The new health care civilization: integration of physician land and manageria

Changes occurring in health care demand that physicians expand their professional knowledge and skills beyond the medical and behavioral sciences. Subjects absent from traditional medical education curricula, such as the economics and politics of health care, practice management, and leadership of professional organizations, will become important competencies, particularly for physicians who serve in management roles. Because physicians occupy a central role in planning and allocating medical care services and other health care resources, they must be better prepared to work with other health care professionals to create a new civilization, even if this means leaving the cloistered domain of "physician land" to serve as interface professionals between the delivery of medical services and the management of health care. Our research findings and conclusions strongly suggest that economic, management, and leadership competencies need to be incorporated into the professional development of physicians, especially in postgraduate and continuing education curricula.     

DO RESPONDENTS REALLY "MARK ALL THAT APPLY" ON SELF-ADMINISTERED QUESTIONS?

An experiment was conducted to assess the effect of using "markall that apply" question instructions on survey reporting aspart of the field test for the Second Follow-up of the NationalEducation Longitudinal Study of 1988 Eighth Graders (NELS:88).Mark-all-that-apply instructions were compared with instructionsasking respondents to indicate "yes" or "no" to each responseoption on responses to three items dispersed throughout thequestionnaire and consisting of different topics and numbersof response options. For the three items, significantly fewerresponse options were selected with the mark-all-that-applyinstructions than with the yes/no instructions, but becauseexternal validity criteria were not available, overreportingto the yes/no instructions cannot be ruled out. Instructiondependentprimacy effects, predicted under the hypothesis that respondentswould engage in more superficial processing when given the mark-all-that-applyinstructions, were not found.     

Women's legal knowledge: a case study of Mexican urban dwellers

In Mexico, the nongovernmental organization Sevisio, Desarrollo y Paz, A.C. (SEDEPAC) is helping poor women acquire legal knowledge in an economic climate characterized by the increased feminization of poverty brought about by the Structural Adjustment Program. The Mexican legal system is grounded in a patriarchal tradition, and the codified laws continue to favor men. Women were not granted full citizenship until 1953, and discrimination against women was not addressed in Mexican law until 1974 as the country prepared to host the First UN International Women's Conference. However, legal advances are not being applied in the family or in larger society where men remain in power. Mexico also distinguishes between private law and public law. Because domestic violence falls in the realm of private law, authorities are loathe to follow-up on women's complaints in this area. Since its founding in 1983, SEDEPAC has applied a gender perspective to its activities and programs. SEDEPAC held its first women's legal workshop in 1987 and realized that most poor women have no knowledge of existing laws or their rights, that alternative legal services for women are scarce, that existing laws must be changed, and that the authoritarian and conservative legal system helps maintain cultural stereotypes. Since then, SEDEPAC has held annual workshops, follow-up meetings, and training sessions and has provided counseling. The main topics addressed are women's social conditions; violence and the penal code; civil rights, power, and dependency; women's bodies and reproductive rights; and women's organization and leadership. The workshops use techniques of popular education such as group participation and use of gossip as a communication tool. The workshops have changed participants' lives and led to the formation of an independent Popular Defenders' Coordination.     

Capitation and informatics

When physicians, hospitals, and allied health professionals bill for services they render, their information processing requirements are relatively simple, at least compared to those of capitated organizations. When payers (insurers or employers) accept financial risk for the health care services of beneficiaries, they have usually invested in claims processing, membership tracking, and, under managed care, utilization review and provider profiling systems. But payers, for the most part, have not invested in electronic collection of clinical information about beneficiaries, nor have they tended to keep all claims they have processed in electronic form for study after accounts are settled and payments disbursed. In this article, we will explore why informatics is so important to capitated organizations and why payers that have traditionally taken financial risk for insuring the health care costs of populations are also learning about the importance of informatics.     

Getting the most for your consulting dollars

Major changes in the health care financing and delivery system have usually been accompanied by an increase in demand within the health care field for consulting services. The passage of Medicare/Medicaid in 1965 is one example. The passage of the DRG-based prospective pricing system in 1983 is another. Both spawned a substantial amount of work, and income, for consulting firms. Now the health care field is engaged in nearly total transformation as the forces of health care reform at the national level are met with myriad adjustments at the local and regional levels. Managed care, already a byword, is being strengthened by a multitude of so-called integrated system initiatives. It is not easy to survive, and the call is out to consultants to save the day, or at least stave off disaster. In the following four articles, Marilyn Kennedy, a member of the ACPE faculty and a consultant herself, gives some advice on how to make the consulting arrangement successful; three physician executives provide a glimpse at consults that have worked, and some that did not work.     

Personal trainer, personal coach

The increasing number of fresh faces in the management ranks, many of them with highly polished credentials but little in the way of practical experience in the work-a-day management world, has increased the need for a new consulting professional--the personal coach. There simply aren't enough volunteer mentors to accommodate the growing medical management profession. Whatever the conditions under which this new professional's services are sought, both the individual to be coached and the organization for which the individual works should approach the arrangement with care and planning. The author offers some guidance for making the arrangement pay off.     

What lies ahead for medical management?

The consensus is that, in spite of a reluctance in Washington to undertake any drastic reform of the health care financing and delivery system, the changes that are already in place in individual organizations and that are in place or being contemplated at the state level are certain to make the health care system of tomorrow very different from that of today. Physician executives can play an important role in the transition that will be required, but they will have to use a flexible, especially nondogmatic approach if they wish to cope successfully in this increasingly whirling environment. For such physicians, the author says, the opportunities, though unknown, are enormous.     

Keeping the "care" in managed care: the importance of the therapeutic relationship and psychosocial factors in the managed care setting

There is much truth in the adage that "the more things change, the more they stay the same." Nowhere does this seem more apparent than in health care where, amidst monumental reconfiguration, basic foundations of physician-patient relationships and attention to the impact of psychosocial factors on health and health care delivery remain as critical influences. While the importance of the therapeutic relationship and the influence of psychosocial factors in medical care has been clear in traditional systems of delivery, these factors may be even more critical in managed care systems. These emphases must be incorporated by design, however, and not left to default.