The financial implications of ACOs for providers

To prepare for a future in which more and more patients will receive care in ambulatory settings, and acute care service capacity will likely need to be considerably downsized, hospitals should pursue five near-term strategies: Convert primary care practices to medical homes, Develop the IT capabilities required to manage and report on clinical and financial processes and outcomes, Integrate the clinical and financial interests with those of their physicians in improving value, Reduce cost per episode of care through bundled payment initiatives, Nurture key relationships with other providers.     

Pattern-of-treatment differences among primary care physicians in alternative systems of care

In a recent study, the average treatment pattern of HMO-based primary care physicians is found to be significantly less expensive than that of indemnity-based primary care physicians. This difference is because the HMO-based physicians' style of medical practice is less hospital-intensive.     

Designing a guideline-based utilization management program

Many public and private organizations are developing and publishing clinical guidelines to assist health care providers and patients in making appropriate medical decisions. Unless clinical guidelines are part of a well-designed managed care program, they have little effect on physician practice styles. This article explores integral components of an effective guideline-based utilization management program. Initial evaluation of this program suggests that, as part of a well-designed utilization management program, clinical guidelines can inform patients and physicians, and create appropriate incentives for effective health care delivery.     

Torts, expertise, and authority: liability of physicians and managed care organizations

We examine optimal individual and entity-level liability for negligence when expected accident costs depend on both the agent's level of expertise and the principal's level of authority. We consider these issues in the context of physician and managed care organization (MCO) liability for medical malpractice. Under current law, physicians generally are considered independent contractors and hence MCOs are not liable for negligent acts by physicians. We find that the practice of reviewing the medical decisions of physicians affects their incentives to take care, which in turn implies that it is efficient for MCOs to be held liable for the torts committed by their physicians.     

Incentives and cost containment in primary care physician reimbursement

The goal of capitation is to place gatekeepers at financial risk for the services the deliver. However, third party payers should provide gatekeepers with some type of protection against random and systematic risk transfer. Gatekeeper physicians' other alternative is to reduce this risk on their own by actively marketing services to healthier individuals and creating barriers to care for their sicker patients. Thus, the proper balance of risk transfer will result in the most cost-efficient, quality gatekeeper networks. However, even with the right balance of risk transfer, capitation may provide incentive for some physicians to withhold necessary services to further increase their profit margins-making quality of care a key concern. Thus, practice guidelines should be developed to ensure quality is not affected. These guidelines afford explicit criteria on how gatekeepers should respond in specific clinical situations.     

DOES ORGANIZATION MATTER? A STUDY OF PHYSICIANS' IDEAL ORGANIZATION

It is a known phenomenon that it is difficult to make organizational changes within professional organizations. One recurring observation and experience from health care studies is that it is difficult to discuss the last organizational change with professionals because the most recent change is always perceived as the worst. In order to avoid this routine response, the authors of this article asked 56 senior physicians from the Swedish health care sector what their ideal organization looks like. The authors note that there is a strong institutionalized idea among the physicians of how health care should be organized. The image is not particularly complicated: the organization should be based on the meeting between doctor and patient. One conclusion in the article is that professionals dislike change, but nevertheless, they still want it. Actual change is not the problem – only changes that are not in compliance with the professionals' opinions of organization and management.     

Managing margins through physician engagement

Hospitals should take the following steps as they seek to engage physicians in an enterprisewide effort to effectively manage margins: Consider physicians' daily professional practice requirements and demands for time in balancing patient care and administrative duties. Share detailed transactional supply data with physicians to give them a behind-the-scenes look at the cost of products used for procedures. Institute physician-led management and monitoring of protocol compliance and shifts in utilization to promote clinical support for change. Select a physician champion to provide the framework for managing initiatives with targeted, efficient communication.     

Audit as Leviathan: Constructing Quality Registers in Swedish Health Care

This paper explores the rise of an audit practice: the national quality registers in Swedish health care. Based on actor‐network theory, the study tells the story of an actor‐network formed by physicians in the 1970s who mobilized themselves around a common object; to develop the knowledge‐base of medical professionals. However, over time more actors became persuaded of the potential of the network and associate themselves with it, resulting in reformed registers. The study shows how the network develops into a macro‐actor, a Leviathan in health care, how this macro‐actor comes to affect health care practices and how it contributes towards maintaining a new governance regime.     

Medicare payment: how low it will go and how to prepare

Hospitals should begin preparing now for a decade of reductions in Medicare payment with strategies aimed at: Partnering with clinical leadership, Performing detailed margin analysis, Engaging with service line managers and physicians, Revamping care coordination, Ensuring efficient operating room utilization, Improving emergency department operations.     

The drive to survive: independent medical practice

The "hospital of choice" for independent physicians will have the following characteristics: Adequate capital for investment in human resources, technology, and facilities. A strong and sustainable market position based on affiliated primary care practices. The ability to engage physicians as business partners. The availability of performance management information.     

