Getting the most benefit from information systems consultants

Consultants are usually well-meaning people who enjoy the variety of organizations and problems they face in their work. Most do not like to get bogged down in fruitless and wasteful consulting engagement any more than managers of health care organizations like to supervise them, but at least the consultants are paid for their time. The health care organization that defines a project poorly, does not know what it wants from consultants, or does not direct consultants will pay the price in increasingly scarce resources squandered. The tips in the following article for managing an information systems consulting engagement apply to most consulting engagements and to the use of other expensive advisers, such as attorneys and engineers. But information systems is a field particularly foreign, and often threatening, to most administrators and physician executives, so the risk of wasting money on unsuccessful consulting engagements is high.     

Medicare and Medicaid: the first successful effort to increase access to health care

The passage of Lyndon Johnson's health care legacy, Medicare and Medicaid, in 1965 represents the last time that health reform legislation expanding access to care was successfully proposed and implemented in the United States. Access, of course, represents only half the pie in health reform, the other part being the organization of the health care system. There has never been any major legislation passed through both houses of Congress and signed by a President that changed the organization and delivery of health services. It seems certain that President Clinton will propose legislation dealing with both access to and organization of our health care system. Though it may not have seemed so at the time, President Johnson had it easy compared to the challenges confronting President Clinton.     

The ethicist

The 1990s seem drawn for major changes in the U.S. health care delivery system. After a quarter century of piecemeal changes to compensate for the cost dislocations caused by passage of the federal Medicare and Medicaid programs, legislators, moved by a high level of demand from buyers, third-party payers, and consumers, are at last positioned for some structural revamping. Nothing is certain, however, as evidenced by the shifting deadline for introduction of the current Administration's approach to solutions. In this article, the author uses a fictionalized scenario to imagine the status of our health care system in the year 2000. As in 1990, much will remain to be done, even if much will have been accomplished.     

Dealing with the demands of change

If evidence of the changes occurring in and confronting the health care field were needed, it was provided in abundance at the College's Perspectives in Medical Management meeting in Chicago in May. The presentations and the discussions among members buttressed the feeling that the health care field is proceeding through a period of transformation. The evolving system will be anchored on managed care, with special emphasis on the word "managed." The accoutrements of managed care--case management, demand management, utilization management, clinical guidelines and protocols, capitation budgeting, and the like--dominated discussion. The "business" of health care is proceeding apace. Maintaining a balance between the financial and quality elements of health care delivery has never been more important. And the definition of that balance will be determined at the local and regional levels. Federal initiatives are temporarily in abeyance. The challenge for physician executives is to assume leadership in moving their organizations, and thus the health care system, toward a new design that corrects present deficiencies and positions both to respond more effectively to the health care market. While it is not possible to cover all of the more than 60 speakers who addressed the meeting, this report, through presentation of the ideas of some key presenters, is aimed at measuring at least the boundaries of the challenges that lie ahead.     

Leading health care into the 21st century.

If there is a consistency in the professional lives of those who manage in the health care field, surely it is characterized by inconsistency. Change. For more nearly two decades now, since the full impact of the Medicare/Medicaid legislation hit, the health care industry has undergone profound, continual, and lasting change. Success can be measured largely in terms of how well a professional or an organization accommodates and manages these changes, making sure that they work for the organization and the career and not against them. The 1990s can be expected to be just as full of change and turmoil as have the past two decades. "What's past is prologue," Shakespeare wrote. The health care field is not apt to see the murderous machinations of The Tempest, but clearly exciting and challenging times lie ahead, and perhaps the outcome will be as positive as Shakespeare's. The scenario that follows provides a glimpse at the issues of change that will occupy the time and energy of physician executives for the coming decade.     

