The looming millennium bug

Evaluating and fixing date sensitive systems by the year 2000 is a significant challenge for the health care industry. Health care executives will be engrossed in this important management activity over the next several months. By now all critical business functions should have been identified and remediated. Contingency planning to ensure the continuity of high quality systems is an essential next step. Physician executives need to have a contingency plan in case Y2K-related failures occur. Most health care facilities have a disaster plan that has been tested in clinical scenarios. These plans should be reviewed to ensure they include procedures for handling problems with office operations, power outages, equipment failure, supply or pharmaceutical shortages, and patient evacuation. Financial systems are at risk at multiple points, including determining eligibility, claims submission, billing, and payments.     

Suicidal tendency,physical health problems and addictive behaviours among general practitioners: their relationship with burnout

The aim of this article is to analyse further the association of burnout with (poor) physical health, addictive behaviours and suicidal tendency among general practitioners (GPs). Four hypotheses were studied: (H1): burnout (i.e. emotional exhaustion, EE, and depersonalization, DP) will be positively associated with suicidal tendency; (H2): will be negatively related to physical health (i.e. large number of physical symptoms and long-lasting impairment); and (H3): positively linked to addictive behaviours (i.e. addiction to alcohol and psychotropic medication) of GPs. Based on the “spiral of losses” depicted by the conservation of resources theory, we also considered whether physical health mediates the relationships of burnout/suicidal tendency and burnout/addictive behaviours (H4). 1890 French GPs completed a questionnaire administered by phone. Information was collected on burnout, three physical health indicators (BMI, number of physical symptoms and lasting physical health problems), four health behaviours (consumption of tobacco, alcohol, anxiolytics and antidepressants) and suicidal tendency (ideation, plan and attempt). Concerning EE, the results supported the hypotheses, except for alcohol consumption. However, the findings showed that DP was associated with more positive outcomes when controlling for exhaustion. The difference in findings for EE and DP are discussed, together with the need for GPs to develop strategies for resilience.     

The implications of practice guidelines for physician medical malpractice liability

Medical practice guidelines are increasingly coming into use, and as more and more physicians are presented with guidelines to follow in the delivery of health care, the question arises of whether these guidelines will become instruments for imposing greater medical malpractice liability on physicians. This column will briefly describe what guidelines are, how they are developed, and how they have been and may be used in litigation against physicians, hospitals, and other health care institutions. As hospitals and managed care organizations continue to implement guidelines, the role these guidelines play in malpractice cases can be expected to increase. It appears, however, that, although guidelines will contribute to the establishment of the standard of care by which a physician's actions will be measured, they are not likely to become the standard that all physician treatment decisions must meet.     

Canada's Health Status: A Public Health Perspective1

Health status assessment and disease surveillance are essential to identify and priorize health issues, to evaluate intervention programs and to plan to meet future needs for health services. Canadians currently benefit by having among the highest life expectancies at birth in the world (81 for females, 74 for males). Disability-free life expectancies for females and males, respectively, were 10.1 and 11.3 years lower for the lowest income quintile compared to the highest. Canada's infant mortality rate in 1990 (7/1000 live births) was one of the lowest in the world but within Canada, the rate in the lowest income quintile (10.5/1000 live births) was almost double that in the highest income quintile (5.8/1000 live births). Fair or poor health was reported by 36% of adult Canadians in the lowest income category in 1990 compared to only 5% in the highest income group. The leading causes of premature death for females in 1991 were breast cancer, coronary heart disease, lung cancer, car crashes, birth defects and suicide; those for males were coronary heart disease, suicide, car crashes, lung cancer, birth defects, and AIDS. Lowest income quintile males had mortality rates at least double those for the highest income quintile for alcohol-related conditions, violence, injuries and emphysema. Cardiovascular diseases, cancer, musculoskeletal diseases, injuries and respiratory diseases imposed the highest direct and indirect economic costs in Canada in 1986. For all of these conditions, improved prevention is possible. For example, the forecasted tobacco-related deaths before age 70 among current male smokers age 15 will far exceed those due to car crashes, suicide, murder, AIDS, and drug abuse combined. Population aging will aggravate trends for many chronic conditions especially those with increasing incidence rates; there will be large increases in the numbers of persons with aging-related cancers, dementias and other conditions. There is an urgent need for Canadian health jurisdictions to ensure that rational priorities, goals/objectives, strategies, and programs are in place to enhance prevention and disease control.     

