Primary care: the driver in health care reform

The changes occurring in the health care industry have resulted in a cost-quality competition that has not been present in the past. Because of this competition, managed care is a growing way of financing and providing health care to the people of the United States. Managed care depends heavily on competent primary care physicians. Because primary care physicians are in short supply, the status and financial rewards of primary care practice are increasing. The primary care physician will be the dominant force in medical practice in the immediate future. He or she is capable in a managed setting of resolving the perceived problems of the health care industry in responding to the drivers of health care reform. Costs are reduced while quality is maintained. Access to health care is improved, and fragmentation of health care is significantly lessened.     

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.     

The emerging health care landscape. The drivers of health care

Other than hold on tight, how does a health care system successfully weather the turbulent conditions facing the industry? This article focuses on key drivers in the three main segments of the health care market: employer-based, commercial/ERISA, and Medicare and Medicaid. Effectively managing the dynamics within these markets will be vital to a delivery system's success and its ability to withstand the forces of change. Given the market changes that are occurring, how does an academic medical center, emerging hospital-sponsored IDS, or a large physician clinic trying to develop a system determine the necessary components and structure? What kind of system will work best? The considerations are numerous and explored in this article.     

Flexible home care scheduling

Home care services are in high demand given how they are steadily becoming the primary source of care for the elderly. Powerful decision support tools are indispensable for effectively managing available staff in the context of ever-increasing demand for care and limited caregiver availability. This paper advances home care literature by introducing flexible task durations, thereby enabling tasks to be completed faster and ultimately more care to be scheduled. This new concept, which originates from practice, introduces an additional decision to be made when creating a schedule, thereby greatly increasing the scheduling complexity. Consequently, this paper introduces a new optimization-based decision support model which allows for scheduling with flexible task duration, as well as other types of flexibility. A computational study quantifies the impact of: (i) scheduling with a finer task granularity thereby enabling accurate prioritization of high and low priority care, (ii) flexibility in task duration enabling tasks to be completed faster and more care to be scheduled, and (iii) increasing the number of different locations visited by a caregiver thereby enabling a trade-off between the number of serviced clients and caregiver workload. A new publicly available real-world data set is used, obtained directly from home care organizations operating in Flanders. Analysis of the computational results demonstrates that significant improvements in operational efficiency may be realized with minimal effort required by organizations. Furthermore, the proposed algorithm’s performance is confirmed by comparison against the bounds obtained by solving an integer programming formulation of the problem. Finally, a management policy scheme is proposed which, when gradually implemented in a home care organization, results in a more efficient and therefore cost-effective deployment of its workforce.     

Credentialing in managed care

Through the use of managed care techniques in recent years, the insurance industry has tried to bring the runaway costs of medical care under control. The result of this control effort is system access limitations, compared to the full choice indemnity plans of the past. This limited system access has now clearly moved HMOs and other managed care organizations into the category of "potentially liable health care entities," based on patient steerage, economic disincentives, and limited choices of the plan's participating providers and facilities. Just as hospitals have had to exercise rigorous care in the credentialing of members of their medical staffs, managed care organizations will have to ensure that the providers they use meet acceptable standards of competence.     

Managed care liability.

Debate is heating up concerning proposals that patients have the right to sue their managed care plans for damages from wrongful denial of benefits or delays in care. Some states have recently passed legislation to address this issue and it is expected to be an area of intense legislative debate during this year. As managed care entities increasingly enter the realm of medical decision-making, the additional burden of this responsibility is taking shape. Whether managed care plans should be treated like providers of care and be held accountable for decisions that impact patient outcomes, or be viewed only as insurers is a policy question of immense proportion.     

Health care is sales

Health care is all about sales--everyone today in the competitive arena of health care is a salesperson. Your selling days began when you applied to medical school. Your product was yourself, and you worked hard to sell it. That was only the beginning. In your daily work as physician executives, you are selling yourself and your ideas-your ideas about relationships, management structures, partnership issues, merger questions, etc. It's a complicated world, and the concepts are often abstract and difficult. But it is your job to communicate with others to get things done. It is the most important part of your job. It is selling, in fact, at a sophisticated level. How do you communicate and sell yourself and your ideas effectively? Here, some ideas on how to listen and communicate.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.     

Providing children with health care

Introducing a new column on health policy issues of relevance to physician executives. What are the legislative options to provide children with health care coverage? Federal health initiatives for children have become the next frontier in health care reform. This column defines the problem in the U.S., describes voters' support for a federal initiative, and provides discussion of the options available to federal legislators.     

Effective health care corporate compliance

The pace and intensity of oversight and investigation of health care organizations has greatly increased at all levels. Well run organizations with ethical management committed to following all laws and regulations are still at risk for compliance violations and punitive penalties. Under the Federal Sentencing Guidelines, organizations with an "effective" corporate compliance program may receive reduced penalties. The seven components of an effective program as defined in the guidelines are: (1) Standards and procedures; (2) oversight responsibilities; (3) employee training; (4) monitoring and auditing; (5) reporting systems; (6) enforcement and discipline; and (7) response and prevention. Lack of a compliance program needlessly exposes the organization to an avoidable risk of damage from non-compliance--whether intentional or not. Moreover, an effective program can contribute to the efficient operation of the organization and be a key piece of its corporate culture.     

