The role of organizational ethics committees

Health care services are increasingly provided in an atmosphere that is fractured by conflicting ethical concerns. This trend had been most noticeable in institutional settings. In response, hospitals have for many years had ethics committees. Their purpose has been to guide providers, patients, and families when decisions with ethical implications have to be made. The shift in focus within the health care delivery system away from hospitals and more to managed care systems and to domination of decision making by primary care providers suggests that expansion of the ethics committee concept may be advisable.     

Möglichkeiten der Öffentlichkeitsarbeit für Krankenhäuser

Possibilities of public relations for hospitals While it is normal for hospitals in the USA to advertise or to do public relations, it is rather uncommon in Germany. Since hospitals in Germany are faced with rising competition and budget restrains of the public health system it seems they are recognizing more and more, that it is difficult to compete in the market without doing public relations. Therefore basic possibilities to reach certain target groups with public relations are presented. Subsequently the case of the Schlosspark-Klinik demonstrates, how it is possible to create public relations, which are strictly oriented towards the main strategy of the hospital.     

Transfer of ownership: antidote to closure

In the 1990s, many hospitals will continue to be confronted with financial, regulatory, and medical staff issues that threaten their survival. Inadequate reimbursement, HCFA certification problems, and aging medical staffs are just a few examples of the many difficult issues health care institutions face today and that have contributed to the phenomenal number of failing hospitals. Failing hospitals must consider all their options, such as turnaround process, modification of service mix, change to a specialty hospital, transfer to a new owner, or closure. Selection of the most appropriate option hinges on the hospital's goals and mission, its need in the community, and its owner's and sponsor's desire or ability to continue in the health care business. This article will discuss the transfer of ownership option.     

Patient Hochschulmedizin

Patient university medicine. Changes of the legal framework of university hospitals in the context of the German health reform The situation of university of medicine can be compared to that of ?a servant of two masters“. Issues of performance and financing as well as legal regulations and administrative procedure have their roots in both the academic and the health system. While medical training is unthinkable without hospital practice, the ?supra-maximalist care“ produced by university hospitals is absolutely essential in the interest of public health. Out of the complexity of teaching, research and medical care grow valuable additional results but also above average costs which could reduce the competitiveness of university hospitals, once the change of financing to DRGs as a consequence of health reform is generally applied. The problem is made worse by outdated academic decision structures, by unsuitable buildings and by the lack of public funds for their structural maintenance and modernization. With this situation in mind the Federal States of Germany in the mid nineties began to search for alternative sources of investment and for a more efficient legal framework. The article explores the question which proposed solutions were subjects of discussion and why the concept of a public law institution became the favourite in the end.     

Hospitals' newest challenge: designing in quality

The job of producing high-quality products is even more difficult for health care providers than it is for those in manufacturing, where the quality movement began. As a part of the service industry, health care providers are in the position of producing products and delivering services at the moment of sale. Our task is to improve the quality of all of these simultaneous and interrelated processes. Traditionally, health care providers have made efforts to improve their products and services without realizing the impact that could be made by also improving resources, processes, and outcomes. This article is an overview of the new direction we have been taking: Retrospective review. Critical pathways. Building quality into all areas (resources, processes, products and services, and outcomes). Focused study of outcomes). We foresee a further evolution that will lead to exciting new methods for understanding and delivering high-quality care.     

Diagnosis-related group system. Can we still earn a living caring for sick people?

Medicare and Medicaid patients are starting to enroll in managed care organizations, as government tries to lower costs of caring for the elderly, disabled, and poor. Because they are the most likely to be sick, taking care of them imposes serious risks on hospitals and medical groups. The federal government uses the diagnosis-related group (DRG) system to reimburse hospitals. The system depends on physicians documenting diagnoses and complications. Physicians see illness as unpredictable, and so feel that detailed documentation of severity is futile. The government and health plans nevertheless follow case mix index and create hospital and physician profiles, relying on the existing imperfect system. For providers to be recognized for the value they add to the care of the sick, physicians must learn to use the DRG system to best advantage, or risk being driven out of business.     

