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.     

Late-stage breast cancer in Connecticut's three largest cities

Among 1,559 breast cancer patients diagnosed in 1984-89 in residents of Connecticut's three largest cities (Bridgeport, Hartford, and New Haven), the proportion of late- (ie, regional or distant) stage cancers increased with increasing poverty level in the census tract of residence. Many census tracts with the highest proportions of late-stage breast cancers were located near a federally-qualified community health center or a hospital. Changing the stage distribution of breast cancer through increased screening by mammography and clinical breast examination may require greater collaboration among community health centers, local hospitals, mammography facilities, and mobile mammography vans, along with continuing medical education programs for primary care physicians in these cities.     

Shoe-surface interaction and the reduction of injury in rugby union

Medical schools, teaching hospitals, and managed care organizations have a vested interest in shaping the knowledge, skills, and attitudes of the next generation of physicians who must adapt to significant changes in the financing and delivery of health care. This article summarizes the rationale for educational partnerships between managed care and academic medicine based on a review of three decades of well-documented experimentation in the literature. Discussed are some of the most important characteristics of the successful partnerships being forged in the current healthcare environment based on new kinds of relationships between faculty and non-university clinician educators. What had been referred to in previous decades as the "teaching-HMO" is now being complemented by community-based links between academic health centers and managed care plans. Several public and private sources have been generous in providing venture capital to support many of these innovations. However, their continued operation will depend on models for health care networks that can identify and manage the revenue and costs associated with the missions of education, clinical services, and research.     

The patient-physician covenant: an affirmation of Asklepios

Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer helper, and advocate for the sick and for the health of all. By its traditions and very nature, medicine is a special kind of human activity--one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest. Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care. We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.     

The service-education linkage: implications for family practice residency programs and community and migrant health centers

INTRODUCTION: Access to quality primary health care for our country's underserved populations is a challenge for both the government and physicians. The Division of Medicine, through funding priorities and other initiatives, is encouraging family practice educators to train residents and students for work in community and migrant health centers (C/MHCs) in underserved areas. The objective of this research was to study linkages between family practice residency programs and C/MHCs and determine the reasons for affiliation, disadvantages and advantages, predictors of successful linkages, and common errors in the linkage agreement. METHODS: We conducted in-depth telephone interviews with the directors of 13 of the 19 family practice residency programs identified as having linkages with C/MHCs. RESULTS: All interviewees at residency programs indicated that their programs had a mission to serve underserved patients. The most commonly cited constraining factor cited by both residency programs and C/MHCs was financial support for residents, on-site faculty, and support staff. Many programs reported that residents training at the C/MHC were able to gain a community health perspective and practice community-oriented primary care. Finally, financing the relationship involved many different approaches, ranging from the residency paying all of the salaries, to a sharing of salaries by the residency, state, and/or hospital, to C/MHC paying the salaries either through its own funds or through grant support. DISCUSSION: These data provide an assessment of the current issues that family practice residencies must address to implement service-education linkages. They provide an empirical basis to outline the steps involved in forming a linkage between a residency and a C/MHC.     

Chromosomal localization of 15 ion channel genes

As academic health center seek to address the changes in the health care system and in medical education, several approaches have been tried, some successfully, others not. The authors describe a successful approach that involves a close partnership between the health professions schools at two academic institutions, and agencies from the surrounding community. Specifically, the Center for Healthy Communities, begun in 1991 and formally institutionalized in 1994 in Dayton, Ohio, is a partnership among the schools of medicine, nursing, and professional psychology at Wright State University (WSU); the department of social work at WSU; the Allied Health Division of Sinclair Community College; more than 200 individuals (from grassroots neighborhood people to civic leaders); and 50 health and human services organizations in the Dayton area. The Center is recognized as a force for change in health professions education and health care delivery both in the community and in the academic settings. The authors explain how the Center was formed, list its goals (such as establishing strong partnerships among community educators and providers and educating students in the delivery of primary health care in the community), explain three principles that have been followed and that were crucial to the success of the Center (for example, individuals in the community must become empowered to capitalize on their strengths), and discuss the major difficulties that the community and the academic institutions encountered and strategies for meeting them (such as the importance of building trust and the importance of learning the needs identified by the community partners, not just those identified by the academic partners). The authors maintain that a successful community-academic partnership must be built on the foundation of community health development, a concept analogous to economic development, and that such a partnership can be a powerful tool for making a difference in the community's health.     

