Effects of the growth of managed care on academic medical centers and graduate medical education

The author offers insights into how the proliferation of competitive health care financing and service delivery systems based on managed care affects the financial support available to academic medical centers (AMCs), especially to their programs in graduate medical education (GME). The paper is based largely on case studies of AMCs conducted by the author in the summer of 1994 in the health care markets of San Diego, California, Minneapolis-St. Paul, Minnesota, and Washington, D.C., complemented by a review of the literature. In sum, the investigator found consensus among all parties that in the current market, managed care plans neither are willing nor feel able to pay much, if any, premium for the services of AMCs, particularly when established, respected alternatives exist, as they typically do for most services in major urban markets. Relatively few short-term adverse effects on AMCs were found from the growth of competitive systems, but AMCs are nevertheless very concerned that managed care will put them at a disadvantage. They are thus seeking ways to position themselves for the future. The AMCs are concerned that at some point, the cost reductions they are making will hinder the fulfillment of their unique traditional mission, since they believe that the costs of their GME programs can be reduced only so far without harming residents' training. Many managed care plans, however, question the AMC mission, taking issue particularly with the training AMCs provide and its relevance to current needs for primary and ambulatory care. The investigators also found considerable support for pooled funding for GME among diverse parties, but no consensus on how this funding should be structured, who should receive it, or what it should support. Potential conflicts were also identified between national, state, and market objectives for provider supply and specialty distribution because these objectives can embody different criteria for assessing the handling and locations of specialists' training. In addition, the findings indicate that it could be unwise to consider AMC policy independent of workforce objectives; doing so could create conflicts about the kinds of physicians who should be trained. The author concludes with a list of approaches to future research that may be constructive.     

The organizational structure of medical group practices in a managed care environment

This article analyzes the organizational structures of 155 medical group practices providing services in the highly competitive managed care environment in the upper midwest. The structure of the group practices and the methods of physicians' payment are analyzed in terms of the proportion of revenue obtained from financial risk-sharing managed care payment systems and the length of time involved with those systems.     

Psychology's future in medical schools and academic health care centers.

An exciting challenge exists for psychology to establish itself in the general health care delivery system. Advances in treating physical as well as emotional disorders offer the discipline the chance to expand its traditional and formerly limited role. Convincing empirical evidence suggests that psychology can simultaneously improve health care treatment and reduce its costs. Opportunities and obstacles on the path to success in this expanded venture are examined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinician-educators in academic medical centers: a two-part challenge

Between 1967 and 1996, > 18,700 strains of Yersinia species, excluding Yersinia pestis, were recovered in Belgium from a variety of gastrointestinal and extraintestinal sites in patients. Full identification and serotyping were performed by the two Belgian reference laboratories. Yersinia enterocolitica serogroup O:3 predominated (79.4% of strains), followed by serogroup O:9 (11.1%). The remaining 9.5% of isolates belonged to serogroups and related species generally considered nonpathogenic. Acute enterocolitis was the most common clinical form of Y. enterocolitica infection, affecting primarily children younger than 5 years of age. Since 1967, there was a steady increase in isolations every year, with 305 cases in 1975 and up to 1,469 in 1986. From 1987 on, there was a clear decrease in the number of reported cases, although the number of participating laboratories and culture techniques remained constant. This significant decrease in the occurrence of Y. enterocolitica infections may be explained by changes in the slaughtering procedures and eating habits of the population.     

Optimizing cardiothoracic surgery information for a managed care environment

The rapid change occurring in American healthcare is a direct response to rising costs. Managed care is the fastest growing model that attempts to control escalating costs through limitations in patient choice, the active use of guidelines, and placing providers at risk. Managed care is an information intensive system, and those providers who use information effectively will be at an advantage in the competitive healthcare marketplace. There are five classes of information that providers must collect to be competitive in a managed care environment: patient satisfaction, medical outcomes, continuous quality improvement, quality of the decision, and financial data. Each of these should be actively used in marketing, assuring the quality of patient care, and maintaining financial stability. Although changes in our healthcare system are occurring rapidly, we need to respond to the marketplace to maintain our viability, but as physicians, we have the singular obligation to maintain the supremacy of the individual patient and the physician-patient relationship.     

