Academic faculty practices: issues for viability in competitive managed care markets

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis-St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.     

Education programs in US medical schools, 1995-1996

We present herein data on US medical education programs and describe how medical schools are adapting to a changing health care environment. The data mainly derive from the 1995-1996 Liaison Committee on Medical Education Medical School Questionnaire, which had a 100% response rate. The data indicate that in the 1995-1996 academic year there were 91 451 full-time faculty members in basic science and clinical departments, a 1.6% increase from 1994-1995. In clinical departments, major increases occurred in emergency medicine (a 10.6% increase in full-time faculty) and family medicine (a 13.5% increase). Applicants for the class entering in 1995 numbered 46 591, an increase of 2.7% from 1994; however, the number of first-time applicants decreased slightly (0.6%). Of the 17 357 applicants accepted, 2179 (12.6%) were members of underrepresented minority groups. Health system changes are affecting medical school clinical affiliations. During the past 2 years, 42 schools saw a merger, acquisition, or closure involving medical school-owned or medical school-affiliated hospitals used for core clinical clerkships. At 15 sites, this change affected the distribution of students across clinical sites. In 1995-1996, 40 medical schools or their universities owned a health maintenance organization or other managed care organization, 93 schools contracted with a managed care organization to provide primary care services, and 96 schools contracted with managed care to provide specialty services. During the past year, 57 schools acquired primary care physician practices, and 70 started primary care clinics in the community.     

Mental health services in managed care: quality questions remain

Primary care physicians are often the professionals to whom older patients turn for advice about medical coverage in Medicare managed care health plans. To assist in this dialogue, these authors outline current characteristics and financial arrangements for psychiatric and mental health services in Medicare managed care. Advantages and disadvantages of Medicare managed care for enrollees with mental disorders are outlined. Mental health "carve-out" and "carve-in" models are defined, and questions are raised about the number of psychiatrists and other mental health care providers needed to provide appropriate care for a plan's enrollees.     

Managed care, school health programs, and adolescent health services: opportunities for health promotion

The rapid expansion of managed care creates opportunities and dilemmas for those involved in school health and adolescent health promotion. Managed care organizations (MCOs), public health agencies, and school and adolescent health providers share certain common goals and priorities including an emphasis on prevention, cost-effectiveness, and quality of care--and a willingness to explore innovative approaches to health promotion and disease prevention. However, MCOs often face conflicting challenges, balancing the goals of cost containment and investment in prevention. In considering support for school health programs, MCOs will be interested in evidence about the effectiveness of services in improving health and/or reducing medical expenditures. Mechanisms for improving prevention efforts within MCOs include quality assurance systems to monitor the performance of health plans, practice guidelines from professional organizations, and the contracting process between payers and health care providers. Development of partnerships between MCOs and schools will be a challenge given competing priorities, variation in managed care arrangements, structural differences between MCOs and schools, and variability in services provided by school health programs.     

Medical management of obesity

CONTEXT: Since the initiation of managed health care, little information has been available on whether family planning agencies are seeking ways to serve (and obtain reimbursement for serving) the growing number of clients who are managed care enrollees. METHODS: A 1995 mail survey sought information from a nationally representative sample of publicly funded family planning agencies about the agencies' involvement with managed health care plans and related clinic services, policies and practices. Completed surveys were received from 603 agencies, for an overall response rate of 68%. RESULTS: One-half of all publicly funded family planning agencies had served known enrollees or managed care plans. One-quarter (24%) had served managed care enrollees under contract, while others sought out-of-plan reimbursement for services provided to enrollees (13%) or used other sources to cover the cost of these services (12%). Family planning clinics administered by hospitals and community health centers were more likely than other types of clinics to have contracts to provide full primary-care services to managed care enrollees, whereas Planned Parenthood affiliates were more likely to have contracts that covered the provision of contraceptive care only. Clinics administered by health departments rarely had secured managed care contracts (10%), and only 36% reported even serving managed care enrollees. CONCLUSIONS: The challenges presented by managed care, and agencies' responses to these challenges, vary according to the type of organization providing contraceptive care. Family planning agencies need to seek relationships with managed care organizations based on those services that their clinics can best supply.     

