U.S. hospitals mired in bureaucracy: 10 roadblocks to change

Given the dot.com revolution in health care, advancing medical technology, and dissatisfaction with managed care, fundamental change is the order of the day in U.S. hospitals. Some hospital leaders are responding effectively to these new century challenges. But too many only tinker with existing systems, hoping to get by with choices that are comfortable, conventional, and convenient. Meanwhile, the sharks of dwindling public confidence and lost political support circle ever closer. The vice president of medical affairs (VPMA) is positioned at the vertex of disparate organizational, interpersonal, and external forces and can lead the way in recognizing and removing common roadblocks delaying needed change. External obstacles include: (1) Too much regulation; (2) too many attorneys; and (3) theatrical local TV newscasts. Internal factors include: (4) A natural fear of change; (5) arguing when we do not really disagree; (6) Cake Committee management mentality; (7) over-aggressive downsizing; (8) natural conflict in choosing a health care ethic; (9) the past; and (10) lack of trust. Hospital leaders need to effectively act, not just think, "outside the box."     

Constitutional rights versus malpractice insurance settlements

The increasing costs and complexity of malpractice litigation have created an statutory right that allows malpractice insurance companies to settle malpractice claims regardless of the desires of the defendant physician. In the past, the consequences of settling a malpractice claim out of court were not as important as they are today. The Health Care Quality Improvement Act of 1986 mandates that any settlement in behalf of a physician be documented in the National Practitioner Data Bank (NPDB), which must be consulted every time the physician is credentialed. This NPDB requirement denies due process to health care providers and thus becomes a violation of the federal and many state constitutions. Physician executives and medical leaders must bring these issues to the table and negotiate solutions before damage to practicing physicians and the U.S. health care delivery system caused by this legal paradox become too severe.     

The health care system has an eating disorder

The health care system crisis has been proclaimed and analyzed so much by economists, policy analysts, politicians, business executives, and journalists that the key statistics and phrases are becoming as familiar as the lyrics of a popular song-14 percent of the GNP goes to health care, 37 million Americans lack health insurance, too many specialists and not enough primary care physicians, etc. What I have not found is a comprehensive assessment of how the health care system got so sick. The different social science specialists focus on their respective symptoms or organs, but do not propose therapies to treat the entire organism. Ilya Prigogine's Theory of Dissipative Structures (now old hat since he won the Nobel Prize in 1977) demonstrated that self-organizing systems, be they health care systems or individual patients, respond in similar ways to the demands of illness and growth. Therefore, a clinical correlation for the health care system may have more than poetic appeal. I would like to offer the following clinical analogy for what ails our health care system.     

Can you take your soul to work?

David White in The Heart Aroused: Poetry and the Preservation of Soul in Corporate America explores ways for professionals to take their souls to work, instead of checking them at the door. "We simply spend too much time and have too much psychic and emotional energy invested in the workplace for us to declare it a spiritual desert bereft of life-giving water." Several ideas are presented to help physician executives preserve their souls in an increasingly corporatized U.S. health care system: (1) Figure out what you are meant to do as your life's calling; (2) know what you think and want; (3) share some of what you think at work, while being careful to not lose your job unless you choose to; (4) be a trustworthy listener and find one; (5) get yourself outside; (6) pay attention to your physical space; and (7) develop some new hobbies or refresh old ones. "One of the disciplines of building a rich soul life seems to be the simple act, on a daily basis, of remembering what is most important to us."     

Health care enters the real world.

The U.S. health care system is undergoing restructuring as a result of a complex interplay of social, political, and economic forces. Where once the medical profession had a monopoly position in the health care system, its position has been challenged by the Federal Trade Commission under the Sherman Antitrust Act. More and more, the health care field is characterized by entrepreneurialism, a concept that is at odds with the traditional tenets of the medical profession. The restructuring of health care in the U.S. has the potential to allow the entrepreneur to function to the benefit of patients, despite the fact that this is a change resisted by those providing health care services.     