Managing health care quality.

Using the cited principles of professional staff credentialing and quality assurance, a department chairman, medical director, or other health care executive will be in an excellent position to assess quality of care against established standards and manage problems in the routine provision of medically appropriate care. He or she will also be able to assure the hospital's board that the hospital and its medical staff are well positioned to meet future challenges to provide effective quality, utilization, and risk management.     

Not your father's health care

We in health care are living and working in a world that, for all its technical changes, differs little in its basic assumptions, structures, payment systems, beliefs, expectations, and job titles from the world of health care a generation back. How much change can we expect over the coming years? A lot more than we are prepared for. Look at the array of new technologies headed our way, from genomic sciences to customized vaccinations. Many of the breakthroughs promise incredible abilities to prevent disease, to profile our proclivities, and to manage our genetic predispositions over long periods of time, rather than merely wait until the disease manifests in an acute phase, then treat the symptoms. Digital technologies bring physicians executives enormous opportunities for new ways of gathering, storing, and mining information, for new types of communication between medical professionals, for new communications with customers, and new ways of steering large, complex enterprises. Unprecedented opportunities for change keep piling in through the door. Vast pressures for change keep building from every side. And the rewards for anyone who can lead the change keep compounding.     

System measures ambulatory care quality

As physician executives, what we need in ambulatory quality assurance is a very carefully thought out system that will enable us to monitor quality in such a way that we will also be able to measure it. Only if we have the capability to measure quality can we begin to manage it.     

Managing continuity of medical care

A key consideration in decisions on allocation of work load in physician groups is preservation of continuity--so key, in fact, that the word continuity is often used as a holy incantation that implies any further argument is blasphemy. But what is continuity? If we can examine the concept along with its advantages and how it is achieved, health system planners on the micro level can design systems rationally incorporating continuity of medical care.     

Managed care is data management

As managed care evolves, it has become apparent that greater control of both the patient and the provider side of the process is necessary. Specifically, improvements are necessary in monitoring the appropriateness of service, accessibility, authorship and authorization of referrals and claims, patient advocacy, and assimilation of data.     

Making integrated health care work

This article summarizes the authors' thinking on value added in health care, and offers examples of the major strategies being implemented by integrated systems across the United States to increase their value and improve their competitive positioning. The research results are based on a review of published literature on 150 health care organizations in various stages of integration, and 20 in-depth case studies of integrating systems.     

Health care trends, Part 2. The new health care team. Panel discussion

In Part 2 of this third annual panel discussion, six experts talk about the growing diversity of health care providers and what it means for consumers and physicians. Americans are getting their wellness and health care services from a wider variety of non-physician practitioners than ever before. The number of allied health and alternative providers with direct patient access is likely to continue growing. This trend is being driven by consumer demand, by the lobbying efforts of non-physician providers, and by federal, state, and private payers who see the potential for reduced health care spending, greater consumer satisfaction, and better outcomes. In practice, this means physicians and non-physician providers, some of whom may not be sanctioned by the medical establishment, are obligated to collaborate as a team. Members of this new provider team will have to communicate effectively (with each other, with consumers, and with payers) and make evidence-based clinical decisions. Physicians may have to share decision-making with other members of this new health care team.     

Spirituality and the care of patients at the end-of-life: an essential component of care

Spirituality is an essential component of the care of patients with serious illness and those that are dying. Dame Cicely Saunders developed the hospice movement based on the biopsychosocialspiritual model of care, in which all four dimensions are important in the care of patients. Of all the models of care, hospice and palliative care recognize the importance of spiritual issues in the care of patients and their families. The National Consensus Project Guidelines for Quality Palliative Care, in the United States, provides specific recommendations about all domains of care including the spiritual domain, which is recognized as a critical component of care (The National Consensus Project for Quality Palliative Care www.nationalconsensusproject.org). Studies indicate that the majority of patients would like their spiritual issues addressed, yet find that their spiritual needs are not being met by the current system of care. Interestingly, spirituality is the one dimension that seems to get slightly less emphasis than the biopsychosocial dimensions of care. Some reasons may include the difficulty with definitions of spirituality for clinical and research purposes, the time constraints and financial burdens in the current healthcare system in the United States, and the lack of uniform training for all healthcare professionals. Yet, there are theoretical and ethical frameworks that support spiritual care as well as some educational models in spirituality and health that have been successful in medical education in the United States. Spirituality can be seen as the essential part of the humanity of all people. It is at its root, relational and thus forms the basis of the altruistic care healthcare professionals are committed to. Spirituality has to do with respecting the inherent value and dignity of all persons, regardless of their health status. It is the part of humans that seeks healing, particularly in the midst of suffering. Spiritual care models are based on an intrinsic aspect that calls for compassionate presence to patients as well as an extrinsic component where healthcare professionals address spiritual issues with patients and their loved ones. Currently in the healthcare system, evidence-base models are the criteria for practice recommendations. Yet, spirituality may not be amenable entirely to strict evidence-base criteria. As hospice and palliative care continues to develop as a field, healthcare professionals are challenged to think of ways to advocate for and include the spiritual dimension of care.