Medical resource allocation: rationing and ethical considerations--Part I

The United States' system of high-quality but expensive and poorly distributed medical care is in trouble. Dramatic advances in medical knowledge and procedures, combined with soaring demands created by growing public awareness, the cost of private hospital and medical insurance, and Medicare and Medicaid, are burdening the medical care delivery systems. The costs of medical care have reached levels that can no longer be sustained. Government officials, insurance planners, labor leaders responsible for union health care benefits, and ordinary citizens are questioning whether it is acceptable to limit health care based on economic considerations. If health care is deemed a social good, the method of allocation must be addressed. Unless society decides that other priorities of the infrastructure are to be subjugated to health service delivery, difficult decisions will be forced upon us, consciously or by default. The discussion in this two-part article explores the ethical considerations of the more formalized approaches to resource allocation that presently exist in our society.     

Health care's power brokers in the 21st Century. Interview by Donna Vavala

Health care has undergone turbulent change in the 20th Century. In addition to dramatic pharmaceutical and technological advances, the entire health care delivery system has been significantly improved. Through all the turmoil, hospitals have been at the center of the health care universe. But, as the 21st Century approaches, that may change, too. What will become of hospitals, which for most of this century have played a commanding role? Will managed care organizations and group practices come out on top? And, once the new power broker takes over, what will be the impact on providers, insurers, and the government, and how will their relationships to each other change? Jeff Goldsmith, PhD, President of Health Futures, Inc., Bannockburn, Ill., and health care futurist, examines tomorrow's health care delivery system and makes some eye-opening predictions.     

The ascendancy of primary care: permanent or temporary?

The conventional wisdom strongly suggests a health care provider food chain for the future: Primary care physicians (PCPs), principally family practitioners, on the top playing the lead role, distantly followed by specialists, with hospitals and other ancillary services even further down the line. Is this a reasonable expectation? Will PCPs dominate the new systems? Or will they be but one of many equally necessary components of these developing integrated health care delivery organizations? Looking at the various models now developing, it would seem that future integrated delivery systems will utilize both PCPs and specialists, but with strong augmentation from a diverse assortment of other health care professionals, including nonphysician providers, educators, and administrators. To separate the illusion of primary care dominance of the coming health care system from the likely reality, we should first determine what is driving the apparent present demand for primary care physicians. Next, we will examine the possible and probable reactions to that demand from an economic standpoint and from the points of view of both health care professionals and the public. Finally, we must try to picture how health care provider organizations of the future are likely to look and how they will integrate their health care professionals.     

Formatting and presenting quality data to medical staffs and hospital boards

A host of historical and practical precedents have made hospitals responsible for the quality of care rendered within their facilities. The medical staff and the board of trustees share in this responsibility. Increasing demands for demonstrative evidence of the quality of care in an institution have made the process data-based. There is no substitute for specific data on the performance of both the hospital and its providers in the delivery of care. The trick, however, is in presenting this information to the medical staff and the board in a fashion that will be understandable and that will still maintain confidentiality of provider and patient. The authors offer a presentation system that has met with success in their community hospital.     

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.     

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.     

Veteran's health care: time for a change?

The Department of Veterans Affairs' mission is "to care for him who are shall have borne the battle for his widow and orphan." The Veterans Health Administration comprises 172 hospitals that are the hub of the health care delivery system. It is the largest provider of graduate medical education, and one of the major research organizations in the United States. The medical care budget exceeds $17 billion annually. Most of the persons cared for are not legally entitled to this health care based on service connected disability. The utilization of acute care hospital beds appears excessive when compared to that obtainable with managed care for Medicare or commercial insurance beneficiaries--the cost per member per month is three times higher. There may also be exploitation of the Veterans Administration hospitals by university medical schools. The Veterans Health Administration is a very expensive way to deliver care to entitled service connected veterans. Therefore, it is suggested that privatization be considered as an alternative vehicle for delivering health care.     