In the mush.

Approaching change, we cannot really know who we will be when we come out the other side. We can envision, plan, and sed goals, and these exercises will make a difference in how the process turns out, but we can never know exactly. When we have come through a profound change, we will have difficulty remembering how we could ever have been anything else. In the midst of profound change, we cannot see with certainty how it will turn out. We are "in the mush." Every change creates a need for learning. This change-induced learning has four phases: (1) Unconscious incompetence, (2) conscious incompetence, (3) conscious competence, and (4) unconscious competence. Health care--not just the industry, but the whole way in which we manage our health, our birth and death, our wellness and comfort--is at or approaching not just one strategic inflection point, but several at once. Physician executives need to guess correctly about this strategic inflection point, and position themselves and their organizations to take advantage of it.     

Complementary and alternative medicine. The daunting challenge.

There is no question that the past few years have seen a tremendous surge in interest in what has come to be known as complementary and alternative medicine (CAM). Health plans contemplating adding CAM benefits face a daunting challenge. How should a plan define CAM benefits? How should a plan define appropriate CAM providers? How can these benefits be managed? Will the addition of CAM benefits undermine coverage policies for conventional biomedicine? The answer to these questions lies largely in uncharted waters, as even CAM advocates will agree that many alternative therapies (even those like Oriental medicine which has been in practice for some 5,000 years) have not yet undergone the type of rigorous, evidence-based analysis that is required to validate conventional biomedicine. This article explores options for CAM benefit design by considering two basic approaches-creating an uninsured benefit or insured benefit.     

Cutting to the chase: what physician executives need to know about HIPAA

All health care providers, plans, and clearinghouses will be affected by the federally mandated uniform standards for administrative transactions. This article presents distilled core information about the Health Insurance Portability and Accountability Act (HIPAA) legislation--the standards, penalties for violations, and status of final rules. It also raises several key unsolved issues of which clinicians, executives, and health care providers must be aware so they can prepare and plan for the upcoming changes. HIPAA is intended to improve the efficiency and effectiveness of the health care system, as well as to increase the protection and confidentiality of individually identifiable health information. The costs of making the transition to the legislated standards and processes remain a worrisome factor. Although there are two years before these standards must be implemented, and cost and compliance issues resolved, work has already begun in many health institutions to identify and address them.     

Partitioning of Dietary Metal Intake—A Metal Dietary Exposure Screening Tool

Detection of heavy metals at trace or higher levels in foods and food ingredients is not unexpected given the widespread unavoidable presence of several metals in nature, coupled with advancement in analytical methods and lowering limits of detection. To assist risk managers with a rapid risk assessment when facing these situations, a metal dietary exposure screening tool (MDEST) was developed. The tool uses food intake rates based on the National Health and Nutrition Examination Survey 2005–2010 consumption data for the U.S. population two+ years and up and for infants age six months to <two years based on the Nestlé Feeding Infants and Toddlers Study, and existing exposure limits for several frequently detected metals (e.g., inorganic arsenic, cadmium, chromium, lead, and mercury). The tool has data entry fields for detected concentrations and includes algorithms that combine metal levels with consumption data to generate screening‐level exposure estimates, which it then compares to MDEST assigned default portions of the exposure limits in the risk characterization module. As a screening‐level tool, the risk assessment output is intentionally conservative, public health protective, and useful for a rapid assessment to set aside issues that are not of concern. Issues that cannot be readily resolved using this screening tool will need to be further evaluated with more refined input data that are tailored to the specific question or situation under consideration.     

Radon Testing Behavior in a Sample of Individuals with High Home Radon Screening Measurements

Although radon exposure has been identified as the second leading cause of lung cancer, fewer than 6% of U.S. homeowners test their homes for radon. This report examines participants'follow-up radon testing behavior subsequent to receiving an initial screening radon level greater than 20 pCi/L. Sixty-two participants in the Iowa State-Wide Rural Radon Screening Survey who had radon screening measurements over 20 pCi/L were questioned by phone survey 3 months after receipt of their radon screening result to assess: whether participants were aware of radon's health risk; if participants recalled the radon screening results; how participants perceived the relative health risk of radon and whether participants planned follow-up radon testing. Only 19% of the respondents specifically identified lung cancer as the possible adverse health outcome of high radon exposure, and the majority of participants underestimated the health risks high radon levels pose when compared to cigarettes and x-rays. In addition, less than one third (29%)of the participants actually remembered their radon screening level within 10 pCi/L 3 months after receiving their screening results. Only 53% of the individuals correctly interpreted their screening radon level as being in the high range, and only 39% of the participants planned follow-up radon measurements. Receipt of radon screening test results indicating high radon levels was not an adequate motivational factor in itself to stimulate further radon assessment or mitigation. Our findings suggest that free radon screening will not result in a dramatic increase in subsequent homeowner initiated remediation or further recommended radon testing.     

