The coming alliance revolution in health care

Like it or not, the health care profession is being "shifted" into a revolutionary new world. The question is not will it change but rather how will it change? Who will determine its fate? What form will these changes take? What are the best alternatives for physicians, institutions, health care workers, insurers, employers, and, most importantly, patients? Some of the changes will come from government mandate, others from market forces. To understand what the future might bring, we should look at both the driving forces behind the changes and how other industries have responded to similar forces. An important consideration for health care professionals will be how, if at all, the concepts of collaboration and cooperation that are inherent in networking and alliances will guide their planning.     

Physician manpower needs under managed care. How to determine the need for MDs by specialty

The concern in the last quarter century in the United States over the shortage of physicians has now been supplanted by the fear of an excess number of doctors, particularly among the subspecialists. This article outlines four methodologies to be used in parallel to determine by clinical specialty whether a predetermined population base has an inadequate, sufficient, or excess number of physicians. Based on various assumptions, physician-population ratios per 100,000 persons for 28 clinical disciplines are supplied. Possibly the most intriguing questions as a result of this study are whether a broad spectrum of HMOs will use general internists or family practitioners as their prime "gatekeepers;" and, whether, in the long-run, the fiscal incentives inherent in the managed care concept will result in a more frugal utilization of physician services.     

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.     

Negotiating. Biases physicians bring to the table

What are some of the obstacles that physicians face as they seek to become more effective at the bargaining table? The author's thesis, based on experience in both the classroom and the front lines of medical practice, is that physicians face a set of systematic "biases" derived from physician training and professional culture that make negotiation especially difficult for them. They outline the biases they have observed, explore some possible explanations, and suggest solutions for physicians who wish to negotiate more effectively.     

I can't believe they think I'd...

Many physician executives experience a personal jolt as they move to work in a very different relationship with their colleagues. What happens? How can we understand this phenomenon? What can we do to minimize the personal toll so often exacted by the transition to leadership? This paper will focus on these essential questions. The inevitable discomfort encountered during this learning curve, which can last from two months to two years, often comes as a surprise. Many physicians who have been elevated to leadership positions because of their success and interpersonal acceptance, have not had to struggle with this sense of being "a fish out of water" since very early in their professional careers. Unless there is someone in place to reassure and mentor, the resulting confusion can be quite unnerving, resulting in reflex defensiveness.     

The physician glut: a different view. Interview by Donna Vavala

An interview with nationally known futurist Leland Kaiser, PhD, on the changes physician executives are likely to face as a result of the coming dislocation in the health professions. Or will there be a shrinking career pie at all? The real question is: What new mental models are we going to use and as a result of the new models, what new jobs are going to be created that will ameliorate some of the surplus we've created in the old model? Dr. Kaiser predicts a model will soon emerge that will open a myriad of new career opportunities for physicians. The new model he foresees is community-based medicine.     

Get real: what will draw physicians to the Web?

What are physicians waiting for? What will it take to stimulate widespread adoption of Internet medical systems? How can health care leaders and physicians help the technology innovators and the executives of technology firms understand the components necessary to assure physician acceptance and utilization of new tools? (1) Don't underestimate the personal nature of a physician's practice. It really isn't a "business." (2) Most physicians are not Luddites; they are just extremely pragmatic and practical. (3) For the majority of physicians to adopt a new technology in their private office practice, it must address three major issues: money, hassle, and patient care. There are many obstacles to adopting the new technologies that are the result of physician training and expectations and the current models of payment and revenue generation. Some technological innovations are presented to physicians without sufficient respect for their knowledge of how medical practices really work. The benefits promised often don't match with the needs structure of the physicians. As a consequence, the cycle of diffusion of these new systems is extended and delayed.     

Administrative fellowships in emergency medicine

Physicians today need to be effective managers, as well as clinicians. In previous years, physicians gained managerial experience either through on-the-job training, degree programs, or continuing medical education courses. The specialty of emergency medicine began its first administrative fellowship in 1990 in California. Currently, three administrative fellowships exist nationally in emergency medicine. This article will describe the purpose of the fellowships and their curricula. Each fellowship has a different emphasis, with the goal to educate physicians who are interested in developing administrative skills to manage emergency departments or management groups or accept roles in hospital leadership. The existence of these fellowships will ideally influence the establishment of administrative fellowships in other specialties.     

Legal issues in accepting capitation

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.     

The challenge for women physician executives

After half a century of constituting 5 percent of the physician population, women will soon make up more than one-third of U.S. physicians. Women now practice in virtually every specialty. This enormous change has created both opportunities and tensions. Within the broader context of the changing role of women in U.S. society, women physicians are exploring new career paths--paths that are both similar to and different from those of their male colleagues. A future challenge for women physicians will be achieving significant representation in the medical management ranks.     

The future of health care, Part 2. The PPMC debate. Panel discussion

In Part 2 of this second annual panel discussion, Jeff Goldsmith, Barbara LeTourneau, Uwe Reinhardt, and physician executives from three physician practice management companies (PPMCs) examine this burgeoning new industry. They grapple with questions (and occasionally with each other), such as: Are PPMCs delivering what they promise? What will separate successful PPMCs from the rest? When PPMCs win, who loses? What value do PPMCs add to health care? What lies ahead for this industry? Could Wall Street pressure cause PPMCs to put profit ahead of physicians and patients? And, what roles will physician executives play in PPMCs?     

Is there a physician union in your future?