Credentialing, the most important function for success

After years of attempting to control costs by changing providers' behavior and practice patterns, it has become apparent that the solution lies in the study and cooperation of practitioners. Computers, reports, analysis, and payment reforms have discovered the truth: Many physicians and hospitals have always provided high-quality care efficiently. Costs will be controlled when these providers dominate the health care delivery system.     

Competition and The Operational Performance of Hospitals: The Role of Hospital Objectives

We examine the effect of a hospital's objective (i.e., non‐profit vs. for‐profit) in hospital markets for elective care. Using game‐theoretic analysis and queueing models to capture the operational performance of hospitals, we compare the equilibrium behavior of three market settings in terms of such criteria as waiting times and patient costs from waiting and hospital payments. In the first setting, a monopoly, patients are served exclusively by a single non‐profit hospital; in the second, a homogeneous duopoly, patients are served by two competing non‐profit hospitals. In our third setting, a heterogeneous duopoly, the market is served by one non‐profit hospital and one for‐profit hospital. A non‐profit hospital provides free care to patients, although they may have to wait; for‐profit hospitals charge a fee to provide care with minimal waiting. A comparison between the monopolistic and each of the duopolistic settings reveals that the introduction of competition can hamper a hospital's ability to attain economies of scale and can also increase waiting times. Moreover, the presence of a for‐profit sector may be desirable only when the hospital market is sufficiently competitive. A comparison across the duopolistic settings indicates that the choice between homogeneous and heterogeneous competition depends on the patients' willingness to wait before receiving care and the reimbursement level of the non‐profit sector. When the public funder is not financially constrained, the presence of a for‐profit sector may allow the funder to lower both the financial costs of providing coverage and the total costs to patients. Finally, our analysis suggests that the public funder should exercise caution when using policy tools that support the for‐profit sector—for example, patient subsidies—because such tools may increase patient costs in the long run; it might be preferable to raise the non‐profit sector's level of reimbursement.     

Can doctors and administrators work together?

The working relationship between physicians and health care organizations has dramatically changed since the introduction of competitive factors. Fifer suggests that future doctors may have as many as five or six economic relationships with their associated health care system, in contrast to the singular role as admitting physician of the past. The physician will continue to admit patients, but may also belong to an HMO or some other joint venture (freestanding ambulatory care center, outpatient laboratory, etc.), be salaried part time for leadership roles, be a leader in some other parallel economic venture, etc. Physicians are already assuming multiple roles as health care providers, private entrepreneurs, and joint venture partners with hospitals. Hospitals and health care systems also continue to change through vertical and horizontal integration. Traditional clinical departments are becoming blended into product line entities, and a sophisticated executive team of market-oriented specialists now augments the traditional administrative leadership. So, from a tradition of predictable roles, relationships, and authority structures, we are now attempting to thrive and prosper with many new partners in an integrated, complex, and conflict-ridden set of interrelationships.     

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.     

Information technology, Part 3. The technology hierarchy

The era of the networked society--and medical care depending on networked intelligence--is dawning. Physicians need to plan for office practice information systems in common, with an eye to conveying data electronically between all the locations of care and all the providers involved in caring for defined populations of people. The shared database will become the most important asset of the collection of providers who make up the delivery system that creates it. This will be accomplished by layering technology on local and wide-area networks of group practices, hospitals, health plans, and payers and developing standards that make data accessible in the same format to all users, no matter where they are.     

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.     

Hospital role on decline.

The era of hospital dominance of the health care field has ended. The new day will belong to insurers and payers. Health maintenance organizations will become the primary actor on the health care scene. If PPOs are added to HMOs, and by 1990 most PPOs will look like HMOs, 70 percent of the U.S. population will be enrolled in such plans. By that time, at least 10 percent of the nation's hospitals will have disappeared.