Unemployment,Vacancies and Unfair Dismissals

In most West European economies the annual number of grievance procedures settling individual complaints against unfair dismissals has been increasing since the 1960s. This development has very often been attributed to the enactment of legal regulations restricting the dismissal behaviour of firms. Econometric analyses using data from Germany and Great Britain show that labour market developments, namely the flow into unemployment and the vacancy rate, have a much stronger influence on the cyclical demand for grievance procedures than changes in the “legal infrastructure” of the labour market. Without denying the importance of institutional differences it appears that the individual costs of unemployment (which, ceteris paribus, rise as the flow into unemployment increases and the vacancy rate decreases) are superior predictors of the demand for grievance procedures than institutional changes strengthening or weakening employees' rights.     

Employee–Employer Grievances: A Review

The focus of industrial conflict has shifted from collective confrontation to grievances between employee and employer. This narrative review encompasses a range of international research on individual employee–employer grievances. The literature is reviewed in four key stages: (1) the incidence of grievable events; (2) the employee's response to a potential grievance issue; (3) the effectiveness of grievance processing; and (4) outcomes. The incidence of grievable events cannot be estimated precisely, because most are either not pursued by the employee or are settled informally (and so not recorded). Most research has been done on the second stage, investigating when a grievance will be pursued. The theoretical frame of exit, voice and loyalty, adapted from A.O. Hirschman (Exit, Voice, and Loyalty: Responses to Decline in Firms, Organisations, and States. Cambridge, MA: Harvard University Press, 1970) has been prominent, but a series of findings have challenged the validity of this model and suggest a range of competing theories which may explain the apparent conundrum of negative outcomes associated with formal grievance procedures. The role of power has regained prominence, and this is part of a fuller understanding of grievance outcomes. The focus has been on the employee perspective, and it is now timely to broaden the focus, modelling a progression through a sequence of stages and emphasizing the role of employers in designing and managing grievance processes which are effective and fair.     

Improving "medical necessity" acceptance by health care providers and consumers

A major problem for patients and providers has existed since establishment of peer review and authorization agency medical necessity guide lines, because physicians and patients who receive denial of proposed procedures and tests on the basis of so called "medical necessity" presume that the authorization agency considers the proposed procedure or test to be medically unnecessary, meaning of no health value to the patient. This may well not be the case. Both providers and consumers can be expected to be more accepting of negative authorization decisions if the principles of continuous quality improvement are brought to bear on the authorization process.     

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.     

Total quality management: care dealers vs. car dealers

Let's turn our "flawed system into the Toyota City of world health care," proposes Fortune magazine. I shudder at the thought. Deming-Juran-type TQM procedures can help to ensure that cars and their drivers do not die on the road. Skillfully adapted for health care, these same procedures can help keep patients from dying on the operating table. These procedures can also respond to Fortune's indictment that the "U.S. medical system is as wasteful and managerially backward as Detroit before Henry Ford." However, people are not cars, and care dealers are not car dealers.     

How should managed care physicians be paid?

When paying a physician for medical or surgical services, most patients expect the traditional bill or charge for that encounter or visit. While most people also pay health insurance premiums, few patients expect to prepay for their health care. But that is the foundation of most managed health care systems-prepaid medicine. PPOs, IPAs, and HMOs are typically health care providers linked together to provide services to a set population for a specific prepaid fee or "capitation" payment. Other providers contract with these managed care insurers to receive a predetermined and often "discounted" professional fee for services. These managed care organizations have already gone through a number of stages in determining how physicians are to be compensated for their services, and further changes loom on the horizon.     

The power of mediation

There is a range of intervention strategies and procedures designed to assist parties in reaching agreement, from negotiation, over which parties have complete control, to arbitration, the process over which they have the least control. In the middle of this spectrum is mediation. Simply put, mediation is assisted negotiation. A mediator is an impartial person (or team) that works with the parties, mostly together and sometimes separately, to help them reach an agreement to resolve a dispute. The cornerstones of mediation are impartiality and confidentiality. The logic of mediation is that disputants can easily fall into many pitfalls trying to resolve a dispute without help. This article explores these common barriers to effective direct negotiations--such as overestimating the likelihood of prevailing through power, litigation, or arbitration--and presents a case study describing how a complex set of problems was resolved through mediation.     