Measures of Industrial Protectionism: Relevance for Trade and Labour Policies

ABSTRACT: Protectionist policies are often supported by an ‘unholy‘ alliance of industrial lobbies and labour unions, under the assumption that trade barriers will favour higher profits, wage rates and employment. Even when one takes the narrow view of self-interest in a single producing sector, however, things are not necessarily what they seem and protectionism may have more profound consequences than those expected by lobbyists and negotiators. The paper reviews the methodologies developed to measure the extent and the consequences of industrial protectionism in order to derive operational guidelines to evaluate alternative trade policies.     

Important points in managed care contracts

Health care is increasingly managed through some contractual relationship. Such contracts vary and the contracting entities may be clinics, universities, health maintenance organizations, individual practitioner organizations, preferred provider organizations, corporate health plans, or other structures. It is estimated that within 10 years more than 70 percent of all health care will be provided through some type of managed care plan.     

When push comes to shove: implementing VBAC practice guidelines

The dramatic increase in U.S. cesarean sections over the past two decades has been significantly driven by repeat C-sections. In response to this trend, clinical guidelines recommending vaginal birth after cesarean-section (VBAC) have been promulgated by national organizations. Adherence to these guidelines would reduce the number of repeat C-sections, lower the overall C-section rate, and improve both the quality and the cost of health care. While these guidelines have received professional endorsement, their implementation has been clouded by issues of patient acceptance and provider payment. To examine implementation of these guidelines by health care organizations, the authors surveyed 156 members of the American College of Physician Executives to determine their policies, practices, and attitudes toward VBAC guidelines. Those surveyed generally were medical directors in HMOs, hospitals, and other practice settings. The findings indicate that the health care organizations represented by these physician executives have not consistently implemented VBAC guideline and that they are reluctant to hold physicians, their patients, or hospitals accountable for the financial, utilization, and quality impact of the elective decision ot to pursue appropriate VBACs. We conclude that, even when widely accepted, clinical practice guidelines may be ineffective in reducing the costs or improving the quality of medical care.     

Exposure Assessment: Then, Now, and Quantum Leaps in the Future

Health risk assessments have become so widely accepted in the United States that their conclusions are a major factor in many environmental decisions. Although the risk assessment paradigm is 10 years old, the basic risk assessment process has been used by certain regulatory agencies for nearly 40 years. Each of the four components of the paradigm has undergone significant refinements, particularly during the last 5 years. A recent step in the development of the exposure assessment component can be found in the 1992 EPA Guidelines for Exposure Assessment. Rather than assuming worst-case or hypothetical maximum exposures, these guidelines are designed to lead to an accurate characterization, making use of a number of scientific advances. Many exposure parameters have become better defined, and more sensitive techniques now exist for measuring concentrations of contaminants in the environnment. Statistical procedures for characterizing variability, using Monte Carlo or similar approaches, eliminate the need to select point estimates for all individual exposure parameters. These probabilistic models can more accurately characterize the full range of exposures that may potentially be encountered by a given population at a particular site, reducing the need to select highly conservative values to account for this form of uncertainty in the exposure estimate. Lastly, our awareness of the uncertainties in the exposure assessment as well as our knowledge as to how best to characterize them will almost certainly provide evaluations that will be more credible and, therein, more useful to risk managers. If these refinements are incorporated into future exposure assessments, it is likely that our resources will be devoted to problems that, when resolved, will yield the largest improvement in public health.     

Benefits and barriers to consumer choice

Any successful health care reform effort must increase the market power of individual consumers. If consumers act in the medical marketplace as they do in other segments of the economy they will make sensible decisions about the allocation of resources (rationing) without the intrusion of third parties and will select providers and medical interventions that meet their needs. This article asserts the importance of consumer influence, focuses on the barriers that prevent consumers from exerting the same muscle in health care that they manifest in other areas of the economy, and suggests ways to remove these barriers.     