Consultation-liaison psychiatric nursing in long-term care

1. The psychiatric and mental health APRN is in an excellent position to use his or her training and expertise to integrate various models of care. 2. Clinical functions of the psychiatric and mental health APRN include patient-focused and staff-centered activities, administrative functions include consulting, performance improvement, and research. 3. The psychiatric and mental health APRN is well-equipped to adapt to developing changes and challenges in the future of long-term care.     

Restructuring public mental health and substance abuse service systems

The authors originally circulated the concepts in this proposal during May 1995. The purpose was to support an open, public dialogue regarding the restructuring of the mental health and substance abuse services in Illinois in anticipation of Medicaid funding changes. Restructuring mental health and substance abuse service systems should follow certain key principles. These principles are applicable to other states, particularly those large in territory and population. The authors propose the temporary use of multiple managed care companies serving as administrative services only (ASO) organizations, each of whom would have responsibility for a given geographic portion of a state. The role of the ASOs would be to organize providers into networks on a regional basis and transfer managed care expertise in financing and clinical management to the relevant state departments and provider groups. Changes in the service delivery system would be phased in over time with reorganization of key components of the system during each phase. Where the provision of mental health, substance abuse, and social services is split among multiple state agencies, these agencies would be merged to achieve unified funding and administrative efficiency. Patients and advocacy organizations would play a key role in overseeing and shaping system restructuring at all levels, including a governmental board reporting to the governor, overseeing ASO organizations' operations and assuring quality and access at the provider level. The authors propose funding of public behavioral health services through use of a tiered, integrated funding model.     

Integrated care management: aligning medical call centers and nurse triage services

Successful integrated delivery systems must aggressively design new approaches to managing patient care. Implementing a comprehensive care management model to coordinate patient care across the continuum is essential to improving patient care and reducing costs. The practice of telephone nursing and the need for experienced registered nurses to staff medical call centers, nurse triage centers, and outbound telemanagement is expanding as the penetration of full-risk capitated managed care contracts are signed. As health systems design their new care delivery approaches and care management models, medical call centers will be an integral approach to managing demand for services, chronic illnesses, and prevention strategies.     

Nurse managed occupational health centers: an overview

1. Nurse managed centers provide clients with direct access to professional nursing care. 2. Lillian Wald, Mary Breckenridge, and Margaret Sanger established nurse managed centers at the beginning of this century. 3. Primary, secondary, and tertiary prevention programs and services are based on the mission, outcomes, staffing, and financing of the occupational health center. 4. Essential parameters for comprehensively evaluating an occupational health nurse managed center include, client outcomes, client satisfaction, and cost-benefit.     

Staffing of mental health organizations, United States, 1988

Between 1986 and 1988, the number of full-time equivalent (FTE) staff employed in specialty mental health organizations in the United States increased 7 percent, from 494,515 to 531,067. Much of this increase could probably be attributed to the increase in number of mental health organizations during this period, from 4,747 to 4,930. With the exception of State mental hospitals and VA psychiatric organizations, all of the other types of mental health organizations showed varying amounts of increase in FTE staff with the most notable gains being reported by private psychiatric hospitals, residential treatment centers for emotionally disturbed children, and multiservice mental health organizations. Of the 531,067 FTE staff employed in mental health organizations in 1988, 72 percent were classified as patient care staff and 28 percent as administrative and support staff. State mental hospitals and VA psychiatric organizations had slightly higher percentages of administrative and support staff (35 and 32 percent, respectively). Seventy percent or more of the staff employed in the various types of specialty mental health organizations in 1988 worked on a full-time basis, the two exceptions being freestanding psychiatric outpatient clinics and non-Federal general hospital psychiatric services in which full-time staff represented only 52 percent and 69 percent, respectively, of all staff. For the most part, the majority (50 percent or more) of each of the staff disciplines employed in mental health organizations worked on a full-time basis. The major exceptions were psychiatrists and other physicians, most of whom worked either on a part-time or trainee basis.     

