The coming medical apocalypse.

Is there a medical apocalypse in our future? Will it happen soon? No one can say for sure, but five ominous trends suggest that a medical meltdown could occur at any time. These trends are: (1) The practice of providing medical care becoming too complex from both a business and a legal perspective; (2) Less money being spent on medical care without any corresponding reduction in services provided, creating long-term operating deficits; (3) Investor-owned, for-profit corporations changing the focus of medicine by putting shareholder concerns ahead of patient care; (4) Employment-linked health care insurance creating a growing uninsured population, adding extra financial stress to our hospitals; and, (5) Providers losing faith in their future and becoming increasingly demoralized about practicing the healing arts. These dangerous trends are considered, along with some suggestions that physician executives and organizations might take to protect themselves.     

Building a vertical provider system

There is probably no geographic area in the United States in which the health care environment is more turbulent than that of Southern California. Long before President Clinton's proposals began serious national debate on health care reform, a massive provider-driven realignment of the system was occurring in that region of the country. Multispecialty medical groups have generally led the way and have acquired ever larger managed care populations through merger and acquisition of other groups and practices. Hospitals, hampered by large fixed capital bases, have struggled to reinvent themselves as cost-effective and primary care-friendly environments in order to be attractive to managed care physicians. Almost ignored in this reconfiguration has been the university teaching hospital. This article discusses one attempt to reconcile contractually an integrated, capitated, and managed care-oriented health care system with an academic medical center in a strategic alliance.     

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.     

Health care reform. Gridlock and pork?

Can Americans expect the same gridlock and pork between now and the 21st Century? What are the possible directions that the United States can move in regarding health care reform and the long-term financing of health entitlement programs? Here, the author offers a snapshot of current politics and some predictions for the next four years. And explores the question: Are Americans willing to make the necessary sacrifices for future generations to profit by the significant changes needed by entitlement and health reform, or will it be business as usual? America's centrist perspective was recently reinforced by the 1996 election, suggesting that no major innovations in entitlement or in the health system should be anticipated in the next four years.     

Public hospitals: an assessment and plan for the future.

We are currently living in very difficult times for most health care providers. Even though we have always known it, the fact that resources for health care are limited is now abundantly apparent to consumers, health care providers, fiscal intermediaries, government (local, state, and federal), health care planners, and policy makers. Hospitals, especially, are being severely pressured to reduce resource consumption and costs. Conditions that are difficult for nonpublic hospitals are critical for public hospitals in general and nearly fatal for rural public hospitals. Fortunately, nonpublic hospitals are beginning to realize for the first time that their future depends, to a significant degree, on a strong and financially healthy public hospital system. If the public hospital, the hospital of last resort, closes, medically indigent patients will have to be treated in nonpublic hospitals, with the resultant medical, financial, economic, political, and social consequences. Therefore, the importance of public hospitals has to be even better recognized and appreciated and these institutions actively supported in order for the private and total health care systems to be successful.     

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.     

The Informatics Institute: why do we need it?

Why should physician executives care about medical informatics? For that matter, what is medical informatics anyway? Broadly defined, medical informatics is the study of the collection, storage, retrieval, and analysis of data and information in health care to support clinical and administrative decision making. Informatics is important because, in the past 10 years, powerful computer, software, and information technologies have been developed to enable health care organizations to automate some of the work of decision making, for improved quality of care and cost control, and for successful managed care contracting. This new emphasis on informatics in health care was the impetus for the founding by ACPE earlier this year of The Informatics Institute, which will be involved in educational and research activities in the growing area of medical informatics. In this new column in Physician Executive, Dr. Marshall Ruffin, President and CEO of the Institute, will discuss the role of medical informatics in health care delivery and financing and its relation to physician executives.     

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.     