The "Trust Gap" Hypothesis: Predicting Support for Biotechnology Across National Cultures as a Function of Trust in Actors

Using results from the 1999 Eurobarometer survey and a parallel telephone survey done in the United States in 2000, this study explored the relationship between levels of knowledge, educational levels, and degrees of encouragement for biotechnology development across a number of medical and agricultural applications. This cross-cultural exploration found only weak relationships among these variables, calling into question the common assumption that higher science literacy produces greater acceptance (whether or not mediated by lower perceived risk). The relationship between encouragement and trust in specific social institutions was also weak. However, regression analysis based on "trust gap" variables (defined as numerical differences between trust in specific pairs of actors) did predict national levels of encouragement for several applications, suggesting an opinion formation climate in which audiences are actively choosing among competing claims. Differences between European and U.S. reactions to biotechnology appear to be a result of different trust and especially "trust gap" patterns, rather than differences in knowledge or education.     

An approach to the impaired physician

The 1988 California Administrative Code requiring all acute care medical staffs to provide assistance to impaired physicians has not resulted in an increase in the annual census in the Medical Board of California Diversion Program. In part, this lack of an increase is due to the failure of some hospitals to form physician aid committees and to the poor functioning of such committees in other hospitals. The common reasons for these deficiencies are that the medical staff leadership does not think there are any impaired physicians on staff and that they don't know what the committee would do if it were formed. This attitude demonstrates a lack of appreciation for the prevalence of impaired physicians and the tremendous amount of work required (establishing policies and procedures) to identify and help them. This article discusses the prevalence of the impaired physician, the types of impaired physicians, a "cookbook" approach to managing these physicians, and the success of intervention.     

Organ transplantation criteria represent insurer dilemma

In its simplest form, technology assessment, as used for coverage decision making, involves an analysis of published data regarding the safety and effectiveness of a technology, either on its own merits or in comparison with a competing technology. However, while the medical literature, and thus technology assessments, typically focus on a well-defined population, a positive coverage policy almost immediately creates pressure for broadening patient selection criteria. A variant on this phenomenon is the patient selection criteria for organ transplantation. These criteria are based not only on the scientific merits of the procedure but also on frequently ill-defined notions of the most appropriate allocation of a scarce resource, which in turn is determined by supply and demand at individual transplant centers. In these cases, the payer may defer to the patient selection criteria of the individual transplant center. However, the situation arises when a patient, rejected at one transplant center, "shops" and finds another center that has more favorable selection criteria. How, then, can the payer resolve these discrepancies and establish consistent policy guidelines? Should allocation of scarce donor organs be part of a technology assessment and coverage decision? The case of liver transplantation will be used here to illustrate the insurer's dilemma.     

Medical resource allocation: rationing and ethical considerations--Part I

The United States' system of high-quality but expensive and poorly distributed medical care is in trouble. Dramatic advances in medical knowledge and procedures, combined with soaring demands created by growing public awareness, the cost of private hospital and medical insurance, and Medicare and Medicaid, are burdening the medical care delivery systems. The costs of medical care have reached levels that can no longer be sustained. Government officials, insurance planners, labor leaders responsible for union health care benefits, and ordinary citizens are questioning whether it is acceptable to limit health care based on economic considerations. If health care is deemed a social good, the method of allocation must be addressed. Unless society decides that other priorities of the infrastructure are to be subjugated to health service delivery, difficult decisions will be forced upon us, consciously or by default. The discussion in this two-part article explores the ethical considerations of the more formalized approaches to resource allocation that presently exist in our society.     

医药代表的高流失率问题探究

在当今医药营销日益竞争激烈的氛围下，医药销售代表的出现成为医药营销中的必然。然而现在医药代表的高流失率却节节攀升，对医药代表流失率高展开阐述，分析了产生的原因，进而探讨了解决的对策及应采取的相关措施。     

The medical examiner and deaths in the hospital setting

There has been a perceived increase in the number of medical negligence claims in recent years. The modern metropolitan medical examiner is increasingly called upon to deal with numerous medical, legal, social, and ethical issues. Nowhere is the role of the medical examiner more important than in the investigation of deaths related to surgical, diagnostic, anesthetic, or therapeutic procedures. Medical examiners have an important role in the investigative process. Through utilization of the offices and services of the medical examiner, questions raised by families, physicians, and other hospital employees may be satisfactorily answered a priori, and litigation may therefore be averted.     

Managing organ transplant issues. A guide for approaching controversial, high tech procedures.