Preventive services in a Medicare managed care environment

The results of a four year demonstration project of preventive services for Medicare managed care enrollees suggest that health promotion programs can impact health behaviors and outcomes. The study provided selected preventive services to 1,800 Medicare enrollees in a managed care environment. Participants were randomly assigned to control and experimental groups with the experimental group receiving an intervention service package and the control group usual care. The results included enhanced health behavior practices, lower depression, and higher immunization rates among those individuals in the experimental group. This study suggests that selected preventive services can be provided in a managed care environment to Medicare enrollees with likely positive health status and utilization outcomes.     

Implementing clinical paths in a managed care environment

The survival of health care institutions depends upon a delivery system focusing on appropriate use of resources and controlling length of stay while monitoring clinical progress toward identified outcomes. Using a clinical path as a tool for managing resources, research activities, continuous quality improvement, and increased collaborative practice can enhance the professional practice environment and benefit patient care.     

Preserving workers' compensation benefits in a managed health care environment

Managed care techniques are increasingly being applied in the workers' compensation setting. Many workers, labor representatives and public health advocates fear that the introduction of managed care into workers' compensation may reflect a broader employer-driven campaign to erode benefits, tighten eligibility criteria, and weaken employees' control over health care and compensation issues. The potential threats to workers can be mitigated by involving them in the design of the workers' compensation health plan and selection of provider organization, assuring access to appropriate specialists and diagnostic testing, minimizing delays, increasing accountability through contract provisions and government oversight, and enhancing communications through the use of ombudsmen and alternative dispute resolution approaches. Additional outcomes studies assessing the long-term impact of managed care in workers' compensation are needed.     

Providing mental health care to older adults: Unraveling the maze of Medicare and managed care.

This article reviews fundamental information about mental health benefits for older adults. Major systems, including Medicare, Medicaid, and managed care, are described. Regulations and policies that influence mental health care for older adults are distinct from those for the general population. In addition, Medicare has adopted managed-care options more recently than the private insurance industry. This relationship between Medicare and managed care is chronicled and future directions are postulated. Finally, we examine several empirical questions that have been raised due to the recent changes in the delivery of mental health care to older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managing wounds in a managed care environment: the integration concept

Integration is being discussed at all levels today in healthcare. The term is confusing and the literature provides numerous definitions and explanations. In general, integration refers to the coordination and reorganization of various healthcare units (such as home health care, acute care hospitals, and skilled nursing facilities) either horizontally, vertically, or via a combination of both. To discuss integration, a healthy understanding of managed care and healthcare trends are essential. With current and projected future trends serving as a backdrop, this article will attempt to describe various integration delivery models. The application of the above to wound care as a specific disease state serves as the closing message.     

Managing information technology in academic medical centers: a "multicultural" experience

Based on a session at the 1997 conference on Information Resources and Academic Medicine sponsored by the Association of American Medical Colleges, this article illustrates how the beliefs and concerns of academic medicine's diverse professional cultures affect the management of information technology. Two scenarios--one dealing with the standardization of desktop PCs, the other with publication of syllabi on an institutional intranet--form the basis of this exercise. Four prototypical members of a hypothetical medical center community--the chairman of surgery, a senior basic scientist, the chief information officer of an affiliated hospital, and the chief administrative officer--offer their perspectives on each scenario. Their statements illustrate many of the challenges of planning, deploying, and maintaining effective information technology in the "multicultural" environment of academic medical centers.     

Building healthier communities in a managed care environment: opportunities for advanced practice nurses

Two paradigm shifts are occurring in health care: managed care and community partnerships. The distinct principles and trends of each paradigm are certain to determine the future practice of advanced practice nurses (APNs). The impact of managed care and community partnerships will affect the resource management, clinical decision making, and time management of APNs. Concomitantly, APNs will have opportunities to influence practice guidelines, individual and community decision making, cultural competence, and the cost-effectiveness of care in communities. Capitalizing on these opportunities will enhance the value of APNs to their managed care plan employer and their community.     