Community health centers and quality of care: a goal to provide effective health care to the community

The uniqueness of community health centers provides for a sound environment for total quality management (TQM). Structure, process, and outcome are valued equally under TQM. With strong management leadership and a framework for quality of care, community health care specialists (e.g., advanced practice nurses) can easily incorporate the TQM measurement criteria in their daily practice routines. By applying the principles of TQM, the community health center will advance toward its goal of enhancing the effectiveness of health care delivery to a community and its members in partnership with the community.     

Immobilizing vacuum litters, IVL

There is increasing emphasis on continuing education of hospital personnel, who need and want access to information in order to be aware of advances in health care. Small hospitals cannot afford to duplicate extensive collections. Personnel of hospitals that are remote from urban centers often do not have opportunities to visit a resource library on a regular basis and do not have experience in searching the medical literature through the use of reference tools. It is increasingly evident that the circuit librarian program has served as a catalyst in establishing relationships between the hospitals and the university health sciences center. The director of the CHSL has consulted with the deans of the nursing and the medical schools and with various professors. They have promised that the schools will try to address identifiable continuing education needs or requests from the hospitals. Moreover, the circuit librarian meets with individual hospital personnel and then obtains information for them from the CHSL and its staff. The circuit librarian program is one way to meet community hospitals' needs for access to health sciences literature and to initiate peer interaction for information exchange.     

Dynein inner arm heavy chain identification in cAMP-activated flagella using class-specific polyclonal antibodies

In 1993, the Medical College of Pennsylvania (MCP), mindful of the rapidly changing environments of health care delivery, created three surveys to gather information from outside the school that would help the faculty plan how the curriculum and advising system could better prepare students and residents for the demands of twenty-first-century medicine. The first survey focused on the MCP seniors graduating that year and asked about their perceptions of their medical education and their specialty and residency choices. The second survey, directed to 40 medical residency program directors in family medicine, internal medicine, pediatrics, and surgery, sought to identify the characteristics of applicants that these directors valued when selecting entrants to their programs. The third survey, of 30 employers of physicians representing four practice environments (private practice, hospitals/other health systems, academic medical centers, and health maintenance organizations), sought information on hiring and recruitment practices and the skills, competencies, and attitudes these employers valued most when hiring recently graduated physicians. The responses showed several differences and/or misperceptions among the views held by the three groups surveyed and suggest that medical educators have not adapted as rapidly as have employers to changes in the health care environment. Academic health centers must broaden their missions and make changes in their own institutional cultures, both to maintain their own viability and to train physicians who have the balance between scientific and technical competency and essential personal characteristics (such as empathy) that the next century's practice will probably demand.     

Economic aspects of anesthesia. I. Health care reform in the German Republic

Implications for Hospitals and Departments of Anaesthesiology. This article outlines the new German health care laws and their impact on the statutory health care system, hospitals and anaesthesia departments. The German health care system provides coverage for all citizens, although financial support from the public sector is on the downgrade. Hence, pressure to reduce public sector health care spending is likely to continue in the near future. Hospital costs account for one-third of total health care spending in Germany, and hospitals are facing increasing economic constraints: the volume and the charges for specific medical treatments are negotiated between the hospitals and the insurance agencies (or sickness funds) in advance. Only part of hospital care is still reimbursed on the basis of a per diem rate, and an increasing number of services are based on fixed payments per case or treatment. Reducing the costs for this treatment is therefore of utmost importance for hospitals and hospital departments. The prospective payment system and the pressure to contain costs demand a controlling system that allows for cost accounting per case. However, an economic evaluation must include comparative analysis of alternative therapeutic options in terms of both costs and outcome. Economic aspects challenge the traditional relationship between physicians and patients: doctors are still the advocates of their patients, but also act as agents for their institutions. Nevertheless, not only economic issues, but also ethical priorities and the value of an anaesthetic practice must be considered in the era of cost containment. Anaesthetists must be actively involved in providing high-quality care with its obvious benefits for the patient and be able to resist efforts to cut out expensive treatment modalities regardless of their benefits.     

