Corporatization of medicine: the use of medical management information systems to increase the clinical productivity of physicians

Large corporate health care firms are seeking to reorganize the production of health services under growing cost-containment pressures from government and business payors. Medical management information systems (MMIS) applications are producing an increasing number of financially motivated utilization management interventions designed to constrain wide variations in the practice of medicine. In this article we examine how innovations in MMIS will be used to monitor practitioners' clinical decisions in order to improve the productivity of physicians and other health care personnel. As MMIS technology shifts power from previously autonomous physicians to corporate health care managers, the medical profession is likely to be subjected to far more administrative and bureaucratic controls than conceivable even a few years ago.     

Changing the nature of physician referral relationships in the US: the impact of managed care

Prior to the era of managed care in the US, health care delivery was managed by the professional activities of physicians. Managed care replaces management by profession with bureaucratic management structures and oversight, such as utilization review and gatekeeping (required referrals to specialty care). Practically, this means that physicians cannot use the professional relationships that typified practice under fee-for-service medicine, potentially changing not only what physicians do (e.g., order test or not, refer or not), but also how they do what they do. In this paper I look at just one of the changes brought about by managed care: contractual arrangements that require primary care providers to refer patients to a closed panel of specialist physicians. Through an in-depth case study of 45 primary care providers' in the USA who face restricted specialist panels for their managed care patients, but not for their fee-for-service patients, I investigate how the practice of referring is changed by this requirement. First, I use interview data to describe primary care providers general preferences for referral consultants, as well as their views of the referral process and potential barriers in it. Next I present data from all referrals over a four-week period to analyze the extent of referral relationships in actual referrals. Finally, I conclude by discussing some ways that managed care entities can facilitate rather than diminish referral relationships among physicians.     

Medical students' opinions concerning the health care system

The opinions of freshman and senior medical students on major health sytstem problems and policies were investigated in 1980–81. Responses of 214 freshmen and 203 seniors are reported in four major areas: (1) physician dominance of the health care system, (2) autonomy in patient care, (3) availability of services, and (4) preventive and social aspects of care. With respect to physician dominance, more seniors (63%) than freshman (44%) agree that physicians should determine health policy and that dominance of other health personnel is necessary (75%) and (61%). Professional review of patient care is generally acceptable to both classes, but more freshmen than seniors agree that evaluation should be a condition for relicensure. Less than a fifth of the students in either class believe that patients should be told as little as possible or that they should accept the authority of doctors without question. More freshmen than seniors consider the availability of medical care a major problem (76%) and (58%), and similar proportions believe it is the responsibility of government to assure access to all. Freshmen and seniors generally agree on the need for greater emphasis on prevention and social aspects of illness. Because of the important role played by physicians in the health care system, it is recommended that serious attention be devoted to education in this area, even though it may have a limited impact on professional attitudes.     

Preventive care attitudes of medical students

Presently developing attitudes of future physicians towards preventive medicine will likely provide either a major impetus for or barriers to the inclusion of preventive medicine content in medical school curricula and in other formats of physician education. In turn, attitudes about preventive care and its role in medical practice will continue to have a large influence on how much disease prevention and health promotion emphasis physicians provide in their practices. Consequently, it becomes important to study how medical students' attitudes evolve during the process of medical education. Furthermore, to the extent that we can better understand how desired attitudes can be developed and nurtured, the practice of preventive medicine may become more purposeful. Beginning and third-year medical students were surveyed with a 100-item questionnaire designed to assess their attitudes regarding: the relative importance of 20 specific preventive services to the practice of medicine and the adequacy of preclinical coursework for preparing them to offer preventive care in medical practice. The confidence of third year students' in the ability of primary care physicians to provide these specific services was also assessed. Preventive care service areas about which third-year students expressed high confidence in the ability of physicians to provide were: immunizations, health screening physicals, blood pressure control, cancer detection education, family planning, health counseling/education, and sexually transmitted disease prevention. Services that students had low confidence in the ability of physicians to provide were: smoking cessation, nutrition counseling/education and weight reduction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Family physicians' observations of their practice, well being, and health care in the United States.

