Important considerations in using indicators to profile providers

The demand is accelerating for information about the clinical performance of providers. In the more competitive and value-sensitive marketplace that is already developing, purchasers (consumers, employers, and insurers) of health care services will require more information to better assess the relative value of providers' (professional and hospital) services. The cornerstone of a wise, value-based strategy in selecting health care services is careful assessment of each provider's performance based on detailed, quantitative data in the form of clinical indicators. The use of indicators to profile the comparative performances of providers allows purchasers to compare as well as to influence provider performance.     

Demanding work schedules and mental health in nursing assistants working in nursing homes

Nursing home assistants have physically and emotionally challenging jobs, and they often work demanding schedules in order to provide 24-h care. While the physical effects of demanding work schedules have been studied, little is known about the impact on mental health. This study explored the relationship between demanding scheduling variables and mental health indicators of depression, anxiety and somatization. A cross-section of 473 US female nursing assistants working in nursing homes was surveyed. Work schedule characteristics included shiftwork, hours per day and week, days per week, number of weekends per month, number of double shifts per month, breaks, and number of jobs worked. Working two or more double-shifts per month was associated with increased risk for all mental health indicators, and working 6-7 days per week was associated with depression and somatization. There was a trend for increasing odds of adverse mental health with increased numbers of demanding work schedule factors. The odds of depression was increased four-fold when working 50+ h/week, more than two weekends/month and more than two double shifts/month. Providing work schedules that are less unhealthy may have implications for both worker retention and the quality of care delivered to nursing home residents.     

Demanding work schedules and mental health in nursing assistants working in nursing homes

Nursing home assistants have physically and emotionally challenging jobs, and they often work demanding schedules in order to provide 24-h care. While the physical effects of demanding work schedules have been studied, little is known about the impact on mental health. This study explored the relationship between demanding scheduling variables and mental health indicators of depression, anxiety and somatization. A cross-section of 473 US female nursing assistants working in nursing homes was surveyed. Work schedule characteristics included shiftwork, hours per day and week, days per week, number of weekends per month, number of double shifts per month, breaks, and number of jobs worked. Working two or more double-shifts per month was associated with increased risk for all mental health indicators, and working 6–7 days per week was associated with depression and somatization. There was a trend for increasing odds of adverse mental health with increased numbers of demanding work schedule factors. The odds of depression was increased four-fold when working 50+ h/week, more than two weekends/month and more than two double shifts/month. Providing work schedules that are less unhealthy may have implications for both worker retention and the quality of care delivered to nursing home residents.     

The consumer choice model: a humane reconstruction of the U.S. health care system

"Consumer choice," "defined contribution health programs," "voucher systems," and "health marts" are variations on a theme: employees buying their own health care. This new approach to health care purchasing, which is designed to minimize the role of employers, is being proposed by an array of economists and by both Republican and Democratic legislators as the best way to address the nation's health care ills. Although enabling national legislation is unlikely to pass soon, the debate will nevertheless change the face of health care in America. The prospect is reminiscent of the debate over "Clinton Care" in 1993--although legislation was never passed, managed care rapidly came to dominate the U.S. health care system. As this reform takes hold, beneficiaries will make their own health plan selections but will have more responsibility and may bear more cost. Providers will have to adapt to new, customer-driven requirements for performance, accountability, and communications but will also find opportunities in a marketplace that they will have a major role in shaping. Physicians, health plans, and insurers should understand how these proposals will transform their role in health care.     

Physician leadership. The time is now

During the past 30 years, third party payers have imposed virtually every imaginable form of external cost controls on the traditional health care system. All have failed. And now those paying the bills--the large-scale health care purchasers--have finally seized control. They are fomenting fundamental structural change in the health care system. In order to continue doing business with these purchasers, health care providers are finding that they must form alliances to present a comprehensive "package" of health services for the constituents of these purchasers. In short, they must form integrated delivery systems. Current developments have created a unique opportunity for physician leaders to take a commanding role in shaping the emerging American health care system.     

Capitation and informatics

When physicians, hospitals, and allied health professionals bill for services they render, their information processing requirements are relatively simple, at least compared to those of capitated organizations. When payers (insurers or employers) accept financial risk for the health care services of beneficiaries, they have usually invested in claims processing, membership tracking, and, under managed care, utilization review and provider profiling systems. But payers, for the most part, have not invested in electronic collection of clinical information about beneficiaries, nor have they tended to keep all claims they have processed in electronic form for study after accounts are settled and payments disbursed. In this article, we will explore why informatics is so important to capitated organizations and why payers that have traditionally taken financial risk for insuring the health care costs of populations are also learning about the importance of informatics.     