Sustainability as the lynch pin of public policy and industry initiatives

Does managed care have a sustainable future? So far, managed care has not lived up to its promises and potential. Admittedly, the health care system prior to managed care was a non-system. But its features included committed health care professionals, caring local institutions, freedom of choice, and laws reflecting public confidence. And it was based on the assumption that needed health care services are a customary, moral, and implied legal right of U.S. citizens. In contrast, today's version of managed care is characterized by financial and legal manipulation, "choice" constricted by provider selection of physician panels, and laws reflecting lack of public trust. Managed care can survive its initial foolish years, if it heeds the voices of those urging that two priorities be reflected in public policy, legislative efforts, and business practices. One of these priorities is accountability for today's actions. The other is preserving this country's health care resources. This article explored the concept of sustainability--the need to strike a balance between seeking immediate profit and preserving available resources.     

Medical practices: hot properties of the '90s

The buying and selling of medical practices is big business around the country. Fueled by fears of where health reform is headed, frustrated by reduced reimbursements and mountainous paperwork, physicians are bailing out of solo practices, and small group practices are approaching large groups looking for safety in numbers. The large groups are aligning themselves with hospitals, and hospitals are luring large groups by offering to build them clinics. Clearly, this is a trend that will be heightened by anticipated structural reform of the health care system, but it is not without its dangers for all those who participate in the process.     

Hospital management's linchpin: the medical director.

The practice of medicine has become increasingly complex in this era of diagnosis-related groups (DRGs) and other direct government involvement in health care; complex and seemingly inappropriate legal decisions; liability chaos; and increasing competition from peers, entrepreneurs, and other health care organizations. In this new environment, an old player, the medical director (vice president of medical affairs) has been given new visibility and increased responsibilities to help physicians live with and overcome these environmental factors. In showing how the medical director can be of assistance in putting these factors into perspective, it is helpful to take a look at some aspects of the history of medicine, analyze the education process for physicians, point out where the profession began to be driven off course, and identify some of the overall problems of the profession and of the health care field. It is my intent here to project the position of medical director as a vital, frequently missing, link in the attempt to maximize communications, understanding, and achievement in health care organizations.     

从中国农民医疗保健支出行为看农村医疗保健融资机制的选择

我们是在一个市场环境中考察财政融资或医疗保险可能会对农民的医疗开支产生什么效应,这些效应又在何种程度上会影响财政平衡?本人绕过了关于农民对医疗服务与药品需求量的度量,证明了在一定条件下,我们可以根据消费者的货币支出量、支出比率、价格与收入,来估算需求的自价格弹性。我们发现,中国财政对卫生的公共支出占全国卫生总支出的比率,已到了世界最低行列！中国占人口80％的农民在非公共卫生支出中只占不到20％！中国西部(11省、区)的农民医疗卫生负担与东、中部农民相比,呈累退趋势:越穷负担越重！中国农村居民对医疗价格与药品价格的弹性为负,卫生支出对收入的弹性为正,因此,引入保险机制与财政补贴会产生医药开支的膨胀,膨胀系数为0.863！中国西部农民对医疗服务价格的需求弹性显著为负,且小于-1;中国东部农民对药品价格的需求弹性显著为负。在补助医还是补助药上,西部与东部应该采用不同的融资方式。计量结果表明,西部农民的看病、买药决策显著取决于收入水平;而在东部地区,这一关系不显著。财政支出在东部已经起到了降低农民医疗负担的功效;而在西部农村,则尚无这方面效果。     

Managed care matures. What's behind the wave of anti-HMO legislation?

At first glance, it may appear as if managed care itself may be doomed. The avalanche of bills, measures, initiatives, Federal regulations, etc., seemed overwhelming in late 1996. Did this, in fact, portend a national shift away from managed care? What does the consumer protection and regulatory activity really mean? What directions for the future can be identified? This article seeks to answer those questions and highlights a case study of "reform gone awry" that may hold lessons for the national scene. The anti-HMO legislation activity does not represent a repudiation of managed care. Rather, it may be seen as a maturing of the entire process of redefining our medical delivery and financing 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.     

