Rationale, principles, and educational approaches of organizational transormation (original) (raw)

The new world of managed care: creating organized delivery systems

Health affairs, 1994

Prologue: In anticipation of reforms at either the state or the national level and in response to rising costs, health care organizations are changing rapidly. "Managed care" has taken on new meanings us the lines traditionally separating hospitals, physicians, and insurers begin to blur. Policymakers struggle to define this new concept of managed care, sometimes referred to us "integrated service networks" or "organized delivery systems." These entities combine the organization, financing, and delivery of health care in wuys that respond to the demographics and economics that prevail in different regions of the country. Ultimately , the system should provide appropriate care in a seamless continuum that uses limited resources most effectively. The way these new organizational hybrids grow and develop in their early years has important implications for the health and health care of Americans for years to come. In this paper Stephen Shortell and colleagues outline their research on organized delivery systems, describe the barriers such systems face, and raise key policy questions that must be answered.

A Perspective on the Corporate Transformation of Health Care

International Journal of Health Services, 1995

The ever-increasing ownership of health service providers, suppliers, and insurers by investor-owned enterprises presents an unforeseen complexity and diversity to health care delivery. This article reviews the history of the for-profit invasion of the health sector, linking corporate purchaser directions to the now dominant mode of delivery in managed care. These dynamics require unceasing reassessment while the United States embarks upon implementation of national health care reform. In 1964, health care was not called an industry. U.S. annual health expenditures wen: less than $40 billion, a mere 5.9 percent of the gross national product (GNP) (1). The boundaries of this "nonsystem" were not viewed much beyond doctors' offices and community hospitals (2,3). The medical profession was believed to be dominant in shaping medical knowledge and its institutions (4,5), most of which wert: nonprofit. Educational institutions and manufacturers and suppliers of pharmaceuticals, technological equipment, and medical supplies intensified their connections subsequent to the founding of the National Institutes of Health and the unparalleled advances in medical science (6). Medical research was generally conducted at select teaching hospitals, which had yet to become part of "medical empires" (7). Medical school affiliations were primarily clinical, typically with municipal and/or Veterans Administration hospitals. In the early 1960s there were no federal monies for nurses' training, health professions education, graduate public health fellowships, neighborhood health centers, community mental health centers, or hospital outpatient department construction (8). While Hill-Burton funds helped to build hospitals across the country from 1947 onward, the Regional Medical Programs and Compre)lensive Health Planning Agencies did not yet exist, Blue Cross, the grand old friend of the hospital industry, signed checks based upon "cost-plus" reimbursement, to cover substantial "free care" offered to the poor, aged, and otherwise uninsured (9, 10). A plethora of private insurance companies had begun to pay even higher

The transformation of health providers

Health Affairs, 1984

The traditional role which doctors have assumed in rendering medical care is that ofthepatient's steadfast advocate. That relationship has worked marvelously well in the American health care system with one critical caveat: the cost of the enterprise has been growing at a rate that society is beginning to regard as exorbitant. Current efforts to control the escalation of cost often involve modification of two basic conditions of the traditional physician-patient relationship. First, they often seek to lock in care to a particular category of providers or to restrict choice to a provider who become-s a gatekeeper to more specialized and expensive services. Second, cost-control efforts modijy the definition of the provider's role from sole agent of the patient's welfare to a role of balancing the patient's wants and needs against the aggregate population and a fixed budget. Thus, as David Mechanic explains so articulately in this article, the role of the doctor and hospital is transformed from advocating to-allocating. Such transformations are inherent in capitated systems (health maintenance organizations), rate regulation, and diagnosis-related group methodologies. Mechanic, university professor and dean of the Faculty of Arts and Sciences at Rutgers University, is one of the nation's leading medical sociologists. Mechanic is also an active member of the National Academy of Sciences' Institute of Medicine. Expressing a belief that "the heavy hand of government causes more problems than it solves, "Mechanic's message is really a plea to the medical profession to work toward achieving three objectives: reducing the variabilities in medical practice that cannot be clinically justified; developing economic incentives to encourage the types of care medical professionals "truly believe should be emphasized," and, finally, designing nonmonetary reward systems that strive to insure the delivery of quality medical care under fixed-budget approaches. on May 25, 2016 by HW Team Health Affairs by http://content.healthaffairs.org/ Downloaded from on May 25, 2016 by HW Team Health Affairs by http://content.healthaffairs.org/ Downloaded from

