Is solo practice really dead?

For years, the demise of solo practice has been predicted as a consequence of the corporatization of health care, the rise of managed care programs, and the creation of preferred provider organizations (PPOs). The predictors of the demise are leaders in the health maintenance organization (HMO) and PPO movement and therefore have much to gain if solo practice dries up. A survey of a random sample of licensed psychologists in New Jersey was conducted to determine the current state of private practice. A 58% return of the anonymous questionnaire revealed that 87% were in solo practice; 90% were not members of any PPO; 92% received either no referrals or less than 5% from HMOs; and 92% indicated that their referral rates and practices have either stayed the same or increased in the past three years. Clearly the predictions as far as New Jersey goes are wrong. The findings are discussed in terms of economics, humanistic concerns, and political concerns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Home healthcare nursing in the managed care environment. Part II. The impact on clients and professional nurses

Part I, published in last month's issue of Home Healthcare Nurse, provided information about managed care and health maintenance organizations (HMOs). This article, Part II, presents an overview of the history of home healthcare nursing, the results of a purposeful sample, and interviews of home care nurses. Interviews were conducted to determine how nurses perceived the impact of managed care on their clients and nursing practice. Conclusions are presented in terms of emergent categories gleaned from the interviews. Recommendations for the continued growth and advancement of professional nursing in the context of managed care are given.     

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.     

Factors influencing survival after gamma knife radiosurgery for patients with single and multiple brain metastases

BACKGROUND: Significant changes are restructurng the U.S. health care delivery system. National health reform is now extending itself into the public sector. Increased health and medical costs by federal and state governments are forcing a reevaluation of major entitlement programs, especially Medicaid. METHODS/RESULTS: Because Medicaid is the single largest item in many state budgets, states are now enrolling Medicaid patients into managed and coordinated care arrangements as a means to control costs and increase access to care. HMOs are not only competing for private patients but also actively seeking the Medicaid population. Nationally, almost one-fourth of all Medicaid patients are now enrolled in managed care plans. Various models and approaches have been developed by individual states. CONCLUSIONS: Because managed care enrollment in the Medicaid program has increased substantially in recent years, selected services including vision care are no longer rendered by any practitioner willing to accept Medicaid fees. Freedom of choice is now restricted to pre-selected and panel practitioners participating with the managed care program. The rules, regulations, billing procedures, fees, and program requisites will differ under managed care programs. Private optometric practitioners must consider entering economic and organizational relationships and linkages that make them attractive to managed care organizations.     

The measurement of constitutive and facultative skin pigmentation and estimation of sun exposure in Caucasians with basal cell carcinoma and cutaneous malignant melanoma

OBJECTIVES: The purpose of this study was to examine the dimensions of physician work satisfaction across a variety of medical specialties and practice settings. METHODS: A modified version of the Scheckler et al survey instrument was mailed to all physicians in Marion County, Indiana. Forty-two percent (777) of the eligible physicians responded. Exploratory factor analysis and internal consistency measures were used to assess the instrument's validity and reliability. Multivariable linear regression was used to predict global and summary scale scores. RESULTS: Four dimensions of physician work satisfaction were identified: relationships with patients (k = 6, alpha = 0.81), autonomy in clinical decision-making (k = 8, alpha = 0.81), office resources (k = 7, alpha = 0.87), and professional relationships (k = 5, alpha = 0.82). Most (73%) of the physicians were satisfied with their overall practice, and the majority were also satisfied with their income. Significant differences were observed in the sources and magnitude of physician work satisfaction across medical specialty, practice setting, and financial arrangement. Physicians in private practice were most satisfied with their overall practice and office resources, whereas physicians in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decision-making. Physicians not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practice. Among primary care physicians, family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their medical practices. CONCLUSIONS: The modified version of the Scheckler et al instrument is a reliable and valid measure of physician work satisfaction. Increases in the market share of managed care have differentially affected the work satisfaction of physicians based on their medical specialty, practice setting, and financial arrangements.     

Genomic organization of six tomato polygalacturonases and 5'' upstream sequence identity with tap1 and win2 genes

A growing number of residency programs are preparing their graduates for the realities of managed care practice. In 1996, The Cleveland Clinic Foundation, a private, nonprofit academic medical center, hosted a two-day conference on managed care education to develop innovative instructional and evaluative approaches that, where appropriate, would build on existing expertise. The conference was attended by invited national experts who had a stake in residents' education: clinical faculty, residents, medical educators, executives of managed care organizations, and representatives of other interested organizations. Participants spent much of their time in four small break out groups, each focusing on one of the following topics that were judged particularly relevant to managed care: preventive and population-based medicine, appropriate utilization of resources, clinician-patient communication, and interdisciplinary team practice. Participants shared existing materials, discussed teaching goals and objectives, and generated ideas for teaching methods, teaching materials, and evaluative methods for their respective topics. The authors summarize the recommendations from the four groups, with an overview of the issues that emerged during the conference concerning curriculum development, integration of managed care topics into existing curricula, staging of the curriculum, experiential teaching methods, negative attitudes and resistance, evaluation of trainees and profiling, program assessment, faculty development, and cooperation between academic medical centers and managed care organizations.     

