How should managed care physicians be paid?

When paying a physician for medical or surgical services, most patients expect the traditional bill or charge for that encounter or visit. While most people also pay health insurance premiums, few patients expect to prepay for their health care. But that is the foundation of most managed health care systems-prepaid medicine. PPOs, IPAs, and HMOs are typically health care providers linked together to provide services to a set population for a specific prepaid fee or "capitation" payment. Other providers contract with these managed care insurers to receive a predetermined and often "discounted" professional fee for services. These managed care organizations have already gone through a number of stages in determining how physicians are to be compensated for their services, and further changes loom on the horizon.     

The semantic distinction between "risk" and "danger": a linguistic analysis

The analysis combines frame semantic and corpus linguistic approaches in analyzing the role of agency and decision making in the semantics of the words "risk" and "danger" (both nominal and verbal uses). In frame semantics, the meanings of "risk" and of related words, such as "danger," are analyzed against the background of a specific cognitive-semantic structure (a frame) comprising frame elements such as Protagonist, Bad Outcome, Decision, Possession, and Source. Empirical data derive from the British National Corpus (100 million words). Results indicate both similarities and differences in use. First, both "risk" and "danger" are commonly used to represent situations having potential negative consequences as the result of agency. Second, "risk" and "danger," especially their verbal uses (to risk, to endanger), differ in agent-victim structure, i.e., "risk" is used to express that a person affected by an action is also the agent of the action, while "endanger" is used to express that the one affected is not the agent. Third, "risk," but not "danger," tends to be used to represent rational and goal-directed action. The results therefore to some extent confirm the analysis of "risk" and "danger" suggested by German sociologist Niklas Luhmann. As a point of discussion, the present findings arguably have implications for risk communication.     

Medically necessary?

Coverage decisions can ultimately be traced back to three words in the original health policy contract: medically necessary and investigational. Investigational as a coverage exclusion applies to the minority of cases, in which there is inadequate data to validate the effectiveness of the intervention. In contrast, the majority of coverage decisions are based on medical necessity. Over the years the concept of medical necessity has evolved to encompass a multitude of medical management strategies. This discussion highlights the variable uses of the concept of medical necessity in terms of: (1) Determining the most appropriate intensity of service and place of service; (2) determining whether the proposed therapy is medically appropriate for the patient's condition; (3) distinguishing between medically necessary services and those that are performance enhancing or discretionary in nature; (4) making a distinction between medically necessary, cosmetic, and reconstructive services; and (5) defining medical necessity in accordance with generally accepted principles of good medical practice.     

The use of imperfect data in managed care organizations

Two critical milestones appear to be occurring in the development of medical groups moving to improve medical care effectiveness. These include the abilities to work with imperfect and unflattering data. There is a clear linkage between these two concepts, because forward clinical improvement or business planning is often delayed as individual physicians seek to await "perfect data" when confronted with unflattering information. In the form of "profiles" in particular, providers often react negatively, with complaints that the information is "imperfect" or that it fails to capture some nuance of their sicker or unique patient populations. The translation of imperfect information to effective clinical practice anyway remains a success fundamental to managing highly competitive medical groups and health plans. It is centrally dependent on the understanding, use, and application of "imperfect data".     

IRS proposed "physician recruitment" revenue ruling offers few kernels in search for

Not to sound corny, but things have really been popping since the Internal Revenue Service (IRS) recently released a proposed revenue ruling regarding the scope of recruitment incentives that may be offered to nonemployee physician members of tax-exempt hospital medical staffs. Commentators have criticized the proposed revenue ruling, however, because it offers little in the way of guidance in all but the most obvious cases of recruitment violations. Nonetheless, the proposed ruling may provide insight that may assist hospitals to prepare permissible recruitment incentives for physicians. The IRS provided a public comment period within which individuals and groups could submit proposals to improve or revise the proposed ruling. However, with or without such comments, clarification of the ruling is called for. "Health Law" is a regular feature of Physician Executive from the Washington, D.C., law firm Epstein Becker & Green. Mark Lutes of the law firm serves as editor of the column.     

Shifting power: is the consumer next?

Consumers are not likely to act as patients much longer. They'll demand the same level of information and service they receive from every other sector of the economy. Dozens of new, innovative companies are changing the health care coverage purchasing methods to allow more control and accountability for consumers. They can be broadly categorized into four groups: (1) the "Charles Schwab" clones, (2) spot markets, (3) "make me a doctor," and (4) personalized health care systems. Physicians become directly accountable to their patients in these new models. But choosing health plans may not be enough. It is only a matter of time before consumers demand the right to build their own customized heath plans using the defined contributions from their employers. This article describes the benefits of personalized health care systems and why the death of medical necessity is not far away.     