The Importance of Management for Understanding Managed Care

The Journal of Medicine and Philosophy, 1999

This paper argues that the concept of management is critically important for understanding managed care. A proper interpretation of management is needed before a positive account of the ethics of managed care can be constructed. The paper discusses three aspects of management: administrative, clinical, and resource management, and compares the central commitments of traditional medical practice with those of managed care for each of these aspects. In so doing, the distinctive conceptual features of the managed care paradigm are discussed. The paper concludes by arguing that the concept of management implicit in the managed care paradigm affords a basis for building a more adequate ethic of managed care.

Transformational change in health care systems: an organizational model

Health care management review

The Institute of Medicine's 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the report's goals, but few have succeeded in making the substantial transformations needed to achieve those aims. This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundation's Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. Five interactive elements appear critical to successful transformation of patient c...

Two Decades of Organizational Change in Health Care: What Have we Learned?

Medical Care Research and Review, 2004

The 1980s and 1990s witnessed a substantial wave of organizational restructuring among hospitals and physicians, as health providers rethought their organizational roles given perceived market imperatives. Mergers, acquisitions, internal restructuring, and new interorganizational relationships occurred at a record pace. Matching this was a large wave of study and discourse among health services researchers, industry experts, and consultants to understand the causes and consequences of organizational change. In many cases, this literature provides mixed signals about what was accomplished through these organizational efforts. The purpose of this review is to synthesize this diverse literature. This review examines studies of horizontal consolidation and integration of hospitals, horizontal consolidation and integration of physician organizations, and integration and relationship development between physicians and hospitals. In all, around 100 studies were examined to assess what was ...

The Corporate Transformation of Medicine and Its Impact on Costs and Access to Care

The Journal of the American Board of Family Medicine, 2003

In 1980, Arnold Relman, former Editor of The New England Journal of Medicine, noted the emergence of the medical-industrial complex, a huge new forprofit industry ranging from proprietary hospitals and nursing homes to diagnostic services, medical devices, hemodialysis, the pharmaceutical industry, the insurance industry, home care, and many other related proprietary activities. He issued this warning 23 years ago: This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. Closer attention from the public and the profession, and careful study are necessary to ensure that the "medical-industrial complex" puts the interests of the public before those of its stockholders. 1 This article has 3 main goals: (1) to examine the extent of corporate transformation within the medical-industrial complex today; (2) to assess the impact of these changes on health care costs and primary health care access; and (3) to offer some suggestions for more effective cost containment as a means to make health care more affordable and to improve access to care.

A Balanced Framework for Change

Journal of Health Politics Policy and Law, 1999

Managed care consists of a set of approaches, organizational arrangements, and strategies with considerable diversity of practice. A key element, which requires considerable management of available resources, is prepayment for care with limited consumer out-of-pocket obligations. Most common among management strategies is the use of capitation, risk-sharing and payment incentives, utilization review, and services substitution. Other developing strategies include physician profiling, use of practice guidelines and clinical pathways, disease management, and quality monitoring.

Getting at the management of care within managed care

Health services research, 1998

The importance of assessing the overall value derived through managed care was a major theme in Stephen Shortell's editorial in the December 1997 issue of Health Services Research. In this issue of HSR, Nelson, McHorney, Manning, and their colleagues augment our understanding of the role and impact ofprepaid managed care plans on the cost side ofthe "value" equation. Like many researchers before them, the authors of this study correctly note the inability of their research to identify what it is about managed care per se-what policies, practices, and protocols-are most influential in generating observed cost-savings. In this editorial, I would like to summarize what we have learned from existing research, the important questions that remain, and perhaps some important and largely untapped opportunities to address these and other unresolved questions about managed care.