Mutation in the prion protein gene at codon 232 in Japanese patients with Creutzfeldt-Jakob disease: a clinicopathological, immunohistochemical and transmission study

The societal and economic forces driving change in medical education are affecting communities as well as universities. Each of the four authors of this paper is deeply involved in one of the components of their locale's well-developed community-based medical educational system, and each describes how change is influencing his role in that system, whether the role be managing a community hospital, directing a local Area Health Education Center, participating as a family medicine faculty member, or being a community preceptor. They agree on some common themes: (1) that it is good that medical students' education is moving into the community (e.g., this validates the importance of the community hospital to medical education, is an acknowledgment of the importance of generalism, and provides students invaluable learning experiences); (2) that educating medical students in the community is expensive, and more funding and resources are needed so that the area's hospitals, community faculty, preceptors, and support services can be fairly compensated for their commitment; and (3) that their community-based education system can no longer absorb the costs of training more medical students. This is not a criticism of academic medical centers, which are under tremendous financial pressures themselves, but is simply to state the community perspective and to urge fairness in the distribution of resources for medical education. Community institutions and academic medical centers will work individually to create their own integrated health care systems but must work together to create a better, more cost-effective system for educating medical students.     

Fatal and non-fatal childhood injuries in Metropolitan Toronto, 1986-1991

OBJECTIVE: To estimate the prevalence of human immunodeficiency virus (HIV) infection among health care workers who donate blood. DESIGN: Point prevalence survey of blood donors. SETTING: 20 U.S. blood centers that participate in an ongoing interview study of HIV-seropositive blood donors. MEASUREMENTS: Prevalence rates for HIV in persons who reported being health care workers were measured directly for 6 of the 20 blood centers. For the other 14 centers, we derived the numerator from the interview study in the same manner used for the 6 centers; we estimated the denominator using blood collection logs at those centers and extrapolations from the survey completed at the 6 blood centers. RESULTS: Between March 1990 and August 1991, 8519 health care workers donated blood at 6 hospitals and other medical facilities. Three persons were HIV seropositive: Two reported being health care workers and having nonoccupational risk factors for HIV infection; the occupation and other possible risk factors of the third seropositive donor could not be determined. Therefore, the highest overall prevalence of HIV infection among health care worker donors at these 6 centers was 0.04% (3 of 8519; upper limit of 95% CI, 0.1%). We estimated that during the same period, approximately 36,329 health care workers were tested for HIV at all 20 centers. Twenty-seven persons infected with HIV who donated at hospitals were identified; 7 did not return for interviews, so their health care occupations could not be verified. Thus, the highest estimated overall prevalence of HIV infection among health care worker donors at the 20 centers was 0.07% (27 of 36,329; upper limit of CI, 0.1%). Of the 20 known health care worker donors, 11 reported nonoccupational risks for HIV infection; 3 of the remaining 9 health care workers described occupational blood exposures that could have resulted in transmission of HIV. CONCLUSIONS: Blood donors can serve as a sentinel cohort when evaluating the risk for occupationally acquired HIV infection. These findings suggest that among the many health care worker donors in this study, HIV infection attributable to occupational exposure was uncommon.     

Employment opportunities for geropsychologists.

Surveyed 224 hospitals, community mental health centers, nursing homes, graduate departments of psychology, and hospices in California, Michigan, New York, and Texas as to their present and future levels of providing services to the aging and their interest in hiring geropsychologists. The most prevalent geropsychological activities were therapy, assessment, and community consultation. Although only 10% of respondents were interested in hiring geropsychologists at present, 43% reported interest in hiring in the future. The greatest interest in hiring was expressed by community mental health centers and hospitals. Regionally, New York expressed the greatest interest. Consistent with the recognized discrepancy between the extensive mental health needs of the elderly and the availability of appropriate professional care, the results document that the employment market for geropsychologists is considerably underdeveloped. (26 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Services for the aged in community mental health centers

The author studied the services provided for the elderly at eight community mental health centers. He describes discrimination against the elderly, the reasons why relatively few elderly persons seek care, and innovations in treatment. He discovered that high-quality care depends more on staff awareness of the unique problems of the elderly than on specialized services. The author recommends a more public-health-oriented approach that would set priorities on the basis of community needs.     

