Locum tenens solve staffing problems.

The use of locum tenens physicians (physicians who work temporary assignments) began decades ago when primary care physicians arranged coverage for their private practices while on vacation. Today, the placement of locum tenens physicians has evolved into a national business. The reason for the increase in the use of locum tenens physicians is because of the benefits they can offer. They can prevent a hospital, HMO, clinic, or physician practice from losing market share due to a gap in medical coverage.     

Compensation for elected hospital medical staff leadership

As physicians' practices become more complex and their practice incomes more difficult to maintain, hospitals concurrently require more physician input into organizational, utilization, and strategic planning matters. Physicians and hospitals across the country are discussing the question of financial compensation to physicians for the time they spend performing these hospital administrative tasks. It is already common practice for hospitals to pay a salary for medical direction of hospital departments such as intensive care units or pulmonary laboratories. The question has become whether this practice should be extended to elected medical staff leadership.     

The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

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.     

Models for medical practice integration

Decreased physician income, increased administrative burdens, and interference with the compassionate delivery of high-quality medical care are threatening the independent practice of medicine in solo and small group practices. Many established physicians, and the hospitals with which they relate, are searching for organizational models that, by integrating some or all aspects of their practices, will preserve incomes and reduce regulatory and administrative burdens. This article will describe several "practice integration models," pointing out advantages and disadvantages to physicians in established practices. (Many of the same arguments could be made for physicians new to practice, with different emphasis). The continuum of integration models is shown in figure 1, page 19. The group practice without walls and its two submodels, the independent group practice without walls (IGWW) and the affiliated medical practice corporation (AMPC) are more recent and more effective models and will be covered in depth in the article.     

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.     

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.     

The implications of practice guidelines for physician medical malpractice liability

Medical practice guidelines are increasingly coming into use, and as more and more physicians are presented with guidelines to follow in the delivery of health care, the question arises of whether these guidelines will become instruments for imposing greater medical malpractice liability on physicians. This column will briefly describe what guidelines are, how they are developed, and how they have been and may be used in litigation against physicians, hospitals, and other health care institutions. As hospitals and managed care organizations continue to implement guidelines, the role these guidelines play in malpractice cases can be expected to increase. It appears, however, that, although guidelines will contribute to the establishment of the standard of care by which a physician's actions will be measured, they are not likely to become the standard that all physician treatment decisions must meet.     

Ounces of malpractice prevention

The source of malpractice claims, contrary to widely held views, is not simply improper or inadequate medical care. In the majority of cases, malpractice litigation ensues because of negative nonclinical factors and the incidence of an unexpected result in medical treatment. High on the list of nonclinical causes are faults in the physician-patient relationship. Patients who are unhappy with the manner in which they have been treated by physicians are much more likely to sue when the outcome is even moderately untoward. Key to reducing the incidence of malpractice suits is helping physicians understand that attention has to be paid to their behavior.     

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.     

Removing barriers to technology

Health care executives need to take every step possible to overcome barriers to adoption of new technology by physicians. Through just a few relatively simple and inexpensive strategies, they can enable their physicians to use the clinical information system and bring value to their patients, health system and medical staff.     

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.     

A hospital protocol to resolve complaints against staff physicians

Complaints of discrimination or harassment in the workplace have become almost commonplace in recent years, increasing in both frequency and variety. In the hospital setting, this trend is manifested in allegations against members of the medical staff by hospital employees as well as by patients or their families. Whether real or fancied, such allegations are reflective of a potentially disruptive undercurrent of organizational tensions. Left unresolved, they can erode the essential partnership between staff physicians and other members of the health care delivery team. Unsatisfactory patient experiences may also damage the reputation of the institution and thereby undermine its viability. With either group of complainants, allegations of malfeasance that are not resolved at the source in a timely manner are far more likely to result in expensive, time-consuming, and potentially damaging litigation.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.     

Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Accounting for the transition from inpatient to outpatient surgery

This article reports on some of the factors that have advanced and impeded hospital progress in moving from inpatient to outpatient surgery. Early on, patients, physicians, and hospital administrators all agreed that outpatient surgery had an intuitive appeal. Patients liked it because they didn't have to go in the hospital. Physicians liked it because they could get in and out of the outpatient surgery center more easily than the main hospital operating room. Administrators recognized the inherent appeal of outpatient procedures but were unable or unwilling to switch services from inpatient to outpatient for a variety of reasons. First, empty hospital beds and diminished scope of inpatient operations are a threat to the power of administrators. Moving surgery from inpatient to outpatient settings reduces inhouse operations. Second, reimbursement incentives were definitely in favor of continued inpatient care long after technology was in place for outpatient care. The third and most critical reason was that cost data on outpatient operations were just not available for making decisions on when to move into the outpatient setting. This review of the literature was intended to document the lack of relevant cost-based accounting. Instead, many other factors that more directly slowed progress were encountered. More than anything, this illustrates the erratic course of progress in health care reform.     

Management education for medical students.

There is little doubt that the economics, management, and delivery of health care in the United States are currently in an unprecedented state of flux. Prospective payment, cost containment, and corporatization of health care delivery are rapidly replacing retrospective fee-for-service reimbursement and unmanaged provider practice patterns. Though ultimately certain to affect significantly physicians now in training, these changes have been afforded little attention in the undergraduate medical curriculum. At Hahnemann University, this is no longer the case. "Management Education for Medical Students" is an elective, intensive, eight-week experience for senior medical students. Following a thorough orientation to the workings of organizations through which health care is delivered, medical students receive both didactic and project-oriented instruction in university hospital administration during the first four weeks. During the course's second half, students are offered specialized training in the part of medical management that links the clinical and the financial aspects of health care management.     

The importance of data warehouses for physician executives

Soon, most physicians will begin to learn about data warehouses and clinical and financial data about their patients stored in them. What is a data warehouse? Why are we seeing their emergence in health care only now? How does a hospital, or group practice, or health plan acquire or create a data warehouse? Who should be responsible for it, and what sort of training is needed by those in charge of using it for the edification of the sponsoring organization? I'll try to answer these questions in this article.     

A protocol for mutual respect and communication

Physicians relating to each other, discussing a patient's problem, needs, and care plans, should be the easiest part of medical practice. Unfortunately, exchanging meaningful information between physicians and their offices is, at times, formidable. This article describes the guiding principles for physician referrals at Hamot Medical Center that were developed to enhance communication between physicians and increase patient care.