Purchasers and the impact of managed care on physicians

In much the same way that demands by managed care organizations are shaping the way physicians practice, health care purchasers impact how managed care organizations operate. Corporations purchase managed health care through their employee benefits programs, and understanding the language, objectives, and limitations of these purchasers is essential to grasping the forces influencing managed care organizations and the modern practice of medicine. The emergence of value-based purchasing as a strategic corporate approach to health benefits programs will dictate the forces on physicians, hospitals, and managed care organizations for years to come. These forces have already led to price reductions, health plan accreditation, employee-directed report cards, outcomes management, and organized systems of care, and they will determine the broad outlines of the emerging U.S. health care system.     

The ethicist

The 1990s seem drawn for major changes in the U.S. health care delivery system. After a quarter century of piecemeal changes to compensate for the cost dislocations caused by passage of the federal Medicare and Medicaid programs, legislators, moved by a high level of demand from buyers, third-party payers, and consumers, are at last positioned for some structural revamping. Nothing is certain, however, as evidenced by the shifting deadline for introduction of the current Administration's approach to solutions. In this article, the author uses a fictionalized scenario to imagine the status of our health care system in the year 2000. As in 1990, much will remain to be done, even if much will have been accomplished.     

Who lost the health care revolution?

Just a year ago, in the March-April 1989 issue of Harvard Business Review, Professor Regina E. Herzlinger of the Harvard Business School took a long look at the U.S. health care system and declared the much touted revolution in the health care delivery system a failure. This article is a summary of the arguments that Professor Herzlinger marshaled for her treatise. In the following two articles, members of the College assess those arguments in terms of the medical management profession and in terms of the organizations, a hospital and a managed care company, for which they work. Finally, Professor Herzlinger returns to the subject with a response to these physician executives.     

Health policy guided by five questions

As the U.S. Congress pursues a course for the restructuring of the U.S. health care system, it will have to carefully evaluate potential solutions in terms of their effect on cost and access. This article explores five questions, the answers to which will have to guide any health care policy changes at the federal level.     

Constitutional guarantees to health care in Spain

This analysis of the Spanish health care system is one in a series of such studies undertaken by the author, following a grid of factors that influence the delivery and financing of health care. The purpose of the national analyses is to facilitate a comparison of the United States' and other health care systems in terms of anticipated reform of the U.S. system. Analyses of the U.S. and nine other national systems are included in a book that has just been published by the College. Spain and nine additional countries will be studied in a book due for publication later this year. A final book with ten additional national analyses will appear in 1996.     

Population health--a new discipline

A new discipline--population health--has emerged with the potential to profoundly impact the U.S. health care system. Multiple forces stimulating the new population health concept include: (1) the increasing dominance of managed care and critical scrutiny of its development; (2) the continued refinement of clinical effectiveness and outcomes assessment research; (3) increasing public policy emphasis on cost-effectiveness accountability for health care services; and (4) a new focus on the importance of collaboration between the medicine and public health enterprises in this country. The need for sophisticated analysis of population health determinants has never been greater in history. New programs, like the University of Wisconsin-Madison's interdisciplinary Graduate Program in Population Health, address the need for analysis, dissemination, and application of information about the many factors affecting the health of populations.     

Is the American health care delivery system ready for change?

In October 1992, the American College of Physician Executives sponsored a study tour to Berlin, Germany, and Amsterdam, Holland. Meetings were held with government officials, third-party payers, and providers, and on-site visits were made at hospitals, clinics, and academic centers. The purpose was to study the health care delivery system in those countries and to share some insights with the countries' hosts on the U.S. system. In a series of reports that began in the July issue of the journal, 5 of the 10 study tour participants describe their impressions of the tour and of the health care systems in the countries that were visited. In this final report, the implications of the German and Dutch systems for reform of the U.S. health care system are discussed.     

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.     

