Cost-effective rehabilitation: Part 2--Approaches to patient management problems

Part one of this two-part series discussed general principles of cost-effective rehabilitation: Patients in rehabilitation programs should be working toward achievement of real-world functional goals. Goals should be realistic, and reachable in a reasonable amount of time. Rehabilitation services should be provided at the lowest safe and effective level of care appropriate to the patient's needs. Patients should be participating to their full potential in an active therapy program. Therapy intended to maintain a patient's current condition should be carried out by nonprofessionals who have had training sessions with rehabilitation professionals as needed. Discharge planning begins on the day of admission to the inpatient or outpatient rehabilitation program. This second of the two-part series will focus on individual patient management issues. It discusses circumstances in which the principles of cost-effective rehabilitation may need to be modified. It also discusses approaches to remedy patient management problems that may lead to excessive or ineffective utilization of rehabilitation services.     

Medicare's ESRD Program, Part 1: Dialysis.

The federal End State Renal Disease (ESRD) program was created by statute in 1972 as a general population entitlement to be administered by Medicare. The program extends all Medicare benefits to patients, regardless of age, who are diagnosed as having ESRD, as long as they are fully insured for old age and survivor insurance benefits (Social Security), are entitled to monthly insurance benefits under the Social Security Act, or are spouses or dependent children of individuals with the foregoing Social Security benefits. About 7 percent of all ESRD patients are excluded from this entitlement by these criteria. The two major therapies embraced by the ESRD program are renal dialysis and kidney transplantation. In this first part of a two-part article, dialysis is the focal point. Kidney transplants will be covered in the May-June issue of Physician Executive.     

Resolving conflicts: principles and practice

Physicians and other medical professionals undergo extensive professional training for the privilege of obtaining their professional licenses. For most physicians, clinical training is conducted in extremely competitive circumstances. Many physicians endorse competition as an appropriate method for producing greater individual and collective competence within the profession. Competition, however, is a very limited way to resolve conflicts. And, in the current environment of greater resource restrictions and reform, the competitive model, at best, seems short-sighted. Many of the current relationships involving physicians and others are transitional, involving various partners in numerous practice and professional relationships. For example, medical practices are merging; hospitals are engaging physicians in numerous business structures, even employment. However, longer term relationships are enhanced by mutual respect and collaboration, rather than chronic competition to "win" one's rights over another. Thus, the need among physicians to enhance their conflict resolution skills is expanded in today's environment.     

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.     

主要排放部门的减排责任分担研究:基于全局成本有效的分析

运用中国能源与环境政策分析模型(CEEPA),从经济全局成本有效的角度,分析了一定减排约束下中国主要排放部门宜分担的减排责任及其减排行为。研究发现,基于排放量进行减排责任部门分担是有助于整体成本的,但对煤炭和运输仓储部门宜做出调整;随着减排目标的增加,应增添运输仓储部门的减排配额比例,减少煤炭部门的减排配额比例;短期内不宜对各部门尤其是煤炭部门设置较高的减排目标。     

Physician organizations. Part 1: A report from the trenches of a start-up PO

How has Community Health Partners, a physician organization based in Kansas City, turned the corner as it rolls into the second year of operation? The biggest indicator is that CHP hammered out the city's first professional risk contracts and the PO has grown from 23 to more than 50 physician member/owners. Looking back, there are at least 10 reasons why CHP made it this far. These are not reasons you learn about in medical school or an MBA program. There is no one-size-fits-all template for building POs. No fixed organizational chart. No neon signs pointing to the best capital partner. Part I explores five reasons for success, such as having a strong board and physician leadership, as well as educating participating physicians about capitation and affiliating with any hospital or payer that really knows how to partner with physicians. Part 2 will focus on five more lessons learned from the trenches of a start up PO.     

The shift from vertical to networked integration, Part 1

Lessons, dangers, and difficulties for health care integrators from the world of mergers, acquisitions, and alliances. The authors examine why there needs to be a shift from vertical integration, with its command and control hierarchical structure, to the more fluid and flexible networked enterprise in health care. By sharing the integration experiences of other industries, the authors make a compelling case for rethinking the integrated delivery system that so many have embraced and explain why the emergence of the extended health care enterprise will be the next stage in the progression. Making the journey into networked enterprises--how to start, what to do, and case studies from St. Vincent's, Cascade Healthcare Alliance, and Mullikin Medical Centers--will be presented in the second article in the June 1996 issue of Physician Executive.     

Closed‐Loop Supply Chains: An Introduction to the Feature Issue (Part 1)

Closed‐loop supply chains (CLSC) have product returns at the center of attention. Our view is that CLSC are best managed from a business perspective where organizations seek to maximize value recovery. The research in the feature issue, and our experiences, shows that there are still numerous, unresolved, managerially relevant issues that deserve further investigation. We also observe that there is a pressing need to validate the assumptions in our models using interdisciplinary, industry‐driven research. The time is right for production and operations management to play a central role in the sustainability movement slowly taking hold in practice.     

Conflict management, Part 1. Conflict management checklist: a diagnostic tool for assessing conflict in organizations

Complex interpersonal conflicts are inevitable in the high speed, high stakes, pressured work of health care. Poorly managed, conflict saps productivity, erodes trust, and spawns additional disputes. Well managed, conflict can enhance the self-confidence and self-esteem of the parties, build relationships, and engender creative solutions beyond expectations. Just as thoughtful differential diagnosis precedes optimum treatment in the doctor-patient relationship, management of conflict is greatly enhanced when preceded by careful assessment. In the first of two articles, the authors present a diagnostic approach, the Conflict Management Checklist, to increase self-awareness and decrease anxiety around conflict.     

Costs of Health Damage from Atmospheric Emissions of Toxic Metals: Part 1—Methods and Results

Significant quantities of toxic metals are emitted to the air by the incineration of waste, as well as by the combustion of coal and oil. To optimize the regulations for their emissions one needs to know the cost of their damage. That requires an impact pathway analysis, with realistic dispersion models, exposure‐response functions, and monetary values. In this article we explain the method and assumptions and present results for arsenic, cadmium, mercury, and lead, the most important toxic metals in terms of damage cost. We also estimate their contribution to the damage cost of waste incineration and electric power from coal for typical situations in Europe. The damage costs of As, Cd, and Pb are much higher than previous estimates because of a large number of new epidemiological studies, implying more and more serious health effects than what had been known before. New cost‐benefit studies for the abatement of toxic metal emissions are advisable. The discussion of the epidemiological studies and the derivation of exposure‐response functions are presented in two companion articles, one for As and Cd, the other for Hg and Pb.