new business model and clinical plan for health care of the future. Here's the complete text of his landmark speech, along with an update on where the plan stands today.     

The health of health care organizations

Abstract

This paper explores the nature and development of health care organizations in terms of a model of organizational healthiness. The model places particular emphasis on the psychosocial subsystems which describe the subjective organization. These represent the perceived internal functioning of the organization in terms of task completion, problem solving and staff development. The implications of such a model for the well-being of health care staff and for the evaluation of service delivery are discussed.     

Credentialing in managed care

Through the use of managed care techniques in recent years, the insurance industry has tried to bring the runaway costs of medical care under control. The result of this control effort is system access limitations, compared to the full choice indemnity plans of the past. This limited system access has now clearly moved HMOs and other managed care organizations into the category of "potentially liable health care entities," based on patient steerage, economic disincentives, and limited choices of the plan's participating providers and facilities. Just as hospitals have had to exercise rigorous care in the credentialing of members of their medical staffs, managed care organizations will have to ensure that the providers they use meet acceptable standards of competence.     

The future of managed care: the debate continues

The Patient Access to Affordable Care Act has acted as a catalyst in the health care debate over the future of managed care. The Employee Retirement Income Security Act, once a sacred cow, is now under intense scrutiny. Congress is laying the ground work to create consumer protections in health care, but time in this legislative session may run out. If Congress acts this year, there could be a fundamental shift in the control over health care.     

The appointment-keeping habits of managed care patients

Among the controversies surrounding the provision of health care in a managed care environment is the belief that patients, because they have no particular allegiance to a single physician, are more casual in regard to their keeping appointments. To test this proposition, the authors conducted a study at a California independent practice association, comparing the habits of managed care patients with those of other types of patients. The findings, although based on a limited sample, suggest that managed care patients do indeed have a greater tendency to be appointment no-shows.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.