25 Health care trends. What's hot,what's not,and what does the future hold

As we usher in 2003, America's health care system remains in a chaotic state. Will managed care live or die? Will quality improvement efforts pay off? Are we ready for the next bioterrorism attack? Will the shortage of physician soon rival the shortage of nurses? To help gauge where health care stands today and what the future holds, The Physician Executive asked doctors who serve on ACPE's peer review panel to list the hottest health care trends in the U.S right now. Then, we took the list to three respected health care futurists -- Leland Kaiser, PhD, Jeff Goldsmith, PhD, and Russel Coile, MBA -- and asked them for their insights on the trends. Yes, Kaiser, Goldsmith and Coile are opinionated. Yes, they're controversial. But no matter whether you agree or disagree with their views, the three health care futurists' comments could spark discussions that will help shape U.S. health care this year and beyond. The trends are presented in no particular order.     

National health insurance--to be or not to be

It has been pointed out by advocates of change in the U.S. health care delivery system that, with the exception of the Republic of South Africa, the United States is the only industrialized nation without a system of national health care. Rising costs and an increasing percentage of Americans without insurance and with limited access to health care services has heightened interest in the development of a mechanism for payment for health care services in this country.     

Equitable Taxation and the Provision of Health Insurance Subsidies

Current U.S. income tax laws allow many taxpayers to exclude from taxable income part or all of the cost of acquiring health insurance through an employer‐sponsored benefit plan. This favorable tax treatment generally applies regardless of whether the employer or employee actually pays the health insurance premiums. We describe the effects of this tax policy on the U.S. tax system's horizontal and vertical equity. We also explain how taxpayers covered by employer‐sponsored plans are significantly subsidized by the government in acquiring health insurance, whereas taxpayers who acquire health insurance by other means or who are not covered by health insurance at all receive no such government assistance. We conclude that any prospective health‐care policy initiatives, including modifications to the 2010 health‐care reforms, should contemplate both the horizontal and vertical equity of the tax treatment of health insurance premiums.     

The health care system should produce health

Reform of the U.S. health care system along the lines to be proposed by the Clinton Administration will not be an easy task, and it will not be accomplished quickly. A fundamental objective of the changes should be a health system whose purpose is improvement in the health of U.S. citizens, and not just the provision of services to all. This column is jointly edited by Kevin M. Fickenscher, MD, and David A. Kindig, MD, PhD, chair and member, respectively, of the College's Forum on National Health Policy. Dr. Fickenscher is participating in various advisory capacities on health care in the Clinton Administration, and Dr. Kindig is Senior Advisor to HHS Secretary Donna Shalala.     

Mandated benefits: a misguided effort

The U.S. Congress is toying with the creation of universally mandated benefits for health care, most specifically in the health care reform proposal offered by the Clinton Administration. The notion of mandated benefits has already become a part of the health care scene in insurance and managed care plans. Instead of benefiting U.S. citizens as a whole, however, mandated benefits are likely to result in a reduction in health care accessibility and quality. The reason is that mandated benefits consume a continuously growing portion of the health care pie. Deming demonstrated that quality brings lower costs, but to obtain quality we must commit adequate resources. The free allocation of resources is negated by mandated benefits.     

System reform in integrated health systems

As the debate progresses on health care reform and the ultimate form of the U.S. system, important lessons can be drawn from examinations of other health care systems. From the U.S. perspective, European health systems appear to have a certain homogeneity about them. Americans tend to look at all European arrangements as single-source financing systems. Because these systems all provide universal coverage, the assumption is that there must be a strong cohesion and similarity among them. Viewed from the European perspective, the reality appears to be rather different. In this article, the health cae systems of Nordic countries are analyzed in terms of their differences both from other European systems and from the United States approach.     

Is health care a right or a privilege?

In this overview of the American health system, the author make arguments for declaring health care a right in the U.S. Constitution. Learn why he believes this is necessary.