With the increase in the requests for high intensity medical procedures such as organ transplantation, the physician executive often is placed in the middle between competing interests. Whether he or she represents the provider or payer side, there is frequently great pressure to make decisions involving complex medical situations in short time-frames. It is necessary to have in place a fair, consistent approach to handling such issues in order to withstand both medical and ethical scrutiny. A process is detailed that will lead the organization to developing such an approach. Although presented in the context of transplant issues, this process can be applied to any similar high technology procedure.     

The use of imperfect data in managed care organizations

Two critical milestones appear to be occurring in the development of medical groups moving to improve medical care effectiveness. These include the abilities to work with imperfect and unflattering data. There is a clear linkage between these two concepts, because forward clinical improvement or business planning is often delayed as individual physicians seek to await "perfect data" when confronted with unflattering information. In the form of "profiles" in particular, providers often react negatively, with complaints that the information is "imperfect" or that it fails to capture some nuance of their sicker or unique patient populations. The translation of imperfect information to effective clinical practice anyway remains a success fundamental to managing highly competitive medical groups and health plans. It is centrally dependent on the understanding, use, and application of "imperfect data".     

Bringing reality to the job hunt process. Interview by Barbara J. Linney

A substantial percentage of the positions that open in medical management are filled through the use of recruitment firms. This is especially true of more senior positions, but it applies across the full spectrum of openings. If the working arrangement between the recruitment firm and the potential candidate is to be effective, certain key ingredients are necessary. The author interviewed a selection of principals of recruitment firms that operate extensively or exclusively in the medical management sector of executive recruitment. What she discovered about their "wish lists" for candidates' characteristics and levels of job hunting sophistication are summarized in the following statements.     

The Economic Impact of Health Policy Interventions

The rapid aging of the U.S. population, increases in the absolute prevalence of chronic diseases, and the associated rise in the proportion of the GNP expended on medical care all indicate the need for methods to accurately forecast future health care expenditures for specific chronic diseases. Additionally, if these methods are biomedically realistic, they can be used to evaluate the economic implications of specific prevention strategies designed to reduce chronic disease incidence, prevalence, and mortality. Projection strategies that are not biomedically realistic, such as models that assume that risks for demographic subgroups do not change over time (e.g., "static component" models), though possibly accurate over the short run, are not suitable for assessing the long term effects of specific proposed health policy interventions which are designed to alter risks.
In this paper we present a strategy for forecasting health care costs which is based on a model that represents the natural history of a chronic disease in terms of a preclinical state, a clinical state, case fatality rates, cures, and the implications of exogenous medical factors. Using this model we project that the treatment costs associated with respiratory cancer in the white male population of the U.S. may undergo a two-thirds increase in real dollars over the period 1977 to 2000. About one-half of this increase is due to a demographic shift to an older population structure, with the remainder due to higher respiratory cancer incidence rates in younger cohorts. Alteration of certain parameters of the model to simulate various interventions suggests that about three-quarters of the cost of this disease could be eliminated, though realization of any significant part of this savings would require a lengthy phase-in period.     

Management competencies required in ambulatory care settings

A study was conducted to identify the most important competencies physician executives in medical groups and other ambulatory settings will need to have in the next five years. The specific job skills, knowledge, and abilities (SKA) that physician executives will need to acquire these competencies were also explored. The Delphi techniques were used to analyze responses from two surveys from members of the American College of Medical Practice Executives. The most important competencies were grouped into 13 management domains, each with specific SKAs. "Managing health care resources to create quality and value" and "fundamentals of business and finance" were rated as the most important competencies. The most frequently rated SKA was the "ability to build and maintain credibility and trust."     

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.     

In pursuit of physician/organization linkage

A friend of mine once said that medical staff/administrative relationships are the Bermuda Triangle of health care management. The Bermuda Triangle, as I recall it, is an area of the Atlantic Ocean into which ships and planes disappear without a trace, for no apparent reason. Sometimes, especially late at night on reruns of "Twilight Zone," these planes reappear years later, crew intact and youthful. Sometimes, salt and sharks get the ships, planes, and voyagers. In a like manner, problems in medical staff/administrative relations draw consultants into a vortex. Sometimes, the consultants and their reports float to the surface a long afterward. Sometimes, they are digested by the organization and become a part of its mythology. Sometimes, they vanish forever. This is the story of three consultations. All were intended to make recommendations concerning the structural relationship of management to the physicians and their groups in our HMO: How to link the physician organization to the corporate structure. Like any narrative, this story is constructed to provide a context for reflection and is not intended to question the value of the contribution of specific individuals or companies.