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.     

Super doc and real health reform

A large array of social, economic, and professional issues will have to be confronted and resolved before primary care physicians can take their logical place as leaders in the health care delivery system. Linkages will have to be forged between primary care physicians and specialists and between primary care physicians and nonphysician providers of primary care. Key to successful resolution of the current dilemma is ensuring that primary care physicians are compensated at a fair level for their skills. It is the disparity in physician incomes that lies at the heart of the problem, according to the author.     

The future of medical practice

Managed care of some kind will dominate the future of health care, but the unresolved crucial question concerns ownership of the managed care plans. An investor-owned managed care industry now holds sway, but I do not expect it to last very long. In the long run, physicians must be in charge of medical care, but they must live within budgets and be accountable to payers and to their patients. The only solution that makes sense to me is one based on multiple local physician networks, organized on a not-for-profit basis. I predict that staff and group-model HMOs will be the mainstay of the medical care delivery system within a few decades.     

Veteran's health care: time for a change?

The Department of Veterans Affairs' mission is "to care for him who are shall have borne the battle for his widow and orphan." The Veterans Health Administration comprises 172 hospitals that are the hub of the health care delivery system. It is the largest provider of graduate medical education, and one of the major research organizations in the United States. The medical care budget exceeds $17 billion annually. Most of the persons cared for are not legally entitled to this health care based on service connected disability. The utilization of acute care hospital beds appears excessive when compared to that obtainable with managed care for Medicare or commercial insurance beneficiaries--the cost per member per month is three times higher. There may also be exploitation of the Veterans Administration hospitals by university medical schools. The Veterans Health Administration is a very expensive way to deliver care to entitled service connected veterans. Therefore, it is suggested that privatization be considered as an alternative vehicle for delivering health care.     

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.     

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.     

Specialist versus primary care: not an easy question

The central focus in the debate to reform our nation's health care system is on cost, quality, and access. There is general agreement that there are too many specialists in the wrong places, which is said to contribute to the rising cost of health care. Physician profiling has supported the concept that some specialists are more costly than primary care physicians, although the severity of illness in patients treated by specialists may often be greater. Increasing the number of primary care providers may be a solution to reduce costs and will clearly improve access. The study reported in this article was carried out to examine the efficiency of primary care physicians and endocrinologists, a specialty that has been cited as one in which resource utilization is high, in caring for hospital inpatients with diabetic ketoacidosis.     

What's ahead on quality: the managed care perspective

Without question, the most important processes occurring in managed care that can be expected to affect quality are accreditation and the effort to obtain and compare uniform information on quality of care across health care organizations, in short, to create "report cards." For both processes, 1993 was an extremely productive year, and 1994 promises to be even more so. These two processes fit hand-in-glove--one is designed to determine that managed care organizations are equipped to serve the public and to implement better health care programs, while the other is designed to help them understand and improve their own performance. Although, in the short run, managed care organizations may view both these efforts as additional costs, in the long run, both should lead to a better industry and to better care for the public.     

St Christopher's and the future

The founding vision of St Christopher's Hospice was based on a recognition that permeating mainstream health care services would be essential and an emphasis on an adaptable philosophy rather than a building. Today, demographic and disease related changes mean that need and demand for end-of-life care will inevitably outstrip professional and financial resource. Hospices must engage with the development of cost-effective models of service delivery and rational planning. Only partnership working with the National Health Service, care homes, and others will ensure that appropriate care is available to everyone wherever the bed in which they die, regardless of diagnosis. Only collaboration and active engagement will ensure that future strategy in end-of-life care retains the original insight that its focus rightly includes not only patients but also the social context that will be affected by their death. Cost and patient choice dictate an emphasis on care at home. Health-promoting, public education and family-focused strategies will be essential. At a pivotal moment for the delivery of health care generally, hospices can play a vital part by marrying the role of "insistent conscience" of the health care service with continued cost-effective clinical innovation.     

The evolving role of the primary care physician

In today's climate of health care reform, the title of this article might more appropriately be "Is the Role of the Primary Care Physician Evolving or Going the Way of the Dinosaur?" According to Koop, primary care is in trouble. Whereas only 29 percent of U.S. physicians are primary care physicians, in Great Britain, 72 percent of physicians are primary care physicians and in Europe and Canada the average is 50 percent. Many U.S. primary care physicians are in the later stages of their careers and nearing retirement age. Unless the supply increases, this number will dwindle further. However, in 1992, only 14 percent of U.S. medical school graduates were headed for primary care careers. Even if the supply of primary care graduates were increased to 50 percent of the graduating medical school class, it would be well into the next century before the ratio of primary care physicians to specialists would be equal. Primary care is at a critical juncture and the next few years will decide the fate of the primary care physician. Given the state of primary care today, I believe that a fundamental look at the assumptions regarding the role of primary care physicians is in order. The current health reform movement has placed a major responsibility on primary care to solve many of the problems in health care delivery today, such as cost, utilization, and prevention. Many health care organizations are planning strategies involving primary care providers, and physician executives can play a key role in these decisions.     