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.     

An alternative to managed care: a "guild" model for the independent practice of psychotherapy

As health care is reconfigured by HMOs and managed care organizations, family therapists often have to decide whether or not to cooperate with the new power structures and their ways of doing things. The chief concern of many therapists is the ethical bind created when the managed care organization demands breaches of confidentiality or makes decisions about the course of treatment that may not, in the therapist's opinion, be in the best interest of the family. Associations of independent, nonmanaged care psychotherapists are springing up in response to these dilemmas. This paper describes the philosophical evolution and organizational development of one such association.     

Some early lessons from the rise of managed behavioral health care in the United States

In the 1990s the United States has, because of an unacceptable surge in health care costs, made a revolutionary shift of the reimbursement process from fee-for-service to managed care's restricted, discounted and capitated payment approaches. Mental health care has for 150 years largely been subsidized by tax supported hospitals and clinics. Federal and state governments have recently instead begun to direct much of their monies to for-profit national managed mental health care companies. While efficiency has improved and the steep rise in costs has been eased, the major drawback of this change is a too enthusiastic focus on corporate profits. Since on the whole managed care organizations do not reinvest profits into medical education or research and may pull out of the health care business once the business is no longer so profitable, clinicians and academicians must become more successful in urging politicians and the citizenry to better manage managed care.     

Reproducibility of different methods for diagnosing and monitoring diabetic neuropathy

The subspecialty of allergy and immunology, like all medical specialties, has been dramatically impacted by the managed care revolution. Many of the changes that have been imposed by our environment are likely to persist, including increased emphasis on efficiency of practice and cost-effectiveness of treatment modalities. It is predicted that these changes will decrease the involvement of allergists and immunologists in the primary treatment of patients with allergic rhinitis and mild asthma, in favor of management by generalists with subspecialty consultation. Conversely, outcomes studies demonstrate the cost-effectiveness of management of moderate to severe asthma by an allergy and immunology subspecialist. It is thought probable that HMOs will recognize this fact and implement it as a pattern of practice. The allergist and immunologist will continue to offer, uniquely, expertise in allergic history taking, patient education, environmental control, and management of allergic inflammation. He or she will also be afforded an opportunity for practice expansion, particularly as an expert consultant, into other areas of immune inflammation, such as autoimmunity and graft rejection. Potentially new and increasingly specific products of the pharmaceutical and biotechnology industries will enhance these opportunities for practice expansion by physicians who combine intellectual understanding with practical expertise in patient management. Realization of these new opportunities will require us to work together as teachers and role models to communicate the excitement of our subspecialty to new physicians. Allergy and immunology is a subspecialty with a bright future, provided that we have the will and the insight to deal effectively with our challenges and to master opportunities that our science presents to us.     

Structure-dependent inhibitory action of the Aconitum alkaloids 14-benzoyltalitasamine and talitasamine in rat hippocampal slices

Pathologists are under siege by corporate medicine, managed care systems, or varieties of government-initiated health care restructuring. The pressure is on us to attend at least equally to fiscal pressures, as well as to our patients' medical needs. These pressures must be accommodated within the limits of our professional duties and responsibilities. We must have more than an intuitive sense of what it is to be a professional and to work in a system that is overseen typically by a directorate and that includes managers and innovators. The example of the failure of the corporate managers and directors of a national blood transfusion service highlights the need to balance the inter-relationships of managers, professionals, and innovators by a directorate knowledgeable in these complex systems.     

The role of the nurse manager in ambulatory care: results of a national survey

Increasing complexity in ambulatory care settings requires nurse managers who can function at higher levels. Little agreement currently exists regarding the role expectations and academic preparation needed for nurse managers in ambulatory care settings. The majority of surveyed ambulatory care nurse managers (40%) have an AD or diploma as their highest level of academic preparation, and have thus acquired the majority of their management skills in the practice setting. The authors express concern that there are pressures to employ non-nurses as managers in ambulatory health care settings and that ambulatory nurse managers are often seen as not needing advanced academic preparation. A wide variety of settings including university and community hospitals, outpatient departments, physician group practices and HMOs, currently employ nurse managers in their multidisciplinary ambulatory care sites. The majority of ambulatory care nurse managers describe their model of care as either the medical model or the functional 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.     

The dilemma of managed care.