Strategic issues requiring public accountability: food for thought

Although the exact outline of U.S. health reform has become fuzzy because of political events, it seems clear that major changes in the manner in which health care is delivered and financed are under way. The initiative for the most part has been assumed by state government and by the health care field itself, as managed care becomes ever more entrenched and the health care system becomes ever more integrated. An expected outcome of these changes will be demands for greater public accountability on the part of health care providers and organizations. In this article, the author discusses some of the issues--professional compensation, documenting community service, ensuring public input into planning efforts, economic credentialing and quality of care, and managing ethics under managed competition--that will have to be addressed at the local level as these shifts take place.     

A conversation on the future of health care

An extensive amount has been written, reported, and spoken on health care reform. It is a time of turmoil and uncertainty in the health care field. There is a great deal of talk at the federal level on reform, but efforts there seem to be at least temporarily stymied. Much is happening at the local and regional level, however, as the health care field itself wrestles with the changes that have already occurred and with the promise of changes that lie ahead. In the following conversation between two fictional physician executives, one with many years experience, the other his junior, some of the issues surrounding health care reform are discussed. Although the specific environment for the conversation is managed care, most physician executives will find themselves somewhere in the conversation. let's eavesdrop as they speak, in the late summer of 1994.     

The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part II

In Part I of this two-part article, in the December 1994 issue of the journal, the author discussed the manufacturing theories of Peter Drucker in terms of their applicability for the health care field. He concluded that Drucker's four principles and practices of manufacturing--statistical quality control, manufacturing accounting, modular organization, and systems approach--do have application to the health care system. Clinical guidelines, a variation on the Drucker theory, are a specific example of the manufacturing process in health. The performance to date of some guidelines and their implications for the health care reform debate are discussed in Part II of the article.     

Zwischen Dank und Drohung: Supervision für Freiwillige im Flüchtlingsbereich

The current article deals with experiences in supervising volunteers in the refugee sector. The work in this field has some particularities. It operates between two extreme poles: enormous gratitude for this work on the one hand and threats against supervisors on the other. The author puts forward his thesis that we have to deal with a new generation of volunteers. Supervision has limitations, and organizational consulting can provide useful support in order to manage the work of volunteers optimally.     

Health care enters the real world.

The U.S. health care system is undergoing restructuring as a result of a complex interplay of social, political, and economic forces. Where once the medical profession had a monopoly position in the health care system, its position has been challenged by the Federal Trade Commission under the Sherman Antitrust Act. More and more, the health care field is characterized by entrepreneurialism, a concept that is at odds with the traditional tenets of the medical profession. The restructuring of health care in the U.S. has the potential to allow the entrepreneur to function to the benefit of patients, despite the fact that this is a change resisted by those providing health care services.     

The ethics of health care system reform

The United States is now engaged in a momentous national debate about health care. How can we provide the best care possible while simultaneously containing cost (to promote the general economic integrity of society) and somehow maintain a semblance of a free health care marketplace. This is not just a political question; it is also a question of ethics. It is an ethical consideration because the current debate is not just about designing or promoting health care systems that can best address our concerns for costs, quality, and accessibility. It appears that at least some participants in the debate would not stop at arguing their beliefs as valid; they would make their beliefs law. Some urge the creation of the right to health care as a matter of law. There are significant differences between beliefs and rights, however, and they need to be considered carefully in the ongoing debate over the future of this country's health care delivery and financing system.     

What is it like to work for a big five consulting firm? Interview by Barbara J. Linney

Is consulting for a big five a career direction you've thought about pursuing? In this column, Barbara Linney interviews physician executive Don Gessler, MD, MBA, CPE, FACPE, to talk about his experience in working for a big five consulting firm. He discusses how he got his position at ABC Consulting Firm, the nature of the work, the rigorous travel schedule, the pluses, and the type of physician executive that is satisfied in this environment. He describes some of the projects and tasks he has been involved in as a consultant. He emphasizes that if physicians don't like to do selling, consulting is not a place for them to be and that it is a very team-based structure.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.     