Health care downsizing: a survival guide

One would be hard pressed today to find a profession that has not experienced the effects of downsizing. Health care management is no exception. Although physicians were once regarded as relatively safe from layoffs, it is now estimated that "at least" 10 percent of physician executives will fall victim to health care downsizing in 1995. Furthermore, with a 14.3 percent turnover rate of hospital CEO positions in 1994, reversing a two-year drop, health care downsizing appears to be on the upswing. This article analyzes downsizing in the health care industry and gives some advice on how physician executives can deal with it successfully.     

Reducing health care costs: a case for quality

Today, it is not quality or access but cost that has become the primary motivator for change in the U.S. health care delivery system. Cost, as the driver, has created a frenzy of nationwide activity, searching, examining, and testing any and all ways that offer promise of financial health care stability. And cost, not quality or access, is the principal motivator for the ever accelerating national health care policy debate. But there is a relationship between costs and quality that has to be addressed if quality is to be maintained.     

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.     

Dealing with the demands of change

If evidence of the changes occurring in and confronting the health care field were needed, it was provided in abundance at the College's Perspectives in Medical Management meeting in Chicago in May. The presentations and the discussions among members buttressed the feeling that the health care field is proceeding through a period of transformation. The evolving system will be anchored on managed care, with special emphasis on the word "managed." The accoutrements of managed care--case management, demand management, utilization management, clinical guidelines and protocols, capitation budgeting, and the like--dominated discussion. The "business" of health care is proceeding apace. Maintaining a balance between the financial and quality elements of health care delivery has never been more important. And the definition of that balance will be determined at the local and regional levels. Federal initiatives are temporarily in abeyance. The challenge for physician executives is to assume leadership in moving their organizations, and thus the health care system, toward a new design that corrects present deficiencies and positions both to respond more effectively to the health care market. While it is not possible to cover all of the more than 60 speakers who addressed the meeting, this report, through presentation of the ideas of some key presenters, is aimed at measuring at least the boundaries of the challenges that lie ahead.     

The next stage of managed care.

Since the turn of the century, we have gone from medicine as a cottage industry, based largely on barter, to the complex entity it is today. What we will see in the coming decade, if not sooner is the emergence of the next level of managed care. As managed care matures, contradictions in the health care system that we have not been able to resolve will be addressed, as well as other value-related issues. The ability to deliver value and then to monitor outcomes will be the nut to crack. The next big movement will be to hone in on outcomes and measurement. This will be the path to increasing the inherent value of the medical care system. This will go hana in hand with accountability, which is where physician-sponsored networks (PSNs) will be an indispensable tool. Centered as they are around accountability and responsibility, PSNs will be a natural starting point for developing the protocols to produce and collect this data. The standardization of care, anchored upon medical evidence, is the objective.     

The impact of health care reform on group practice

Just two years ago, it would have been very difficult to imagine that reform of the health care system would today be a national domestic priority and that Congress would be considering one of the most significant and far-reaching pieces of legislation in the past 50 years. The issue is still in doubt, but it seems clear that, in this session of Congress or the next, legislation of far-reaching consequences will likely be passed. In fact, change on a widespread scale has already begun. During 1993, every state legislature except those of Nevada and Wyoming considered measures that would alter the way medical care is financed and delivered. Of the states that acted, both last year and in recent legislative sessions, eight have passed laws with the ultimate objective of ensuring access to medical care for all citizens. Government, at both the state and federal level, is clearly taking on the health care issue. The impact of reform on physicians, and thus on group practices, will be substantial. This article outlines the current course of health care reform and addresses its specific implications for the management of group practices.     

The ethics of health care system reform

The United States is now engaged in a momentous national debate about health care. How can we provide the best care possible while simultaneously containing cost (to promote the general economic integrity of society) and somehow maintain a semblance of a free health care marketplace. This is not just a political question; it is also a question of ethics. It is an ethical consideration because the current debate is not just about designing or promoting health care systems that can best address our concerns for costs, quality, and accessibility. It appears that at least some participants in the debate would not stop at arguing their beliefs as valid; they would make their beliefs law. Some urge the creation of the right to health care as a matter of law. There are significant differences between beliefs and rights, however, and they need to be considered carefully in the ongoing debate over the future of this country's health care delivery and financing system.     

What happened, what next?

Many physicians and other health care professionals breathed a collective sigh of relief when the 103rd Congress adjourned without passing the Clinton Health Security Act or any other health care reform legilsation. The ambition of this brief paper is to describe why health care reform did not pass in 1994, the issues that need to be resolved if we are to pass legislation, the political forces that will need to be addressed before legislation is passed, and the type of struggles we can expect to see in the coming session of Congress.     

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.     

Abschlussprüferhaftung bei unpräzisen Sorgfaltsstandards und Ambiguitätsaversion

The Ellsberg-paradox suggests that individuals are subject to ambiguity aversion. When the standard of due care is not precisely defined, the context of auditor’s liability can be considered as an ambiguity situation. The paper shows that compared to an Expected Utility framework an ambiguity-averse auditor will exert less care with low damage payments but higher care with high damage payments. Hence, it might be advisable to put a liability cap. With strict liability there is no ambiguity situation and thus, there are no distortions from ambiguity aversion.