Responds to the article by L. S. Brown (see record 84-21642) regarding managed care and false memory movement issues in social justice-oriented psychology. The current author argues that Brown abandoned psychologists be declining to think through how responsible and ethical people can work their way out of binds. Buchholz also contends that a greater call to unity and action among psychologists is needed to fight the dehumanizing and threatening effects of the HMOs and insurance companies on mental health service delivery. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Managed care and social work: constructing a context and a response

Managed care is described as a strategy developed by the health care industry as a means to control profitability in the dispersement of health care resources. Control of utilization, cost and information are the essential elements of this strategy. The potential impact of each strategy on social work practice is explored. A number of suggestions are made to insure that managed care balances the needs of its corporate sponsors with those of the consumer public and providers of health care.     

Health maintenance organizations and children with special health needs. A suitable match?

OBJECTIVE: To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans. DESIGN: A cross-sectional survey. MEASUREMENTS/MAIN RESULTS: Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers. PARTICIPANTS: Individual HMO plans. SELECTION PROCEDURE: A sample of 95 geographically representative HMOs were selected; 59 (62%) responded. INTERVENTIONS: None. CONCLUSIONS: Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.     

Managed care in workers' compensation: analysis of cost drivers and vendor selection

1. Managed care for employee benefits provides a model of cost containment for workers' compensation; however, significant differences must be understood. 2. Purchasers of managed care services must perform an internal assessment to determine the cost drivers for workers' compensation. Managed care does not address all cost drivers. 3. A model for evaluating managed care vendors places them on a continuum of risk, similar to insurance risk, where a variety of cost containment strategies may be used together. 4. By reviewing seven key aspects of a managed care vendor, a purchaser can rate the vendor's ability to meet their needs.     

Managed Care: Implications for School Psychology. Comment.

Comments on the article by Sanchez and Turner (see record 2003-03405-005) examining the implications for practice and training in psychology in the era of managed care. The current author states that Sanchez and Turner should be commended. Their article amplifies and clarifies critical issues psychologists must consider while practicing within an era increasingly shaped by health insurance policies and practices. Nevertheless, the author feels that several intriguing facets of managed care were not highlighted. Discussion focuses on the impact that reimbursement and managed care is having on school (and clinical) psychologists. The author points out that it is unknown to what extent managed care may (and has) altered psychological services delivered by school psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A collaborative program for advanced practice in trauma/critical care nursing

The students and faculty enrolled in the first TNP class have set a standard for future TNPs: a rigorous course of education with advanced practice and scholarship within an advanced practice collaborative model. Because of the increasingly number of trauma victims and the highly specialized care they require, nurses must come forward and provide quality care. The TNPs and their faculty must promote further recognition of the TNP role, become leaders in the field of acute care, and continue to develop and maintain collaborative relationship with physicians in support of advanced practice nursing in many areas of tertiary care. The first three graduates of the trauma/critical care practitioner class are now employed in advanced practice roles and are applying their education within trauma/critical care settings. Two of the students are trauma nurse practitioners in a community hospital, and one is a critical care nurse practitioner in a university hospital. Currently, there is an acute care nurse practitioner certification examination that is appropriate for nurses in the field of trauma/critical care. Co-sponsored by the AACN Certification Corporation and the American Nurses Credentialing Center, this examination is offered twice a year, in June and October. AACN is active in supporting and promoting the TNP role and, in conjunction with the American Nurses Association, has developed new standards of care and scope of practice to include this expanded role for the advanced practice nurse. The future for this exciting and demanding role looks bright for the advanced practice nurse interested in the care of the acutely ill patient. The time is right for this collaboration between nurses and physicians.     

The productivity of physician assistants and nurse practitioners and health work force policy in the era of managed health care

Managed care is spreading rapidly in the United States and creating incentives for physician practices to find the most efficient combination of health professionals to deliver care to an enrolled population. Given these trends, it is appropriate to reexamine the roles of physician assistants (PAs) and nurse practitioners (NPs) in the health care workforce. This paper briefly reviews the literature on PA and NP productivity, managed care plans' use of PAs and NPs, and the potential impact of PAs and NPs on the size and composition of the future physician workforce. In general, the literature supports the idea that PAs and NPs could have a major impact on the future health care workforce. Studies show significant opportunities for increased physician substitution and even conservative assumptions about physician task delegation imply a large increase in the number of PAs and NPs that can be effectively deployed. However, the current literature has certain limitations that make it difficult to quantify the future impact of PAs and NPs. Among these limitations is the fact that virtually all formal productivity studies were conducted in fee-for-service settings during the 1970s, rather than managed care settings. In addition, the vast majority of PA and NP productivity studies have viewed PAs and NPs as physician substitutes rather than as members of interdisciplinary health care teams, which may become the dominant health care delivery model over the next 10-20 years.