PER Pressure: New Jersey''s "Population Emissions Ratio" Environmental Equity Screening Model

In recent years, much attention has focused on how to incorporate environmental equity considerations into government permitting programs for environmentally regulated facilities. On February 4, 2002, the New Jersey Department of Environmental Protection (NJDEP) became the first state environmental agency to propose a broad legally binding rule intended to guard against environmental inequity in its permitting decisions. The proposed rule centered on an innovative computerized environmental equity (EE) screening model that used "Population Emissions Ratios" to identify small geographic areas in which environmental equity concerns might exist and to simulate the effect on statewide environmental equity of increasing environmental risks in small geographic areas. The NJDEP's model examined an extensive array of ethnic groups, included a variety of environmental risks, evaluated most of those risks in terms of human health, and used an innovative simulation process designed to identify permitting decisions that would worsen statewide environmental inequity. The results of the NJDEP's efforts, however, pose substantial concerns. For example, some key provisions of the NJDEP's model were inadequately explained and some were illogical and would bias its results. The model might be susceptible to generating implausible results due to small, meaningless, and/or essentially random fluctuations in its data inputs. The model used relatively large geographic areas as the units of analysis and interpolated results between them, rather than using smaller geographic areas and avoiding interpolation errors. Finally, the environmental risks evaluated by the model were both arguably over- and underinclusive. Thus, the NJDEP's efforts, although noteworthy, raised more issues than they settled.     

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.     

Legal issues in accepting capitation

The effort to reduce the cost of medical, hospital, and ancillary services increasingly focuses on shifting the financial risk for the cost of these services to those who provide them. Shifting arrangements include capitation for physicians classified as "primary care" physicians; capitation arrangements that include primary and specialty services; risk shifting to medical groups, IPAs, and other physician organizations; as well as the packaging of physician and hospital services on a "full risk," "per case," or other basis. Accepting financial risk for the cost of medical and other health care services, as well as the responsibility for managing the provision of services, may very well be the only remaining opportunity for providers to maximize reimbursement and maintain administrative and clinical self-direction. However, physicians must work with managed care organizations (MCOs) through negotiation of contracts and throughout the relationship to make sure: Unnecessary financial and legal risks to the MCO and physicians are eliminated. Risks that cannot be eliminated are apportioned between the MCO and physicians. All risks are managed in a coordinated fashion between the MCO and physicians.     

If patients are now "customers," what does that make physicians?

As patients become "members" and "customers," as physicians become "practitioners" and "providers," the practice of medicine becomes more complex and more demanding. The changes that have affected the daily lives of physicians across America will continue and will likely become even more dramatic in the future. There is much to mourn in the passing of the medical practice of the recent past, but there is every reason to celebrate the ongoing triumphs of medicine and its successes in improving the human condition. The job of being a physician is not becoming any less important. The job has just gotten tougher. Successful physicians will cope with the multitude of changes in which the health care field is engaged and make themselves effective agents of change within their organizations.     

The telephone encounter: the cast of characters encountered by the physician executive

Volumes have been written about telephone productivity, decorum, behavior, and economic impact. Although every physician is skilled in telephone communication, medical directors must approach this communications modality from a different vantage point. The attending physician uses it as an information receiver and transmittal station. The medical director uses it as a negotiation platform. It is estimated that 50 to 90 percent of the medical director's time is spent on the phone. "Working smarter" can increase productivity to save time and stress. This article identifies and categorizes many of the problems that the medical director deals with on a daily basis. It pertains to phone conversations in which there is a question about a procedure, appropriateness of care, medical necessity, or quality of care.     

"Conflict management" and "conflict resolution" are not synonymous terms

Robbins sees functional conflict as an absolute necessity within organizations and explicitly encourages it. He explains: "Survival can result only when an organization is able to adapt to constant changes in the environment. Adaption is possible only through change, and change is stimulated by conflict." Robbins cites evidence indicating that conflict can be related to increased productivity and that critical thinking encourages well-developed decisions. He admits, however, that not all conflicts are good for the organization. Their functional or dysfunctional nature is determined by the impact of the conflict on the objectives of the organization. The author identifies several factors underlying the need for conflict stimulation: (1) managers who are surrounded by "yes men"; (2) subordinates who are afraid to admit ignorance or uncertainty; (3) decision-makers' excessive concern about hurting the feelings of others; or (4) an environment where new ideas are slow in coming forth. He suggests techniques for stimulating conflict; manipulating the communication channels (i.e., repression of information); changing the organizational structure (i.e., changes in size or position); and altering personal behavior factors (i.e., role incongruence). Robbins stresses that the actual method to be used in either resolving or stimulating conflict must be appropriate to the situation.     