OBJECTIVE: Our goal was to characterize how family physicians perceive recent changes in the health care system and how content they are with various factors. STUDY DESIGN: We performed a cross-sectional mailed survey. POPULATION: The survey was completed by a random sample of 361 family physicians practicing in the United States. OUTCOME MEASURES: The survey evaluated attitudes about corporate managed care, health care reform, career satisfaction, compensation, personal life satisfaction, workload stress, personal well-being, and residency training. We reported percentages for Likert-rated survey items, factor analysis of the survey, and a regression model for statistical prediction of the 4 major factors. RESULTS: Relative to survey data gathered in 1996, fewer family physicians in our survey reported that they were satisfied with their careers (59% vs 82%); fewer were satisfied with their compensation (55% vs 65%); and fewer would again choose family practice as their specialty (66% vs 75%). Thirty-one percent worried that they were "burning out" as physicians, and 48% reported that they had experienced more stress-related symptoms in the past year. Only 7% agreed that corporate managed care is the best way to provide the health care America needs at a cost society can afford, but only 36% unequivocally endorsed the concept of a national health plan. Forty-two percent of the respondents reported that they had witnessed bad patient outcomes they perceived to be attributable to managed care business processes. CONCLUSIONS: The morale and career satisfaction of family physicians seems to have eroded in recent years, and discontent is common. As a group, family physicians are unhappy with the current health care system and quite unified about certain specific reforms, yet they are far from such consensus about more sweeping reform.     

Why doctors don''t use computers: some empirical findings.

The attitudes of 148 medical students, 141 residents, and 644 practising physicians towards computer applications in medicine were studied. The results indicate that physicians recognize the potential of computers to improve patient care, but are concerned about the possibility of increased governmental and hospital control, threats to privacy, and legal and ethical problems. In general, all three groups are uncertain as to the potential effects of computers on their traditional professional role and on the organization of practice. Practising physicians, however, express more concern about these potential effects of computers than do medical students and residents. While attitudes appear to be somewhat independent of prior computer experience, they significantly affect the extent to which physicians use a computer-based hospital information system. This may be a major reason for the slow introduction of clinical computer systems.     

Privatizing health care: caveat emptor

Many Western European countries are moving toward privatization of their health care systems. The United States' health care system, since it is almost entirely privatized, is therefore worthy of study. Doing so raises several questions. How is privatization being managed in the US? How could its management be improved? What management lessons must be kept in mind if it is to be used effectively? What potential pitfalls should European countries consider as they move toward greater privatization? With operating costs, European countries must avoid the mistakes that have led to dramatic increases in annual health care costs in the US, simultaneous with reductions in access and quality. Doing so requires designing systems that promote hospital behavior consistent with a country's health objectives. With capital costs, an approach must be designed that allows policy-makers to work closely with both managers and physicians in order to make strategically sound choices about access and quality. Such an approach will require physicians to incorporate their clinical judgments into community standards of care, and to adopt a regional (rather than an institutional or personal) perspective in the determination of any incremental capital expenditures. By making regulation proactive and strategic, rather than punitive, health policymakers in Western Europe can achieve the best privatization has to offer without feeling the sting of its unintended consequences. In so doing they can help to move their health systems toward achieving the multiple and illusive goals of access, quality and reasonable cost.     

Public health medicine: the constant dilemma

There is a well-known quotation by the nineteenth-century sociologist Virchow (quoted in Ref. 1) that aptly captures the dilemma that has confronted public health medicine since the specialty was created as a discrete entity in 1848. Virchow said: 'Medicine is politics and social medicine is politics writ large!' What does this mean in relation to effective public health medicine practice and how is it likely to affect its future? There is increasingly limited freedom of expression within the current context of political correctness, central control and a rapidly burgeoning litigious climate. The purpose of this paper is to explore these issues and to propose a means of maintaining public health medicine integrity within a working environment where action is becoming rapidly constrained by political rigidity. An additional factor to be included in the dialogue is the current context within which public health physicians work. Because the majority of public health doctors are employed within the National Health Service (NHS), they are finding themselves being expected to take on tasks and responsibilities marginal to their essential purpose and function. For example, public health physicians spend a great deal of time involved in detailed deliberations about health service provision. Although there is a great deal of evidence to show that good quality health care provision positively affects the health of the individual, there is no evidence to show that this activity has any effect on the population's health status. The essence of public health medicine practice is the prevention of ill-health and the promotion of the health of the population and, consequently, attention needs to be focused on the root causes of disease. However, as these are outside the aegis of the NHS, public health medicine involvement in such issues as education, nutrition, housing, transport and poverty is regarded as marginal to the NHS corporate agenda.     

Professional integrity in the age of managed care: views of physicians.