Physician-sponsored networks. Will physicians take back medicine?

Until about the late 1980s, American physicians and their allies, hospitals and the health care manufacturing industries, dominated all facets of the health system--the clinical, the economic, and the political. The bulk of these providers' revenue flowed to them from a highly fragmented insurance system whose governing principle was to provide each insured patient free choice of doctor and hospital. Two distinct, concurrent shifts threaten to erode the medical profession's traditional dominance. The first is a rapid, general shift of control from the supply side of the health sector to its demand side. The second is a shift away from government control, over which organized medicine held much sway in the past, toward private regulators--the executives of the managed care industry. Is the trend towards greater dependence of practicing physicians on non-physician executives inevitable, or can physicians retain--and, in part, regain--their hitherto autonomous position in the health system?     

Leadership for the next millennium: the physician executive

We continue to muddle through using tourniquets and bandaids on a health care system that is in dire straits. And the future is even less promising. There will be millions without basic health care, let alone basic health care coverage. Rural and inner-city hospitals will close, with progressive public apathy, as we focus on the marvels of expensive technologies that serve only the few. Costs will continue to rise at double digit rates, and our nation's employers will fall further behind in the global marketplace. Preventive care will be uncommonly provided and only more rarely reimbursed, while a couple more children die of measles in Mississippi. It's not a pretty picture, and it simply doesn't have to come to pass. "What we really need is leadership," the public cries. That leadership can and should come from medicine through physician executives.     

Zur Bedeutung der Supervision bei stationärer Psychotherapie am Beispiel von psychosomatischen Kliniken

The importance of supervision in inpatient psychotherapy settings such as hospitals for behavioral medicineThis article deals with the organization of supervision in hospitals that offer intensive inpatient psychotherapy (hospitals for behavioral medicine). The ?integrative model“ for supervision proposed by A. Schreyögg (1991) constitutes the theoretical basis. The author discusses the qualification of supervisors as well as aspects of different approaches to supervision, such as the psychoanalytical and the cognitive-behavioral approach. In doing so, she puts primary importance on the reflection of issues on the systemic, i.e. organizational level. At the end, a model for the organization of qualified internal supervision is proposed.     

From managing access to managing care: the impact of primary care on health care delivery organizations.

Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.     

Shifting Concepts of Autonomy in the Hong Kong Hospital Authority

The Hong Kong Hospital Authority is the main provider of public health care services in Hong Kong. It operates 41 public hospitals, 74 general out-patient clinics and 45 specialist out-patient clinics. This article examines the reason for its establishment as a statutory body in 1990 and offers an assessment of its success in meeting the goals of the reformers. A belief that health care service delivery would be improved is largely supported by the evidence, but this may have more to do with budget and policy consistency than management autonomy and flexibility. Statutory independence, with its promise of improved efficiency, has its limits in the highly complex field of health where there are multiple players and where professional autonomy remains a key claim. In recent times, the authority has been subject to several reform attempts and, together with the SARS epidemic in 2003, these have had a significant impact on its organizational structure and practices, in particular, on its degrees of autonomy.

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Universities Need a Market Orientation to Attract Non-Traditional Stakeholders as New Financing Sources

Reflecting the level of priority currently attributed to public university financing in ongoing discussions, the objective of this article is to debate alternative forms of attracting resources from stakeholders not normally associated with the financing of public universities. We begin by detailing sources of university financing as it slowly migrates from the public sector to the market. After we move on to describe the main public university stakeholders and the respective relationships between the parties. Finally, our discussion focuses on different means and alternatives ways, to finance public universities through use of non-traditional stakeholders giving some examples. In conclusions we find that despite university managers normally being aware of such entities, the other internal university actors show a lack of pro-activeness regarding the opportunities presented by different stakeholders. So the public universities need to actively engage with the marketplace, and this reality can be achieved if at internal level they are assigned priorities for the relationships with these new stakeholders.