The role of the coordinator of care

Regardless of the specific outcome of the current health reform debate in Washington, it is likely that major changes to the health care system are in the offering. These changes, many of which are already in place or imminent in some locations, will have a major impact on the evolving relationships between physicians and hospitals. Most expect that these changes will accelerate the development of integrated health care delivery systems that will compete in the marketplace for a mixture of public and private health insurance dollars. In this system of "managed competition," health care dollars will flow to those systems that can ensure the best clinical outcomes while using the least economic resources. In this scenario, competing collaborative health networks that can manage the continuum of care will be central to the health care delivery system. The economic and political ties between physicians and hospitals will become more closely linked as government and private payers of health care services foster the development of these integrated, value-based health care delivery systems.     

Compliance with patients' end-of-life wishes by nursing homes in New York City with conscience policies

Nursing home patients have a constitutional right to refuse treatment. The Patient Self-Determination Act confirmed that right. State laws address the obligations of health care providers and facilities to honor that right. The New York State law is more specific than those of many other states. It allows exemptions for "reasons of conscience" and imposes a number of requirements on nursing homes claiming such an exemption, including the transfer of a patient to a home that will honor an end-of-life wish. This study, conducted by FRIA, investigated the refusal of some nursing homes in New York City to carry out patients' end-of-life wishes because of conscience-based objections. The study also investigated the willingness of homes which did not have such policies to accept patients transferring from a home with a policy so that the patient's end-of-life wishes would be honored. Implications for administrators, policy makers, and regulators are discussed.     

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.     

I get paid fast; what about you?

The process of billing an insurance company for health care services has changed radically. In the past few years, the emphasis has been on automation. The change is fueled by the opinion of cost containment experts who claim that automation will help reduce costs in the U.S. health care delivery system. Key to success for the provider in adapting to this change will be understanding the coding used in the billing process and following standards of accuracy and fairness. This article is not intended to represent the adjudication rules of any particular insurance company. It is the result of experience as a practicing surgeon and as a consultant in the health care field.     

The importance of end-of-life care in nursing home settings is not diminished by a disaster

The emphasis in disaster situations is on preserving life, and this goal is both appropriate and laudable. There is a risk, however, that the needs of people who are dying can become lost when there is a sudden surge of people needing acute intervention. There are significant ethical considerations inherent in society's prioritization of care needs across the acute, rehabilitative, and palliative spectrum in general, let alone in a disaster situation. These ethical conundrums are not the focus of this article. Rather, we anchor our discussion on the assumption that care needs are equally valid, and our purpose is to explore the issues that impact the provision of quality end-of-life care in nursing home settings for those who require this care when a disaster occurs. Nursing home residents, in particular, are at heightened risk for experiencing negative disaster-related outcomes due to compromised physical or mental health that requires skilled nursing care. Moreover, within the already vulnerable nursing home population are many people who are receiving palliative end-of-life services when a disaster strikes. Education and training in end-of-life services for nursing home staff, disaster emergency responders, and other lay people is vital to build capacity for adapting the delivery of these services in disaster situations in the interest of equity and human rights. Given the present lack of guidance in the literature as to what end-of-life care looks like when adapted to the context of disaster response, there is also a pressing need for research to inform this discussion. The purpose of this article is to draw attention to this topic and highlight some of the critical issues, gaps, and opportunities.     

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.     

The new production theory for health care through clinical reengineering: a study of clinical guidelines--Part I

Drucker writes that the emerging theory of manufacturing includes four principles and practices: statistical quality control, manufacturing accounting, modular organization, and systems approach. SQC is a rigorous, scientific method of identifying variation in the quality and productivity of a given production process, with an emphasis on improvement. The new manufacturing economics intends to integrate the production strategy with the business strategy in order to account for the biggest portions of costs that the old methods did not assess: time and automation. Production operations that are both standardized and flexible will allow the organization to keep up with changes in design, technology, and the market. The return on innovation in this environment is predicated on a modular arrangement of flexible steps in the process. Finally, the systems approach sees the entire process as being integrated in converting goods or services into economic satisfaction. There is now a major restructuring of the U.S. health care industry, and the incorporation of these four theories into health care reform would appear to be essential. This two-part article will address two problems: Will Drucker's theories relate to health care (Part I)? Will the "new manufacturing" in health care (practice guidelines) demonstrate cost, quality, and access changes that reform demands (Part II)?     

Physician-centered management guidelines.