The protocol solution: a mildly acidic commentary

Protocols have captured the imagination of American's health care guru's. These self-proclaimed experts promise decreases in health care expenses of up to 25 percent if protocols for the appropriate use of expensive procedures are adopted throughout the country. With the establishment of several proprietary protocol companies and the push to develop national clinical guidelines, protocols have appeared on the health care scene with a vengeance. However, protocols will have dramatically different effects, depending on how and where they are implemented. This article will concentrate on the challenges of implementing protocols in a single health care institution, typically a hospital or a managed care institution.     

The pitfalls of managing contingency workers

Contingency workers have proven so cost effective that they may constitute half of the health care industry work force before the end of this century. However, because these workers don't have stakes in the companies and are bitter about losing their full-time jobs, they are often difficult to motivate and even more difficult to manage. In fact, their attitudes negatively affect the morale of their full-time coworkers and poison the overall work environment. The author offers some tips to make contingency workers feel more a part of organizations in hopes that their attitude and performance will improve.     

Are health providers still patients' chief advocates?

The pressures of competition and the health care marketplace have changed the relationship between health care providers and patients. Patients, and the third-party payers who control health care dollars, are less in awe of providers' prerogatives, and providers have become timid in asserting their rights and their knowledge in the health care equation. Providers can regain their role as patients' advocates, however, if they acknowledge the realities of the marketplace but are open in their dealings with patients.     

Why an MBA?

As physicians move into medical management, leaving clinical practice behind to play a major role in managing physician performance and clinical processes, they are having to deal in the business world. Physician executives are donning the pinstripe suit instead of the white coat, and adding a business acumen to their clinical skills. Many have opted to pursue executive MBA programs to learn the business competencies they need to manage health care organizations. This article summarizes the educational opportunities available in executive MBA programs and discusses the value of business training for aspiring physician executives.     

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.     

Health care futures. What lies ahead? Where are we going? Panel discussion

Who would have guessed that managed care would dominate the health care industry in the final two decades of the millennium? That physicians would be joining labor unions? Or that they would be going back to school to become Fellows of the American College of Physician Executives? To find out what may be in store for health care in America five to 10 years hence, The Physician Executive asked nine health care experts to participate in a two-part panel discussion. Here's what they see ahead in managed care, information technology, and biotechnology. Part 2 will appear in the July/August Issue of The Physician Executive.     

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.     

Defined contribution--the future for health care

Employers are seeing breathtaking health care premium increases. As action-oriented people, they are not going to cough up additional money to pay for these rate increases. The real question is what solution might employers move to? The most logical answer is defined contribution--a way that employers could give employees health benefit funding that resembles what they have already done in pension funding. Today, facing massive cost pressures from their health care premiums, many employers are wishing that they could create or use the equivalent of a defined contribution plan for health care. The next major evolution of defined benefit health financing needs the full-scope functional equivalent of a 401 (k) administrator to make the concept work--someone to give employers the tools needed for employees to make meaningful choices. Up until now, no one has been able to give consumers meaningful data about health care and health benefit alternatives. A viable 401 (k) health administrator will need to offer an array of choices that will work for all players.     

Reporting quality of health care to the board

The reporting of quality of health care to the governing board has long been an enigma. Now we are in the midst of a revolution in health care, as we shift our focus from solely the clinical performance of individuals to a broader scope of assessing and improving all activities around patient services and patient care--i.e., management outcomes integrated with clinical outcomes to help identify opportunities to improve patient care. In addition, apprised of corporate liability for the quality of care provided in health care organizations, governing boards are raising questions and demanding more information. To maintain this high degree of interest in quality of health care, information should be restricted to what the board needs to know. This article will be confined to the hospital's organizationwide quality system of monitoring and evaluating. While medical staff credentialing and privileging are also board responsibilities and quality management activities should be used in the privileging and credentialing process, they will not be addressed in this article.     

In-house recruiters: on the inside looking out

Few smaller hospitals or managed care companies have in-house physician recruiting departments. Their low hiring volume simply doesn't support such an operation. But most health systems and large managed care organizations say they literally couldn't afford to be without an internal system for the recruitment of physician executives and other health care professionals. They also claim they can find a better candidate faster than their counterparts on the outside. A number of them explain why.     

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.     

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.     

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.