A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

This exploratory study describes the nature and magnitude of the problem of health referrals, health-seeking behavior, perceptions, and knowledge at the district level in Zimbabwe. Data were obtained from focus groups with 159 persons in Tsholotsho and 132 persons in Murewa; from discussions with health personnel from the 6 health centers in Murewa and the 2 rural hospitals in Tsholotsho; and from records among a systematic sample of 400 new outpatients during October 1993 and March 1994 in Murewa district. Findings indicate that 71.8% in outpatient departments at Murewa Hospital had no access to a health center. 24.3% by-passed the health center for treatment at the hospital. 3.8% were referred by health centers. The absolute number of referrals did not change during 1991-93. However, the number directly accessing services from outside the district rose. Focus group participants reported their intention to use the nearest clinic for an illness. In Tsholotsho, people initially used the village community worker/headman. If illness was perceived as serious, patients would go to a hospital. For minor illness, people used traditional herbal remedies. If illness did not change after remedies, the clinic was consulted. Some illnesses were perceived as outside the realm of medicine. Most distinguished between a health center and a hospital, but were unaware of the important, superior functions of the health center. Most did not understand the logic behind the referral system, but appreciated referrals and not the cost of hospital treatment or transportation. The community was unaware of Ward Health Teams. Many did not understand the new fee policy introduced in 1994.     

The impact of managed care on clinical research: a preliminary investigation

Rapid growth in managed care enrollment is likely to affect clinical research at the nation's academic medical centers (AMCs). Our site visit interviews indicate that managed care has not markedly reduced coverage for research-related care. However, market competition in some areas has limited AMCs' ability to subsidize research activities with clinical revenues. As they gain market share, managed care organizations will have a growing influence on research priorities. Therefore, it is important for the academic community to work with managed care leaders to identify areas for collaboration and an agenda for moving forward in the future.     

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.     

The Fresno Asthma Project: a model intervention to control asthma in multiethnic, low-income, inner-city communities

The Fresno Asthma Project targeted the entire low-income, inner-city, multiethnic population of Fresno, California. For 36 months following a 6-month planning phase, continuing education was provided to a high proportion of physicians, pharmacists, nurses/respiratory therapists, emergency medical technicians, school personnel, and allied health professionals involved in asthma care in Fresno, including virtually all those providing care/services to the target population. Small group patient education was made available and provided in age- and culturally appropriate formats to patients/families in clinics, hospitals, and schools. General and ethnic media and a Speakers Bureau were used to raise public awareness of asthma as a serious but controllable health problem. This community intervention model is particularly appropriate to multiethnic communities. It is relatively low cost (total direct costs were $140,000 per year), uses existing educational resources, and appears to have minimized counterproductive competition. Although morbidity and mortality trend data are not yet available to monitor program impact, penetration into the target community has been substantial: community physicians refer patients to asthma classes, asthma educator training is ongoing through the local American Lung Association chapter, hospitals and managed care systems serving low- income/MediCal patients offer asthma classes, and public schools and HeadStart are institutionalizing asthma awareness and self-management classes.     

The association between prenatal sella turcica morphology and notochordal remnants in the dorsum sellae

This report examines the relation between state variations in the regulation of nurse practitioners (NPs), physician assistants (PAs), and certified nurse midwives (CNMs), and the employment of these nonphysician providers (NPPs) by community health centers (CHCs). Data for this report came from a 1991-92 survey of CHCs assessing the employment of NPPs, and secondary available data. The dependent variables examined were the numbers of NPPs currently employed by CHCs. Independent variables included 1992 practice environment scores, CHC location, number of CHC physicians, and NPP-to-population ratios. The number of NPs and PAs employed by CHCs was significantly associated with practice environment for these practitioners. NPP-to-population ratios and the number of CHC physicians are also significantly associated with NPP employment by CHCs. State decision makers may reduce legislative and regulatory barriers to practice as a way to improve the practice environment for nonphysician primary care providers, particularly NPs and PAs. Thus, community health centers can employ adequate number of NPPs to fulfill their mission of serving the poor and underserved population.     

Survey of the degree to which ET nurses are performing current procedural terminology-coded services

ET nurses practice in many different settings including hospitals, home health, independent practice, and contract services. Reimbursement for their services is widely varied. To contribute meaningfully to health care reform, the services being provided by ET nurses must be identified. Familiarity with how these services overlap with those provided by other health care providers is essential. Current Procedural Terminology (CPT) codes, the language of payment within the health care system, are prepared and published annually by the American Medical Association for purposes of physician payment. Physicians are being paid for services that are also performed by ET nurses. This study identifies the CPT-coded services used in the practice of the ET nurse and also codes that overlap those for which physicians are paid. Identification of ET nurse-provided CPT-coded services delineates the ET nursing scope of practice and may serve as a foundation to address other practice issues, including reimbursement.