Health care futures. Part 2: The future of physician executives? Panel discussion

What is the future of health care in America? This is Part 2 of The Physician Executive panel discussion that explores the future of health care in America. To narrow this ambitious focus somewhat, the future is defined as five to 10 years hence. In Part 1, which was published in the May/June issue, Russell C. Coile, Jr., Barbara LeTourneau, MD, MBA, FACPE, James Reinertsen, MD, Uwe Reinhardt, PhD, Marshall Ruffin, MD, MPH, MBA, FACPE, and David Vogel, MS, shared their opinions about what the future holds in managed care, information technology, and biotechnology. In Part 2, Susan Cejka, Barbara LeTourneau, MD, MBA, FACPE, John Henry Pfifferling, PhD, Uwe Reinhardt, PhD, and James Todd, MD, share their views on the future of medical education and physician executives.     

The Limitations and Opportunities of Business Process Re-engineering in a Politicized Organizational Climate

This paper is concerned with the organizationalchange and project management issues raised by theimplementation of a business process re-engineering(BPR) approach in the politicized hospital context. This is a report of research in progress,focusing on the issues arising at the problem definitionand project planning stages of a BPR application in anoperating theaters department experiencing problems with scheduling and delays. The research designrelies on a case study approach, with the researcher asparticipant observer, as both an adviser to the projectteam and as field interviewer. The paper argues that an ambitious BPR agenda is compromised inat least two regards. First, the lack of precisionsurrounding the focus and methodology of BPR givespolitically motivated actors considerable influence with respect to defining terms of reference in wayswhich will shape potential outcomes in their favor.Second, the complexity and indeterminacy of the businessprocess or patient trail can also diluteredesign attempts. The principal limitations of theapproach thus concern the impracticality of embarking onrapid and radical change working from a blanksheet of paper with respect to organizational and job design. BPR, unlike other organizationdevelopment interventions, is not a contextsensitive approach. The role of project manageris critical in establishing a working balance betweenindividual, occupational, and organizational goals in a manner perceivedto be legitimate in the context. Effective BPR projectmanagement thus requires a combination of political andprocess analysis skills. The principal opportunities of BPR derive from its process orientation,which brings a fresh perspective to a traditionally andfunctionally fragmented organizational setting, andwhich presents a potentially valuable platform for anevolutionary approach to process improvement.     

Ability, disability, and the oldest old

A measure of range of ability is used to profile the 85-years-old-and-older (oldest old) population, including the highly disabled institutional population. This new measure uses two new questions available in the 1990 Decennial Census concerning a self-care limitation and a mobility limitation as well as the usual question concerning a work limitation. In addition to examining the extent of disability among the oldest old, the article examines the extent of care potentially available in the household as well as the economic characteristics of this age group. It is also profiled in terms of relevant personal characteristics, including age, gender, marital status, race, ethnicity, rural residence, education, and employment. A key question addressed is the need for help or care among the oldest old and how various long-term care proposals would meet such needs. A careful analysis of this unique and growing population is necessary to both allay fears of the cost of care or help as well as to dispel stereotypes of this age group as frail and dependent, and in need of institutional care.     

Worldviews or Social Groups as the Source of Moral Value Attitudes: Implications for the Culture Wars Thesis

Individual moral value attitudes are typically explained by reference to social experiences as indicated by social group variables. Contrary to this view, the emergent culture wars perspective claims that two worldviews that transcend social groups are ultimately and fundamentally responsible for moral value attitudes. Although this relationship has been claimed for the general population, it has not been investigated with national representative data. This paper contrasts the worldview and social group explanations by examining the relative importance of the worldviews implicated in the culture wars literature and the social groups found to be important in previous research. I find social groups to be more important than worldviews, but that worldviews also have explanatory power. I conclude with a discussion about possible clarifications of the culture wars thesis.     

Evaluation design for a community prevention trial. An environmental approach to reduce alcohol-involved trauma

The Community Prevention Trial was 5-year effort to reduce alcohol-involved injuries and death through a comprehensive program of community awareness and policy activities. The three experimental communities were of approximately 100,000 population each (one in Northern California, one in Southern California, and one in South Carolina). Matched comparison communities were used for each experimental community. This article describes the evaluation approach used in a program that sought to change environmental factors not a specific population or target group. This approach demanded unique evaluation approaches for determining overall community aggregate effects, that is, distal outcomes, as well as changes in key mediating variables, that is, process effects. The problem of trending and lagged effects of community prevention programs are discussed.     

Summing up. Recommendations and experiences for evaluation of community-level prevention programs

This article provides recommendations and observations about evaluation of a locally based prevention project to reduce problems at a total community or aggregate level. The shift from targeting specific individuals or subpopulations to the overall structure and environment of a community is most demanding. Evaluation tools and analysis techniques have lagged behind program development because community-level interventions are not linked to a specific target group who can be separately studied. Thus assumptions about using random assignment and/or comparison communities as means to control for confounding variables are weakened when the unit of analysis is the community itself and dependent measures are subject to trending and the effects of history.     

Net worth and the economic diversity of the elderly

Using data from the 1984 panel of the Survey of Income and Program Participation (SIPP), this article examines characteristics of the older population disaggregated by net-worth quintiles. The authors argue that income is not a sufficient measure of economic status for current policy discussions on issues such as changing Medicare co-payments, increasing the taxation of social security benefits, or means-testing under Medicaid. Net worth is a better measure of economic status, particularly for the elderly, because it represents the net value of assets accumulated over the life course. Their results indicate that there is considerable diversity in the economic status of the older population, which is masked by aggregate statistics (such as means and medians) typically used to summarize the economic status of population groups. Stereotypical views of the elderly based on such aggregates result in misdirected policy formulation. In the future, policymakers will need to formulate policies and programs using information on the distributions of income and assets among the older populations rather than relying on statistical aggregates.     

How well is debt managed by nonprofits?

Little is known about why nonprofits accrue debt, how much they owe, and whether the funds they borrow are used productively. This article distinguishes between productive, problematic, and deferred debt. Employing a data base representative of 114,726 tax-filing charitable nonprofits in the United States in 1986, it examines the pervasiveness of nonprofit debt and the relation between this debt and nonprofit financial health. The analysis finds that over 70 percent of the nonprofits hold debt, the distribution of this debt is highly concentrated, and the level of debt and leverage varies with asset size and type of activity. Nonprofits with higher leverage and absolute debt levels are financially healthier than those with lower levels. While the analysis does not determine whether financially stronger nonprofits are better able to borrow, the results support the view that borrowing in the nonprofit sector is economically efficient.