At the end of 1997, one quarter of the American public used health maintenance organizations. This paper reports findings on physicians' perspectives on the role of managed care in their professional practices. The research data come from mailed surveys to physicians who are selected from the Cigna Directory of Physicians practicing in the State of Ohio. Subjects were asked to explain what managed care meant to them, and how long they have been practicing medicine. Questions also focused on professional autonomy, quality of care and career aspirations for the future. The results from the study suggest that managed care has had a negative impact on how physicians practice medicine. Several of our respondents reported that they are playing the role of a "double agent" and feel a sense of frustration in doing so. The degree of antipathy toward managed care differs between primary care physicians and specialists.     

Defining and assessing the competence of health care professionals in France

INTRODUCTION: During the past decade, the public, health care professionals, and governments have shown much interest in ensuring that professionals, specifically physicians, are skilled in their work and competent in managing health care organizations. The need to assess competence in the health care sector was explored, with the aim of proposing a policy for monitoring and assessing competence during active professional life. METHODS: A literature search and semistructured interviews were conducted. The 16 health care professions listed in the French health care code were included. The main questions were: What is your organization's definition of competence? What are the principal elements that define competence in health care activities? How can a system for assessing competence be implemented? Which methods for such a system are most appropriate, based on foreign experiences? Who are the players in the field of competence? And how can organizations participate in monitoring competence? RESULTS: 265 people representing 148 French organizations were interviewed. Competence in health care should be defined as follows: "professional competence is based on the initial diploma, the implementation of effective continuing education, a minimal professional activity and a regular peer review process." There was an agreement on the basic elements of competence, on the responsibilities of public institutions and professional organizations, and on the need to work together. DISCUSSION: We have shown that in France health care professionals would like to have a better system that allows them to exchange more information on the main health care issues; this is a serious requirement for most professionals.     

Family practice: professional identity in transition. A case study of family medicine in Canada

With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identity-a matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicine-three areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician-patient relationship is considered a core characteristic of family medicine that is much valued by patients and physicians-both generalists and specialists-as something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions' traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating "specialist" general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system.     

The need to incorporate health information technology into physicians' education and professional development

Nationwide, as physicians and health care systems adopt electronic health records, health information technology is becoming integral to the practice of medicine. But current medical education and professional development curricula do not systematically prepare physicians to use electronic health records and the data these systems collect. We detail how training in meaningful use of electronic health records could be incorporated into physician training, from medical school, through licensure and board certification, to continuing medical education and the maintenance of licensure and board certification. We identify six near-term opportunities for professional organizations to accelerate the integration of health information technology into their requirements.     

Improving health care communication for persons with mental retardation.

There has been little effort directed at training health care professionals in behaviors and attitudes that are effective in communicating with persons with mental retardation. Such training would be beneficial not only to assist those with congenital cognitive deficits but for those with acquired central nervous system conditions as well, for example, dementia. Persons with mental retardation are living in community settings in greater numbers and increasingly participating in vocational, residential, and health care programs. Yet, most health care professionals are not routinely offered an opportunity to gain experience interacting with people who have limited ability to express and understand health care information. An education program was focused on health care professionals' use of basic communication skills when providing health information to an adult who is mentally retarded. A self-study instructional text and a 20-minute companion video provided methods of communicating with a patient with mental retardation in medical and dental care settings. Resident physicians, medical students, nurses, and nursing assistants improved their communication skills, knew more about mental retardation, and were more proactive in health care interviews following training. Health care training needs to incorporate educational opportunities focusing on skills to assist special populations. Brief, structured, and interactive skill training in communication offered early in the health care professional's career has positive benefits for the recipient and the provider.     

Proletarianization or restratification of the medical profession? The case of obstetrics

Professional dominance, autonomy, and control have been consistently emphasized in theories of the medical profession. Recently, however, the professional hegemony that physicians have enjoyed is increasingly being questioned in the light of profound changes that are taking place in the organization of health care in the United States. Debates about the implications of the power of medicine and the means by which it is maintained are being replaced by attempts to understand professional decline. Proletarianization (McKinlay and colleagues) and restratification theory (Freidson) are two prominent and competing predictions for the future of the medical profession. Taking obstetrics as a critical case, this article considers the relative ability of these theories to elucidate the changing organization of maternity care in one state and presents a case study of patient care in one hospital. It suggests a disjuncture between obstetricians' inability to protect their interests as a corporate body and their relative ability to control the organization of everyday medical work. It is concluded that more theoretical clarity is needed on professional behaviors at the macro and micro levels.     

