IRS offers safe harbor in physician employment contracts

Last year, the Internal Revenue Service (IRS) issued Revenue Procedure 93-19 (Rev. Proc. 93-19), which provides guidelines regarding service and other contracts involving facilities financed with tax-exempt bonds. Rev. Proc. 93-19 creates four "safe harbors" for certain contracts signed by tax-exempt organizations that will not jeopardize the organizations' tax-exempt bond interest. Those guidelines and methods for complying with them are the subject of the following article. "Health Law" is a regular feature of Physician Executive contributed by Epstein Becker & Green. Mark Lutes of the law firm's Washington, D.C., offices serves as editor of the column.     

Administrative knowledge and skills needed by physician executives

A survey was mailed to 100 physician executives identified through the 1991 American College of Physicians Executives directory. The subjects were asked to rate 17 managerial areas on their value to the subjects' current work, on the subjects' preparation in the areas, and on the need for training in the areas. In addition, the subjects were asked how best to accomplish training in the areas and for a list of areas of greatest importance in the future for physician executives. The subjects rated communication skills, quality assurance, utilization review, and personnel management as being of primary value in their current roles. Preparation was most adequate in communication skills and most inadequate in the areas of finance and organizational management. Training was deemed desirable in all areas, but was thought to be most necessary in communication skills, negotiations, strategic planning, and organizational management. There was least desire for training in the areas of labor law and employment law. The most popular means of training were doing a fellowship in administrative medicine, receiving continuing education through seminars or workshops, or getting a degree in management.     

Zeroing in on leadership effectiveness: The methodological challenges of benchmarking leadership practices

Business success in the 21st century will be based on the widespread mastery of leadership roles, rather than on the directives of a professional or leadership elite. The first step for systematically enacting a leadership development agenda for our nation is to identify the factors, values or qualities most important to leadership effectiveness. Next, we must improve our understanding of how these guiding ideas and insights translate into what successful leaders do. As we perfect this understanding, we will need to operationally define the best practices of successful leaders. These best practices must then become benchmarks for intensive leadership development efforts.This article considers nine methodological challenges of the first agenda item-identification of the factors, values or qualities most important to leadership effectiveness. To illustrate these challenges, the authors use their own business leadership research as a case study. This research surveys 127 chairmen, chief executive officers, and presidents-a cross section of successful U.S.A. business leaders, including men and women from all parts of the nation who have diverse industry, racial, ethnic and religious backgrounds. The authors identify where methodological improvements are needed to cope with the challenges of leadership research. They suggest important directions for methodological development and propose three minimum standards for future leadership research.     

A comparison of quality and utilization problems in large and small group practices

Physicians practicing in large, multispecialty medical groups share an organizational culture that differs from that of physicians in small or independent practices. Since 1980, there has been a sharp increase in the size of multispecialty group practice organizations, in part because of increased efficiencies of large group practices. The greater number of physicians and support personnel in a large group practice also requires a relatively more sophisticated management structure. The efficiencies, conveniences, and management structure of a large group practice provide an optimal environment to practice medicine. However, a search of the literature found no data linking a large group practice environment to practice outcomes. The purpose of the study reported in this article was to determine if physicians in large practices have fewer quality and utilization problems than physicians in small or independent practices.     

A rational approach to career change

Recently, the number of physicians who have been interested in alternative careers has vastly increased. Many physicians express dissatisfaction with clinical practice, but they are uncertain about which nonclinical options are appropriate for them. Pursuing a different career after many years of studying and practicing medicine can seem like an overwhelming task. In this article, the author briefly outlines a decision-making process that can be used in analyzing career options and suggests some careers that have provided challenging opportunities for physicians.     

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.     

Ascendancy of primary care will create role intensification for physician executives

The need for physicians in management roles in the health care system has never been greater. And the years ahead will see that need broadened and intensified. To maintain their leadership role in medical affairs in hospitals and other types of health care delivery organizations, physician executives will have to envision provider organizations and systems that have not yet been conceived, let alone developed and implemented. They have to become totally open-minded and futuristic in their thinking. And they will have to help other physicians accommodate this new way of thinking if the medical profession is to continue in a leading role in health care matters. Although numerous factors will have to be anticipated and analyzed by these new physician leaders, the ascendancy of primary care in a managed health care world long dominated by the technical and technological superiority of hospital care will present a particular challenge to the physician executive.     

Environmental hazards and the health status of women and children in a riverine community in Nigeria: Nikrowa in Edo State

Nikrowa is a riverine village located in Ovia North-East Local Government Area of Edo State. This paper examines the relationship between the environment and the health status of women and children in the village. Data used in this essay were obtained mainly in focus groups from a study of women and health service utilization in Nikrowa. Women in Nikrowa farm, fish, collect water and firewood, and process and prepare food. They also bear many children. Their hard physical labor causes them to suffer continuous body aches and pains. Environment-related illnesses such as malaria, measles, dysentery, and diarrhea are prevalent among children. The geographical isolation of Nikrowa limits access to modern health care facilities, so traditional therapies are used to treat prevailing illnesses. It is suggested that women have access to fertilizers in order to improve soil fertility and agricultural yields. Fuelwood and adequate and safe water supplies should be made readily available to women. Moreover, access roads to rural areas should be improved to facilitate transport to modern health care facilities, and rural primary health care facilities should be helped to provide efficient services by providing trained staff and ensuring regular supplies of drugs.     

Emigration dynamics from and within South Asia

This review of current knowledge about emigration dynamics from and within South Asia (Bangladesh, India, Pakistan, and Sri Lanka) opens with a brief history of the three phases of emigration from the area since the 1830s (plantation labor; postindependence to the UK, US, Canada, and Australia; and labor migration to the oil-exporting countries). The influence of the creation of Pakistan and Bangladesh is also covered as are British colonial and commonwealth policies. It is noted that migration data are incomplete and that India exhibits an ambivalence about collecting such information. The discussion then turns to emigration since 1970 and considers permanent migration from South Asia to the traditional receivers; South Asian asylum seekers in Europe; South Asian refugees, illegal migrants, migrant workers (flows and destinations), the stock of contract migrant workers (and their characteristics); returnee migrant workers; and skill levels. Analysis is provided of macro level determinants of emigrations such as gross national product (level and growth), the general demographic and social situation, labor force growth and structure, poverty and inequality, and internal and international migration. Environmental factors causing displacement in Southern Asia include floods, cyclones, river bank erosion, drought, and desertification. Global warming could displace millions of people in the region, and development projects have contributed to displacement. The remainder of the report covers political and ethnic factors, micro-factors influencing migration decision-making, the policies of sending and receiving countries, the consequences of emigration, and the potential for migration in the future.