Physician unions are in the news. Patient management and patient care decisions are increasingly being taken out of the hands of physicians and put into the hands of "The Suits." To take their case for a return to physician-driven patient care to the people, some physicians are joining unions. Some are even collectively bargaining for salary and other issues that are historically more closely associated with unions. The simple fact is that physician unions exist and the number of physicians joining them is expected to increase. What are the pros and cons of unionization? What motivates physicians to join unions, and what potential negative and positive factors are associated with physician unionization? This article reviews the pros and cons and the issues related to physician unions, for physicians attempting to answer the question, "Is there a union in my future?"     

Physician executive contracts: negotiating the future

Once viewed as a matter of standard protocol, physician executive contracts have become as complex as the health care industry itself. Historically, hospital administration and physicians negotiated a few key points, then sent the ideas to an attorney for insertion of standard legalize and boilerplate. Today, physician executive contracts are an important part of the changes in health care. They not only cover traditional hospital and physician relations, but increasingly apply to new types of relations (such as employment) between hospitals and physicians, physicians and physicians, and health plans and physicians. In this article, we will explore both the "content" and the "context" of physician executive contracts. Content will deal with the specific provisions typically included in contracts. Context will address issues associated with preparing for and negotiating a contract.     

The new breed

Structural changes within the health system--particularly in the organization and financing of services--have made new and different opportunities available to physicians interested in management. What types of physicians are currently going into management? How do they compare to others who have been in management for a longer period of time and to the "traditional" portrait of the physician executive? The author profiles the emerging, contemporary physician executive and explores the implications for the viability of the field of medical management as a whole.     

打工与回乡:就业转变和农村发展——关于部分进城民工回乡创业的研究

“民工潮”之后出现的“创业潮”受到社会的普遍关注。如何认识这种现象的产生和发展及其理论意义,对城乡就业和农村发展产生了什么样的影响,以及政府应采取什么样的态度和对策,是本文研究的主题。民工回乡创业作为外出打工的一种派生现象,对拓展农村就业,发展县域经济有着重要的积极意义;对促进农村城镇化发展有积极的影响。如何认识和对待民工回乡创业现象,在学术界存在着不同看法,本文讨论了与其相关的认识和实践问题,对民工回乡创业作了客观的评价,并从分析影响民工回乡创业的因素入手,提出了适应民工回乡创业的政策调整意见。     

If patients are now "customers," what does that make physicians?

As patients become "members" and "customers," as physicians become "practitioners" and "providers," the practice of medicine becomes more complex and more demanding. The changes that have affected the daily lives of physicians across America will continue and will likely become even more dramatic in the future. There is much to mourn in the passing of the medical practice of the recent past, but there is every reason to celebrate the ongoing triumphs of medicine and its successes in improving the human condition. The job of being a physician is not becoming any less important. The job has just gotten tougher. Successful physicians will cope with the multitude of changes in which the health care field is engaged and make themselves effective agents of change within their organizations.     

The courageous follower

With the recent changes in the delivery of medical care in the United States, physicians are being thrust into new and unsettling roles. Many are finding themselves for the first time in the role of the follower, subject to myriad types of leadership. Leaders frequently complain that leading physicians is like "herding cats." What are the characteristics of followers? Do physicians make good followers? This article examines the role of the "cats"--what is effective followership, why physicians may fall short in followership skills, and how physicians might become better "followers."     

Forming physician organizations. Part 2: The underlying reason a PO succeeds: an offense, not defense

How has Community Health Partners been able to move the ball down the field toward the goal of a preferred network in its community? What are the specific offensive strategies CHP has implemented to bring about its vision? Part 1 of this series explored five reasons for CHP's progress: (1) A working, knowledgeable board of respected physicians, (2) A board that moves ahead on simultaneous tracks, (3) a willingness to affiliate with any hospital or payer that really knows how to partner with physicians, (4) developing quick wins and communicating the progress, and (5) educating physicians about the new ground rules for capitation. Here are six more reasons for CHP's success in forming a PO.     

Physician glut. Physicians--the next victims of "downsizing?"

Should physicians really be polishing up their CVs or preparing to enter another line of work? In a word: No. What a recent survey makes clear is that, while managed care is driving physicians from some markets, jobs are still available in other markets traditionally underserved by physicians. This is not to suggest that the physician employment market has gone unchanged. Many physicians, particularly specialists, have taken income hits, and some specialists truly are in need of work. Primary care physicians, however, have seen their stars rise and are now in a position to work wherever they want. Physicians may no longer be able to practice within 50 miles of where they were raised or where they were trained, as has been their wont. Instead, they will have to do what other professionals have long done--go where job opportunities take them. In short, they will have to add a career strategy to their scientific mindset, and that means an aggressive job search, coupled with a strong consumer orientation.     

A new industrial order for physicians: a talk with Jeff C. Goldsmith, PhD. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Jeff C. Goldsmith, PhD, President of Health Futures, Inc. on October 12, 1999 to discuss how the Internet will affect health care delivery in the millennium. One of the most profound changes that he sees is how the relationship between physicians and patients will be altered. Empowered consumers are where the real revolution is happening--a trend sometimes overlooked by physicians. Goldsmith says, "The key thing physicians have missed is that the patient is in charge of the process.... The Internet has enabled patients to aggregate their collective experience across disease entities." But there is too much information. "It is almost universally acknowledged by patients and physicians that there is a terrible quality problem. Getting from information to knowledge is a huge commercial opportunity for somebody." He doesn't think that people have put enough emphasis on the collective learning part of this new technology.