建立“世界级企业”：优势、路径与战略选择

针对中国企业提高国际竞争力的问题,运用"世界级企业"的概念和企业国际化战略的相关理论,分析中国企业建立国际竞争优势的战略实践,提出中国发展世界级企业的必要性,阐述了中国企业成为"世界级企业"所具有的国家特有优势和需要建立的企业特有优势,指出了成为"世界级企业"的路径与战略选择。"世界级企业"概念的提出及其对相关问题的阐述,不仅为中国企业构建国际竞争优势提供思路和借鉴,而且也是对中国特色的国际化战略理论的深化和发展。     

Strategically integrating hospital/home care services for improved profitability

Because hospitals and home health agencies have been predominantly separate organizations, coordination of their efforts has not been optimized. However, with the recent proliferation of hospital-based home health agencies, opportunities to integrate these health care service delivery systems have increased. Bethesda Memorial Hospital, Boynton Beach, Fla., is a 362-bed not-for-profit community hospital with a Medicare-certified home health agency organized as a department of the hospital. Until recently, the home health agency was generally perceived as a separate entity whose services were distinct from hospital services. Progress toward integration of hospital and home care services was given impetus through collaboration of the home health agency administrator and a newly appointed director of medical affairs who was given the responsibility as medical director of the home health agency. A prime responsibility of the director of medical affairs was to reduce length of stay and hospital costs through appropriate resource management.     

The "moment of death"

The "moment of death," once a dominant concept in preparing for a "good death", has been eclipsed by a focus on the wider concept of the "dying trajectory". However, findings from interviews with 25 bereaved individuals suggest that dying loved ones' final moments may still be experienced as highly significant in their own right. In some accounts the dying individual's final moments did not feature or made little impression, either because the survivor was not present, or there was no obviously definable moment, or because other, usually medical factors, such as whether to resuscitate the person, took precedence. However, in six cases such moments were constructed as profound, special, and memorable occasions. These constructions are explored in relation to achieving a good death, the dying trajectory as a whole, and making sense of the bereavement experience. Their implications for sociological theories of identity and embodiment are also considered.     

Stringency of Workplace Air Contaminant Exposure Limits: A Case Study of OSHA Risk Management

Political context may play a large role in influencing the efficiency of environmental and health regulations. This case study uses data from a 1989 update of the Occupational Safety and Health Administration (OSHA) Permissible Exposure Limits (PELs) program to determine the relative effects of legislative mandates, costly acquisition of information by the agency, and pressure applied by special interest groups upon exposure standards. The empirical analysis suggests that federal agencies successfully thwart legislative attempts to limit agency discretion, and that agencies exercise bounded rationality by placing greater emphasis on more easily obtained information. The 1989 PELs were less significantly related to more costly information, contained safety factors for chemicals presenting relatively more ambiguous risks, and the proposed standard stringencies showed evidence of being influenced by vying industry and labor interests.     

从委托理财收益率看上市公司委托代理问题

本文将委托理财收益率作为研究对象,考察了上市公司的委托代理问题.通过研究发现,"可操控现金"与委托理财收益率显著负相关;若给定"可操控现金",大股东持股比例越高的公司其委托理财收益率越高.这一结果说明,"可操控现金"越多,上市公司的委托代理问题越严重;大股东的持股比例越高,其对管理层代理问题的约束力越强.研究还发现国外同类研究常用的"自由现金流"变量不能捕捉这一现象.     

The five "S" levels of enterprise health.

Whether pride, necessity, or inattention is at the root, some "slowly boiling" physicians find themselves working harder for fewer compensations of all sorts, and may not be fully cognizant of their circumstances. This article helps to diagnose and manage the health of physicians' practices and/or related enterprises. There are five levels of enterprise health, ranging from success (S-1) to shutdown (S-5), that serve as weather vanes about how the enterprise is adapting to changes in its environment. How should physicians respond to chaos and the threats of deteriorating enterprise health? A five-step approach is offered: (1) Discern what is important; (2) place and keep your program in alignment with those patient interests that will enhance your enterprise viability; (3) keep score with an internal balanced scorecard; (4) manage and shepherd your resources in a manner that demonstrably adds value to patient care; and (5) know the score and use it.     

Quo Vadis? Suggestions for future corporate governance research

In this paper I first review the basic tenets of agency theory and theory of managerial capitalism as well as some of the major research in these areas then suggest for areas for future research that go beyond the extant empirical work. First, I suggest that it would be useful to reconsider the basic nature of the agency relationship, taking into account that while equity holders can be considered the principal, the board of directors may be more realistically in need of agent-like controls. Second, the complementary or supplementary nature of the monitoring/incentive alignment relationship has been shown theoretically but the empirical evidence is equivocal and needs future investigation. Third, there has been very limited research on the construct validity of archival measures of the sort used in agency theory. This requires the use of methodologies outside those of the more conventional type used in agency theory (i.e., from economics and finance). Finally, agency theory development would profit greatly by more extensive use of research methods such as laboratory studies and survey methodology and the integration of concepts such as personality and control processes.

Management must role for physicians

It is not the same subject that was projected in the '70s when quality assurance leaped on the health care scene. As complex as quality assurance is, contemporary discussions of quality are much more multifaceted. At the core of health care quality, however, is clinical practice. The consensus among speakers at the College's National Conference of Physician Executives in May in San Antonio, Tex., is that medical quality will not be managed in the interests of patients, buyers, and providers in the absence of significant involvement by physician executives.