The U.S. home infusion market

Medicare legislation stimulated the development of home care services but also resulted in fragmentation of service components. In the 1980s, prospective pricing and diagnosis-related groups, and resulting pressures to reduce inpatient length of stay, prompted additional growth of the industry. Even so, in 1995 home care represented only 3% of total national expenditures on health care. The annual growth rate of the home infusion industry dropped from 64% in 1982-86 to 24% in 1986-93. While revenue per patient for home infusion is expected to decrease under managed care, an increasing number of patients will support continued market growth. The home infusion market is highly competitive, with only a few large national providers and many small local providers. In 1996, 29% of acute care hospitals provided or were developing a home care program. Community pharmacists' options in the home infusion area include independent services, partnerships, joint ventures, contracts with hospitals, and franchises. The home infusion market is being integrated into alternative sites, such as ambulatory infusion centers (AICs), as providers attempt to diversify to maintain managed care contracts. AICs provide infusion therapy and nursing to noninstitutionalized, nonhome-bound patients. Untapped sources for future growth of the infusion market include long-term-care facilities. More consistent studies of the home care market are needed. Despite slowed growth in recent years, home care has a strong market in the United States.     

Psychiatry in crisis

Psychiatry today faces sociopolitical, economic, and philosophical pressures that threaten its existence as a valued medical specialty. Recent legislation that decreases the numbers of foreign medical graduates eligible to practice in the United States, increases the numbers of community mental health centers and types of services they offer, and limits federal support of psychiatric education will affect the future of psychiatry as a profession and discipline. Forthcoming legislation and federal health policies will be related to the ability of the profession to demonstrate its unique role in the provision of mental health and health services. The authors offer suggestions for the education of the American public regarding the important role of psychiatry in America's health and mental health care system.     

The role for regional autopsy centers in the evaluation of covered deaths. Survey of opinions of US and Canadian chairs of pathology and major health insurers in the United States

OBJECTIVE: To evaluate the advantages and disadvantages of, as well as the attitudes of health care professionals and insurers toward, the development of regional autopsy services. DESIGN: Survey of 150 medical school departments of pathology in the United States and Canada and 12 representative major health insurers in the United States. RESULTS: Of the 25 respondents from the pathology departments, most were in favor of regionalization of autopsy services, if properly underwritten. Of the five respondents from the health insurers, most were disinterested in the autopsy as a measure of outcome and unwilling to provide support. CONCLUSIONS: Health care is being regionalized around networks of insurers rather than hospitals. The networks are defined by a mixture of hospitals, physician groups, and other health care professionals. Within networks, the goal is to subscribe groups of patients, covered lives, for all medical needs from primary to complex care. As the economic risk of caring for patients is shifted to physicians, the incentive to provide service at the lowest possible cost grows, as does the need to assure that medical mismanagement does not occur. To provide quality care at affordable costs, it is necessary that outcomes, including deaths, be professionally evaluated. The present system of death investigation involves hospital colleagues and is potentially biased. Regional autopsy centers that provide timely expert information should be part of the health care system. Medical schools are potential sites for regional autopsy programs because they have the personnel needed to conduct appropriate death-related studies. Most schools are affiliated programmatically and economically with surrounding hospitals and physicians in a manner in which outcomes, costs, and quality of clinical service are of common interest.     

Attitudes of psychiatry residents toward psychology.

Discusses how the development of health psychology will facilitate the trend for psychologists' continued involvement in medical settings, principally in departments of psychiatry. With the shortage of psychiatrists, it is anticipated that today's residents will assume major administrative roles in departments of psychiatry relatively early in their careers. The attitudes of 201 psychiatric residents with regard to organizational issues involving psychologists and the role of psychology in assessment, treatment, research, and training were assessed via a questionnaire. The majority of Ss felt that psychologists should not hold senior administrative roles in departments of psychiatry, and 47% felt that the medical model should be basic to both research and practice. There was substantial support for maintaining divisions of psychology within (rather than separate from) departments of psychiatry. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatrists' and internists' knowledge and attitudes about delivery of clinical preventive medical services