The hospital-based group in a managed care environment. Reading the terrain

The root-level changes in health care delivery that are in progress will make demands on pathologists that are almost without precedent in the post-Medicare era. Their turbulent pace and uncertain direction confer an added sense of urgency to the need for an effective response. For pathologists, the most uncomfortable changes may involve assuming responsibilities that are a marked departure from traditional training and practice. Chief among these are a need for more familiarity with the ways a corporate structure operates, a more thorough understanding of the needs and wants of buyers of physicians' services, and the ability to manage a practice successfully as an enterprise. Despite the variety of current approaches to managed care, there are common themes that invite the careful consideration of pathologists. Many of these reflect basic problems with which care managers must cope routinely. Of equal importance to the future success of pathology practice is the need to develop a high level of skill in constantly evaluating the strengths, weaknesses, and future directions of one's own practice.     

Cardiac surgical education in the managed care capitated environment

OBJECTIVE: To determine the effects of the androgenic anabolic steroid nandrolone decanoate on uterine endometrium and myometrium and on the mammary gland of female cynomolgus macaques by using morphologic, histomorphometric, and histopathologic determinations. DESIGN: Histologic and histomorphometric measurements were performed on uteri and mammary glands that were collected at necropsy from animals that had been used in a long-term experiment to examine the effects of nandrolone decanoate on bone and coronary arteries. The animals were surgically postmenopausal cynomolgus macaques randomized into four treatment groups: (a) intact sham ovariectomized (sham; n = 12), (b) ovariectomized (OVX; n = 15), (c) ovariectomized + nandrolone decanoate for 2 years (OVX + ND; n = 14), and (d) ovariectomized + nandrolone decanoate for 1 year, beginning 1 year after ovariectomy (OVX + NDdelay; n = 11). Intramuscular injections of nandrolone decanoate (25 mg every 3 weeks) were given to the two nandrolone-treated groups of animals (OVX + ND and OVX + NDdelay): one starting 3 weeks after ovariectomy and continuing for 2 years and the other group 1 year after ovariectomy. The sham and OVX groups were given an intramuscular injection of sterile vehicle every 3 weeks. RESULTS: Nandrolone treatment was moderately uterotropic in all treated versus ovariectomized animals. Changes induced were an increase in uterine weight, endometrial thickness, and glandular area, and a high incidence of mucometra. Glandular architecture was altered by nandrolone treatment such that glands extended into the myometrium (producing an adenomyosis-like lesion). Mammary gland changes were mild and equivocal. CONCLUSION: Nandrolone induced pathologic changes in ovariectomized monkeys similar to adenomyosis in the uterus.     

Functional performance of older adults in a long-term care setting

Motivation has been identified as an important factor in the older adult's ability to perform functional activities. The purpose of this study was to explore functional performance and factors that have an impact on functional performance in nursing home residents. Participants included 44 White older adults from two nursing homes. The majority of the participants were female (84%). The mean age of the participants was 88 +/- 6.4 years and, on the average, they had been institutionalized for 2.85 +/- 2.8 years. Following data reduction of the predictors, two factors--motivation (efficacy beliefs and intrinsic motivation) and lower extremity function (contractures and standing balance)--were identified. In a stepwise multiple regression analysis, these two factors were the only variables that significantly predicted functional performance and accounted for 81% of the variance in function.     

Screening older adults for depression in primary care settings.

Primary care is a logical environment for depression recognition in older adults. Most older adults are diagnosed and treated for depression by primary care providers. Recognition systems for depression in this setting are particularly needed because the prevalence of depression in older primary care patients may range from 7% to 36%, depending on the instrument and diagnostic criteria used. Implementing systematic detection systems in primary care settings has proven difficult. In one study, only one third of all physicians surveyed used any formal screening tool. Though a number of barriers to recognition of depression have been identified, the authors focus their discussion in this article on two, time and patient factors, and review two screening instruments, the Geriatric Depression Scale--Short Form and the Center for Epidemiologic Studies Depression Scale, that may be able to address these factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)