Health care's power brokers in the 21st Century. Interview by Donna Vavala

Health care has undergone turbulent change in the 20th Century. In addition to dramatic pharmaceutical and technological advances, the entire health care delivery system has been significantly improved. Through all the turmoil, hospitals have been at the center of the health care universe. But, as the 21st Century approaches, that may change, too. What will become of hospitals, which for most of this century have played a commanding role? Will managed care organizations and group practices come out on top? And, once the new power broker takes over, what will be the impact on providers, insurers, and the government, and how will their relationships to each other change? Jeff Goldsmith, PhD, President of Health Futures, Inc., Bannockburn, Ill., and health care futurist, examines tomorrow's health care delivery system and makes some eye-opening predictions.     

The HIPAAcratic oath: do no harm to patient data

Physician executives need to prepare their organizations for the next great system-wide challenge--HIPAA, the Health Insurance Portability and Accountability Act of 1996. Organizations will have to plan for and execute a compliance program with the same vigor and system-wide participation as they did for Y2K. This article provides a brief overview of HIPAA, emphasizing the privacy and security components that will be the biggest challenge for physician executives. Physician leaders must become actively involved in the policymaking process to ensure a balanced approach to protecting the confidentiality of health information, while giving providers optimal access to data to make informed decisions on patient care and management. Ignoring HIPAA is simply not an option.     

Defined contribution--the future for health care

Employers are seeing breathtaking health care premium increases. As action-oriented people, they are not going to cough up additional money to pay for these rate increases. The real question is what solution might employers move to? The most logical answer is defined contribution--a way that employers could give employees health benefit funding that resembles what they have already done in pension funding. Today, facing massive cost pressures from their health care premiums, many employers are wishing that they could create or use the equivalent of a defined contribution plan for health care. The next major evolution of defined benefit health financing needs the full-scope functional equivalent of a 401 (k) administrator to make the concept work--someone to give employers the tools needed for employees to make meaningful choices. Up until now, no one has been able to give consumers meaningful data about health care and health benefit alternatives. A viable 401 (k) health administrator will need to offer an array of choices that will work for all players.     

Leadership theory and practice: Fostering an effective symbiosis

Leadership theory has not lived up to its promise of helping practitioners resolve the challenges and problematics that occur in organizational leadership. Many current theories and models are not contextualized, nor do the dynamic and critical issues facing leaders drive their construction. Alternatively, practitioners too often approach leadership problems using trial and error tactics derived more from anecdotes and popular fads than validated scientific data and models. Yet, while this gap between theory and research has bedeviled the leadership community for much of its history, there have been few if any systematic examinations of its causes. In this review, we have sought to highlight the particular barriers on the leadership practice and theory-building/testing constituencies, respectively, that constrain efforts to integrate them. We also offer a number of propositions and guidelines that we hope can break through these barriers and help stakeholders create a more effective leadership theory and practice symbiosis (LTPS). Finally, we have offered two cases of effective LTPS as examples and models for such integrative research efforts.     

A health strategy for Nigeria

Improving the quality, acceptance and innovation in plans developed for sectors of an economy is a critical concern to both administrators and management scientists. This article reviews the planning system for health in Nigeria and attempts to identify problems and prospects. Priority setting has been identified as a major bottleneck to the achievement of a wider health coverage to benefit the majority of the people. Recognition is given to the fact that emphasis has been misplaced in terms of budgetary allocation to health and the intra-sector allocation between curative, preventive and promotive health subsystems. Perhaps what is needed is the development of a HEALTH STRATEGY FOR NIGERIA. Community participation in setting health priorities and health education will speed up the process of achieving Health for All (HFA) by year 2000.     

New market forces are special challenge to academic health centers

New market forces--insurer integration into the provider business, "mega-mergers, price and premium reductions, a scramble to create specialty carve-out networks, and the like--have emerged that are placing significant pressure on academic medical centers. All of these forces are accelerating the pace of managed care market maturation. In order to effectively compete in this new marketplace, academic health centers have substantial barriers to overcome. To do so will require the creation of a system to manage the health care of populations while minimizing system costs and maximizing quality. This will require the establishment of a unified medical center approach to markets and value management. Academic health centers will by necessity develop strategies to include strong primary care-based network affiliations in order to accomplish these tasks.