Medical foundations: one model for hospital-physician alignment

Some states that enforce a corporate practice of medicine prohibition have created medical foundation statutes allowing hospitals or health systems to own corporations providing physician services. Medical foundations may be useful in the coordination of care through employed or contracted physicians. Medical foundations that qualify as a tax-exempt entities have lower risks associated with tax-exempt rules as long as payments to physicians are reasonable and don't result in private inurement.     

Medical Labour Supply and the Production of Healthcare

Medical labour markets are important because of their size and the importance of medical labour in the production of healthcare and in subsequent patient outcomes. We present a summary of important trends in the UK medical labour market, and we review the latest research on factors that determine medical labour supply and the impact of labour on patient outcomes. The topics examined include: the responsiveness of labour supply to changes in wages, regulation and other incentives; factors that determine the wide variation in physician practice and style; and the effect of teams and management quality on patient outcomes. This literature reveals that while labour supply is relatively unresponsive to changes in wages, medical personnel do react strongly to other incentives, even in the short run. This is likely to have consequences for the quality of care provided to patients. We set out a series of unanswered questions in the UK setting, including: the importance of non‐financial incentives in recruiting and retaining medical staff; how individuals can be incentivised to work in particular specialties and regions; and how medical teams can be best organised to improve care.     

医疗服务规模经济中的博弈分析——以上海市为例

对上海医疗服务市场现状进行分析的基础上,建立了基于协同竞争理论的非对称二人博弈模型,医学专科特长作为技术性软件是现有医院合作的稀缺资源,而平台性医院的稀缺资源主要存在于国际化的品牌、服务、营销等非技术性软件上.通过模型的渐进稳定性分析对平台性医院与现有医院的合作机制进行了模拟,利益分配是影响医院间合作的关键.最后从政策、平台性医院科室设王与营销等方面提出了实现这一构想的必要条件.     

Leaving an unethical managed care plan: an exploratory look at doctors' intentions

To address the problems of unnecessary care and limited resources, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing pressures. This article briefly considers four ethical situations that doctors face under managed care systems. The article surveys a national random sample of general practitioners and surgeons to determine how doctors would respond to these dilemmas and the extent to which exposure to such situations influences them to leave a managed care plan.     

Primary care physicians: increasing demand, shrinking supply

Any serious proposal for reforming the U.S. health care system must include a consistent, coherent national policy for increasing the supply of primary care physicians.     

The health care market: can hospitals survive?

Does it sound familiar? Resources are scarce, competition is tough, and government regulations and a balanced budget are increasingly hard to meet at the same time. This is not the automobile or oil industry but the health care industry, and hospital managers are facing the same problems. And, maintains the author of this article, they must borrow some proven marketing techniques from business to survive in the new health care market. He first describes the features of the new market (the increasing economic power of physicians, new forms of health care delivery, prepaid health plans, and the changing regulatory environment) and then the possible marketing strategies for dealing with them (competing hard for physicians who control the patient flow and diversifying and promoting the mix of services). He also describes various planning solutions that make the most of a community's hospital facilities and affiliations.     

Evolve and integrate: a new imperative for ambulatory care

A highly evolved ambulatory care delivery system possesses four key attributes: high-quality care, exceptional levels of access, outstanding patient and staff satisfaction, and cost-effective delivery of care. Such a system seeks to ease management of the patient care continuum by delivering as many services as possible under one umbrella. High-quality, cost-effective care is achieved through improved care coordination and cost management, resulting from a tight connection between physicians and hospitals and between inpatient and outpatient settings. Improved access is an important means to improving patient satisfaction.     

Preventive medicine for hospital costs.

The reality of soaring health care costs has hospital administrators facing the prospect of mandatory state regulation or voluntary restraint on their financial expenditures. In either event, whether formulated and implemented through external rate setting or internal cost containment, managers should be preparing to adjust their hospitals' management control systems to the emerging requirements of tighter budgetary limitations. The authors discuss the implications such cost-containment programs have for hospital control systems, identify the five cost-influencing variables that must be monitored, and consider the critical importance of incorporating attending physicians into the management control effort.     

Physicians and administrators can work together

This article describes the working relationship between the administration and medical staff of the Mid-Maine Medical Center which is comprised of two separate modern hospitals. The authors advocate the philosophy that "a hospital which harnesses the medical staff's considerable talent and expertise through sound organizational input will be a stronger institution." They explain that patient care is becoming increasingly complex and that management decisions impact heavily on the care provided. In 1973, the Medical Center changed from its traditional organizational form of having a full-time medical director and an administrator report to the board of directors, to a modified corporate model designed to increase physician involvement. In the new organization, the vice president of finance and a part-time chief of staff (acting as vice president for medical affairs) report to the president (former medical director) who, in turn, is responsible to the board of trustees. The authors attribute the success of the reorganization to the CEO's willingness to delegate and share authority, not to the CEO's physician background. Planning at the institution involves a committee of six physicians, four administrators, and one full-time planner. A budgeting committee of three physicians and three administrators is responsible for the review of the budget as well as for making recommendations for the executive board for the expected volume of services. It is concluded that there is no perfect way to run a hospital, but the involvement of doctors in hospital decisions is necessary.