OBJECTIVE: Changes in the health care environment have placed a greater responsibility on psychiatrists to deliver basic primary care services. The study assessed baseline knowledge and attitudes about clinical preventive medical services among psychiatric faculty and psychiatric residents at a tertiary care medical center. METHODS: Residents and faculty in psychiatry and general internal medicine completed a structured questionnaire, including 20 case scenarios, that assessed their baseline knowledge of clinical preventive medical services, their attitudes concerning delivery of those services, and their beliefs about the effectiveness of those services in changing patients' behavior. The case scenarios and knowledge questions were based on the clinical preventive medical services recommendations outlined by the U. S. Preventive Services Task Force. RESULTS: Psychiatrists reported more frequent assessment of and counseling about the use of illicit drugs and weapons, and internists were more likely to query about measures related to physical health such as cancer screening and immunizations. The two groups reported similar attitudes toward the need for and the efficacy of preventive medical services. Commonly cited barriers to the delivery of preventive care included lack of time and education. Psychiatrists scored reasonably well on baseline knowledge about guidelines for preventive medical services, particularly given their recent lack of specific education in these matters. CONCLUSIONS: Psychiatrists believe clinical preventive services are important and express interest in their delivery. Additional educational interventions are needed to train psychiatrists in clinical preventive services to avoid missed clinical opportunities for intervention in psychiatric populations that may have poor access to other medical care.     

A Survey of Hospital Psychology in Canada.

Despite the major advances in health psychology over the past decade and the changes that have taken place in the Canadian health sector, there remains a paucity of information available about the structure of psychological services in Canadian health-care settings. The most current information about psychology in Canada's hospitals was gathered in 1982 - almost 20 years ago (Arnett, Martin, Steiner, & Goodman, 1987). This article updates the previous information, as it presents the results of a survey that was sent to 975 acute, psychiatric and continuing care health facilities with a minimum patient bed count of 100. Detailed information about the number of psychologists and administrative organizations of psychological services in Canada are reported. The range of services provided by psychologists in health-care settings has expanded, and professional autonomy, as shown by the existence of independent departments of psychology, has changed. The implications of these results for the organization and delivery of psychological services in Canadian healthcare, and for advocacy on the part of psychology, are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Issues in mental health services for children and adolescents

Existing system of psychiatric care for children and adolescents is in need of basic reorganization. The authors propose: 1) reestablishment of the speciality of children's and adolescent psychiatrist, a specialist in children's and adolescent narcology, a psychiatrist of early child's age and a pediatric medical psychologist; 2) carrying out the reform of child mental care equal in rights with general psychiatry; 3) preservation and widening of both specialized inpatient and outpatient clinics in general system of child's mental care; 4) legislative and public rehabilitation of children's psychiatry, which suffered considerably from antipsychiatric campaign; 5) professionally organized systematic elevation of psychohygienic, psychiatric and psychotherapeutic knowledges of allied medical and other specialists as well as of parents and of all population too; 6) integration and interaction of govermental services concerning mental health of children and adolescent; 7) organization of regional psychoprophylaxic interdisciplinary centers for children and adolescent.     

St Jude Children's Research Hospital's International Outreach Program

Over 80% of children with cancer live in developing countries, where access to medical services is limited to varying degrees. In many of these countries, economic conditions and general health care have improved sufficiently to permit the development of more sophisticated medical services. The introduction of pediatric oncology programs becomes appropriate as deaths from malnutrition and infections decrease and cancer emerges as an important cause of childhood mortality. In the absence of such services, the worldwide war against pediatric cancer will ultimately be lost because of the rapidly growing pediatric populations in developing countries that now lack the facilities and expertise to treat childhood malignancies. We believe that the development of pediatric cancer centers in many of these countries is both appropriate and feasible. Partnerships in which established pediatric oncology centers work with the governments and private sectors of developing nations to implement key facilities are an efficient and cost-effective way to introduce such services. The challenges of these outreach efforts are significant -- as are the expected benefits.     

Provision of psychotherapy under managed health care: A growing crisis and national nightmare.

Managed care was intended to save money by eliminating unnecessary services. However, for both physical medicine and mental health care, it is easier to save money by simply cutting needed services. This is what is happening in managed care in the US today. However, data exist for arriving at reasonable procedures to provide real help and still be cost-conscious, a fact that is being ignored by managed care companies. The German national health system covers up to 300 sessions of psychotherapy if needed, but only 3% of their outpatient medical costs are used for such psychotherapy. Unfortunately, the American managed care systems aim at short-term cost savings, even if it means higher costs in the long run (or making patients go outside the managed care health plan for help or forgo getting psychological help at all). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.