The "Fortune 500 Most Admired" companies fully understand the irreverent premise "the customer comes second" and that there is a direct correlation between a satisfied work force and productivity, service quality, and, ultimately, organizational success. If health care organizations hope to recruit and retain the quality workforce upon which their core competency depends, they must develop a vision strategic plan, organizational structure, and managerial style that acknowledges the vital and central role of physicians in the delivery of care. This article outlines a conceptual framework for effective physician management, a "critical pathway," that will enable health care organizations to add their name to the list of "most admired." The nine principles described in this article are based on a more respectful and solicitous treatment of physicians and their more central directing role in organizational change. They would permit the transformation of health care into a system that both preserves the virtues of the physician-patient relationship and meets the demand for quality and cost-effectiveness.     

Will physicians replace MHAs?: reflections from Australia

Tom Weil, in the preceding article, sees the physician executive playing an increasingly significant role in negotiations between payers and service providers, in offering the public acceptable explanations for the inevitable changes in the provision of care, and in developing more cost-effective methods of delivering high-quality health care at affordable prices. Effective involvement of physician executives will be facilitated by their having received professional training somewhat different from that of the traditional MHA. How do these prognostications relate to the health care scene in Australia? Factors that must be taken into account in considering their applicability to Australia include differences in the structure and management of the Australian health care system, the current state of that system, the background of the leadership that makes the key managerial decisions in the Australian system, and emerging trends within the system.     

Making the health care delivery system accountable.

Accountability has become the fact of life for the health care provider and the delivery system. Until recently, accountability has been viewed primarily through the judicial process as issues of fraud and liability, or by managed care entities through evaluation of the financial bottom line. It is this second consideration and its ramifications that will be explored in this article. Appropriate measurement tools are needed to evaluate services, delivery, performance, customer satisfaction, and outcomes assessment. Measurement tools will be considered in light of the industry's unique considerations and realities. All participants, including insurers, employers, management, and health care providers and recipients, bear responsibilities which necessitate assessment and analysis. However, until the basic question, "Who is the customer?" is resolved, accountability issues remain complex and obscured. Accountability costs and impacts must be evaluated over time. They go way beyond bottom line cost containment and reduction. Accountability will be accomplished when the health care industry implements quality and measurement concepts that yield the highest levels of validity and appropriateness for health care delivery.     

Computer-based patient records: a building block for health care reform

The fundamental need for better information management capabilities in health care is at risk of being overlooked in the proposals for major national changes aimed at providing health security, controlling costs, enhancing quality, and expanding access for citizens. In addition to these proposed macro changes (e.g., universal access, guaranteed benefit package, national health board, regional health alliances), successful reform will require transformation of health care delivery at the micro level. We must overcome provider-dependent variations in clinical practice patterns, in quality of performance, and in costs of services. We must ensure movement toward appropriate care rather than simple rationing. Individual health care professionals and institutions must acquire and use tools that will enable them to provide their services cost-effectively with consistent results. We must be able to assess and ensure value--i.e., appropriateness, effectiveness, and cost--of health services, apply that knowledge in each and every patient encounter, and track the impact of clinical decisions through an analysis of aggregated databases.     

Health care reform. Pan American Uni-Care Health Insurance Plan

Something is definitely wrong with the American health care system. Too many citizens are denied health care, and health care costs continue to rise at an uncomfortable and intolerable rate. Ensuring care for all is a paramount goal. There is no way to simultaneously cover everyone; leave the reimbursement of physicians unrestrained; ensure instantaneous access to every imaginable high-technology service; subsidize the world's costliest and least efficient health bureaucracy; and contain costs. Widespread dissatisfaction in all quarters--physicians, hospitals, third-party payers, regulators and consumers--has led to an avalanche of reform proposals. Rapidly changing social, political, and economic environments; rising fiscal pressure; and an evolving understanding of the major determinants of health have also created pressure for changes. There are some new and hopeful signs that America is facing up to the need for changes in the health care delivery system. The Pan American Uni-Care Health Plan that is described in this article may serve as a reasonable balance among these competing priorities.     

The digital transformation of health care

The arrival of the Internet offers the opportunity to fundamentally reinvent medicine and health care delivery. The "e-health" era is nothing less than the digital transformation of the practice of medicine, as well as the business side of the health industry. Health care is only now arriving in the "Information Economy." The Internet is the next frontier of health care. Health care consumers are flooding into cyberspace, and an Internet-based industry of health information providers is springing up to serve them. Internet technology may rank with antibiotics, genetics, and computers as among the most important changes for medical care delivery. Utilizing e-health strategies will expand exponentially in the next five years, as America's health care executives shift to applying IS/IT (information systems/information technology) to the fundamental business and clinical processes of the health care enterprise. Internet-savvy physician executives will provide a bridge between medicine and management in the adoption of e-health technology.     