Health care reform. Pan American Uni-Care Health Insurance Plan

Something is definitely wrong with the American health care system. Too many citizens are denied health care, and health care costs continue to rise at an uncomfortable and intolerable rate. Ensuring care for all is a paramount goal. There is no way to simultaneously cover everyone; leave the reimbursement of physicians unrestrained; ensure instantaneous access to every imaginable high-technology service; subsidize the world's costliest and least efficient health bureaucracy; and contain costs. Widespread dissatisfaction in all quarters--physicians, hospitals, third-party payers, regulators and consumers--has led to an avalanche of reform proposals. Rapidly changing social, political, and economic environments; rising fiscal pressure; and an evolving understanding of the major determinants of health have also created pressure for changes. There are some new and hopeful signs that America is facing up to the need for changes in the health care delivery system. The Pan American Uni-Care Health Plan that is described in this article may serve as a reasonable balance among these competing priorities.     

The foundation for future health care.

In the March-April issue of Physician Executive, Thomas Ainsworth, MD, provided his view of the current status of health promotion within the health care delivery system. The potential, he wrote, is far greater than the realization to date, and physicians can have a significant role in the development of health promotion programs. In this article, the theory is posited that the prime factor in the failure of health promotion to achieve a more significant position in the health care field is inertia. The forces for the status quo have simply been too great to be overcome. However, consumers, providers, and payers are almost certain to be involved in a health promotion strategy that will revolutionize the health care industry.     

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.     

Spirituality and the care of patients at the end-of-life: an essential component of care

Spirituality is an essential component of the care of patients with serious illness and those that are dying. Dame Cicely Saunders developed the hospice movement based on the biopsychosocialspiritual model of care, in which all four dimensions are important in the care of patients. Of all the models of care, hospice and palliative care recognize the importance of spiritual issues in the care of patients and their families. The National Consensus Project Guidelines for Quality Palliative Care, in the United States, provides specific recommendations about all domains of care including the spiritual domain, which is recognized as a critical component of care (The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org). Studies indicate that the majority of patients would like their spiritual issues addressed, yet find that their spiritual needs are not being met by the current system of care. Interestingly, spirituality is the one dimension that seems to get slightly less emphasis than the biopsychosocial dimensions of care. Some reasons may include the difficulty with definitions of spirituality for clinical and research purposes, the time constraints and financial burdens in the current healthcare system in the United States, and the lack of uniform training for all healthcare professionals. Yet, there are theoretical and ethical frameworks that support spiritual care as well as some educational models in spirituality and health that have been successful in medical education in the United States. Spirituality can be seen as the essential part of the humanity of all people. It is at its root, relational and thus forms the basis of the altruistic care healthcare professionals are committed to. Spirituality has to do with respecting the inherent value and dignity of all persons, regardless of their health status. It is the part of humans that seeks healing, particularly in the midst of suffering. Spiritual care models are based on an intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where healthcare professionals address spiritual issues with patients and their loved ones. Currently in the healthcare system, evidence-base models are the criteria for practice recommendations. Yet, spirituality may not be amenable entirely to strict evidence-base criteria. As hospice and palliative care continues to develop as a field, healthcare professionals are challenged to think of ways to advocate for and include the spiritual dimension of care.     

What kind of leaders will be successful?

The U.S. health care system is fundamentally changing. The pace of change is swift but will vary, depending on regional market forces and state legislative mandates. This complex change is leading to rapid market consolidation of providers and insurers into organizations called "integrated health care systems." There is, as yet, no proven role model that will guarantee success. The purpose of this article is two-fold: To help individuals who see an expanding role for themselves in integrated health care management decide if they have what it is going to take to be successful. To identify individual management training needs by use of a self-evaluation tool. Some of the needed skills can be enhanced by education and experience. However, some are personality and style characteristics that may not be changeable.     

Strategic alliances. Partnerships with a purpose

During the past few years, health care providers, managed care companies, and insurers around the country have formed a variety of strategic alliances aimed at stemming runaway costs, broadening referral bases, and generally preparing for the formal arrival of health care reform and the mandates it may carry. The list of such ventures is long and creative, and it grows as major changes in the health care delivery and financing system become more imminent. In interviews with physician executives and others whose organizations have undertaken integration efforts, the author explores some of the arrangements that are already in place or under development.