Settings for learning: the community beyond

The primary objective of medical education to medical students should not be the recruitment of specialists or to provide instructions about highly sophisticated clinic medicine. Our responsibility towards them is rather to enable them to learn about medical practice in its most prevalent context, which is the community medical practice, and to contribute to their general medical education and the health welfare of their community. The health needed by the nation cannot possibly be provided by specialists. It is a task for all doctors. If we agree that the ultimate goal of medical education is to secure health and proper care (whether primary, secondary or tertiary) for the population, medical curricula and learning settings should be open for any modifications that ensure a proper approach to our patients' practicalities, resources and needs. A major modification involved in that process would be for the educational setting to move from the hospital into the community and doctors to acquire the skills and conviction of working as part of a health team, in which they are not necessarily the leaders.     

Social policy and professional self-interest: Physician responses to DRGS

Prospective hospital reimbursement based on Diagnosis Related Groups (DRGs) began in 1983 for Medicare patients, and many states are adopting similar systems for Medicaid recipients in an attempt to curb rising health care costs. Because of their unprecedented intrusiveness compared to previous cost-containment measures and because they explicitly introduce financial incentives to reduce services, DRGs have great potential to affect health care delivery.To determine the effects of DRGs on hospitals and physicians, six months of ethnographic fieldwork was carried out on the medicine and pediatrics services of a university-affiliated hospital during the first year of DRG-based reimbursement. Observations and interviews were used to discern institutional responses to DRGs and physician knowledge of, experience with, and reactions to this cost-containment effort.Our findings indicate that the hospital instituted many changes to protect its interests. Data gathered from patients' abstracts suggest providers are successfully dealing with the new system; the average length of stay for Medicare patients was reduced by 38% in the first year of prospective reimbursement, compared with a 15% reduction for other patients (P < 0.05)As a group, the physicians made no organized effort to educate themselves about the new cost-containment regulations. Their knowledge of DRGs was vague and included many misconceptions. Their response was not a coherent one taking broad social concerns into account. Cost-containment was viewed negatively, as a threat to the financial integrity of the hospital, patient care, and professional autonomy. They responded on a case-by-case basis, generally complying with the formal procedures associated with the new regulations, while attempting to avoid or minimize the constraints imposed on their behavior. Their response represents an adaptation aimed at maximizing reimbursement for the hospital while insuring adequate care for individual patients. The response appears to have moderated the impact of cost-containment regulations, without wholly neutralizing them.These attitudes and responses to prospective payment are ones which have been promoted and reinforced by medical practice and education for some time. Yet they keep physicians from taking a positive role in forming effective public policy for cost-containment in medicine. Until physicians think more about cost-containment and its larger policy implications and develop a set of defensible responses to it, they will be unlikely to make a valuable professional contribution toward one of the most pressing policy issues confronting medicine today.     

Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.Funds for this study were generously provided by the L.K. Whittier Foundation. Samuel A. Skootsky's salary was in part supported by Southern California Edison.     

Rise of Health Consumerism in China and Its Effects on Physicians’ Professional Identity and the Physician–Patient Relationship and Communication

The physician–patient relationship in China is highly strained. This study examined the professional identity of physicians and their perceptions of the physician–patient relationship against the backdrop of the rise of health consumerism in China. Structured interviews with 29 physicians found that the marketization of medical care and the rise of health consumerism caused physicians to have a conflicted professional identity. The traditional bureaucratic relationship between physicians and patients based on implicit trust was gradually replaced by an arm’s length relationship characterized by self-interest, opportunism, and mistrust. In addition, the transition from physician-centered communication to patient-centered communication in China was tenacious. Theoretical and practical implications of the current study are discussed.     

Impact of health care system on physicians' discontent

This study was designed to investigate the impact of physicians' perceptions of the health care system on their discontent with their profession. By using a random digit dialing technique, a structured telephone interview was conducted with 401 generalist physicians (343 men, 56 women) who were practicing medicine at least for five years and were younger than 65 years. Physicians' willingness to choose medicine again was correlated with their perceptions of different aspects of the health care system. Of the total participants, 288 (72 percent) indicated that they would choose medicine again, 91 (23 percent) would not choose medicine, and 22 (5 percent) were not sure. Results of the stepwise logistic regression showed that after adjustment for physicians' gender and age, those who would not choose medicine again were more than twice as likely as other physicians who would choose medicine to believe that the health care environment will deteriorate more in the future (odds ratio = 2.1, p < .01), were less than half as likely to believe that physicians nowadays share more responsibilities with other health care professionals (odds ratio = .42, p < .01), and were less than half as likely to confirm that patients understand their health insurance better than before (odds ratio = .46, p < .01). Findings suggest that physicians' discontent can be predicted by their negative perceptions of the health care environment. Findings have implications for improving the quality of professional and personal life of the physician, thus improving the quality of care and satisfaction of the patient.