The health of health care organizations

Abstract

This paper explores the nature and development of health care organizations in terms of a model of organizational healthiness. The model places particular emphasis on the psychosocial subsystems which describe the subjective organization. These represent the perceived internal functioning of the organization in terms of task completion, problem solving and staff development. The implications of such a model for the well-being of health care staff and for the evaluation of service delivery are discussed.     

The future of American health care in the "post-reform" era

"As the debate over health care reform rages in Washington, the market is reforming itself. For any given market, it's a question of 'How soon will it hit?', not 'Will it hit?'" Health care reform and market restructuring are ushering in a new era of integrated health care. Although the future is not fully clear, there are at least three competing models for the creation of regional and statewide health systems that will integrate the financing and delivery of services to large enrolled populations of consumers: Payer-driven networks. Provider-sponsored systems. Partnership models. Whatever the future scenario, physician executives will play a larger, more dominant role. Research on integrated health systems has identified three critical success factors for future success: physician-hospital integration, clinical integration and information integration. For managed care to be successful, there must be clinical leadership. The essence of managing care is clinical efficiency, based on "critical-path" treatment protocols and real-time patient care management, supported by integrated information systems.     

Physician leadership. Learning to be a leader

As the business role of health care delivery expands and complex reform is imposed, physicians must assume leadership roles and imprint medical expertise on business dynamics. Before the end of this century, health care and its delivery will likely become unrecognizable to those who ended their practices only a decade ago. Traditional management will wither away to be replaced by self-managed, self-trained, and self-motivated workers, no longer employed in jobs but working through processes, projects, and assignments in integrative health care delivery systems. Becoming a leader is an active and arduous process that can no longer be approached haphazardly. To be effective, the physician must plot a course with clear and calculated intent and effort, which requires acquiring organizational tools and administrative skills to innovatively alter medical care for the good of all.     

Political Exhortation, Patient Expectation and Professional Execution: Perspectives on the Consumerization of Health Care

A central theme underpinning the reform of public-sector services in western economies since the 1980s has been the emphasis on reorienting service provision around the user. Public-sector organizations have been forced to reappraise the design of the service delivery process, in particular the service encounter, to take account of the resultant changes in service users' expectations. Such focus on the service user has fundamental implications for public-sector professionals, specifically challenging the dominance of service professionals in the design and delivery of services. Based on a survey of patient attitudes towards service provision in the National Health Service in Scotland (NHSiS) and in-depth interviews with senior hospital clinicians and managers, the paper critically examines the reaction of both patients and professionals to politically driven initiatives to reorientate the delivery of health-care services. Specifically the paper explores the emerging perspectives of both patients and professionals towards the consumerization of health care and the changing nature of the relationship between patients and professionals within a publicly funded health-care system.     

A new industrial order for physicians: a talk with Jeff C. Goldsmith, PhD. Interview by Richard L. Reece

Richard L. Reece, MD, interviewed Jeff C. Goldsmith, PhD, President of Health Futures, Inc. on October 12, 1999 to discuss how the Internet will affect health care delivery in the millennium. One of the most profound changes that he sees is how the relationship between physicians and patients will be altered. Empowered consumers are where the real revolution is happening--a trend sometimes overlooked by physicians. Goldsmith says, "The key thing physicians have missed is that the patient is in charge of the process.... The Internet has enabled patients to aggregate their collective experience across disease entities." But there is too much information. "It is almost universally acknowledged by patients and physicians that there is a terrible quality problem. Getting from information to knowledge is a huge commercial opportunity for somebody." He doesn't think that people have put enough emphasis on the collective learning part of this new technology.     

Transition to capitation. Aligning incentives for success

Horror stories abound about providers that have failed to modify their incentive systems and have exhausted their annual capitation budget in the first six months of the plan year. Aligning the business strategy and financial incentives in advance is the best way to ensure that your integrated delivery system's transition to capitation is a success story. Rarely are physicians or hospitals with experience limited to the fee-for-service arena prepared to jump into a managed care or capitated compensation system. The transition can be eased by implementing a "shadow" capitation or similar arrangement that will test physician performance under a risk arrangement in advance. The information can be used to restructure the compensation system to ensure that the behaviors being encouraged will promote successful care and fiscal management.