Going the distance: the evolution of VCU's Executive Distance Learning Program over 12 years.

Drawing upon the twelve-year history of Virginia Commonwealth University's (VCU) online distance learning Executive Program, this article identifies factors important to the success of online distance learning and major changes in distance learning over time. It discusses curriculum, instructional design, technology infrastructure and support, educational strategy and pedagogy, faculty, and student program dimensions. As one of the oldest online health administration or business programs, the Executive Program at VCU and this examination thereof are particularly suited to identify significant lessons learned from experience with online education. The article concludes with a summary of challenges facing this and other distance learning programs in health administration.

The prevalence of hospital health promotion and disease prevention services: good news, bad news, and policy implications.

In recent years, American health care has shifted toward an emphasis on population health in communities. National data from the American Hospital Association Annual Survey of Hospitals are used to describe the prevalence of 26 services provided by general hospitals that could contribute to health promotion and disease prevention (HPDP). Cross-sectional descriptive analyses, based on national data sources, linked HPDP services to hospital characteristics, and factor analysis identified significant categories of HPDP activities. The results showed that many specific HPDP services are offered by thousands of hospitals, but prevalence, distribution, and availability of the services are uneven across the size and ownership of hospitals and their communities. Policy initiatives could increase the prevalence of hospitals' health promotion and disease prevention services, thereby improving the health status of their communities.

Recent determinants of new entry of HMOs into a Medicare risk contract: a diversification strategy.

This study provides knowledge of more recent entry of health maintenance organizations (HMOs) into the Medicare risk program than earlier analyses. Based on a diversification framework, this study examines new market entry from three dimensions: attractiveness of the market, market area attributes, and organizational attributes. The analysis uses a 1994-1995 cross-sectional, lagged time sample with 440 HMOs that did not have a Medicare risk contract as of January 1994; it defines an HMO's market as its service area. HMO enrollment growth in the market, individual HMO enrollment size, and adjusted average per capita cost (AAPCC) rates are found to be significant in predicting new market entry.

Predicting whether patients receive continuity of care after discharge from state hospitals: policy implications.

This article reports the results of a comprehensive study of predictors of factors influencing continuity of care for individuals discharged from state hospitals to communities. Continuity of care is defined and the predisposing, enabling and need factors are examined using a statewide database. The conceptual model is based on community support system principles, and it drives the research. The findings will influence policy, which will then affect community support system principles. Logistic regression analysis is employed as statistical analysis that lends itself to graphical form. Implications for policy and future research are presented.

Well-being revisited: improving the health of a population.

Changes in society and the healthcare system are challenging healthcare executives to do more than provide medical services. Leaders now take broader responsibility for the health and well-being of the people and communities they serve. Health--the "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (World Health Organization 1944)--is determined by four forces: environment, heredity, lifestyle, and medical care services. Health-care managers who want to improve the health of their served populations must improve these forces. Strategic and operational lessons can be learned from the pioneering work done by several hospitals, health plans, and healthcare systems to improve their local environment, heredity, lifestyles, and medical care services. Managers who wish to improve health in their communities should strongly embrace and commit to "health" rather than mere "medical services" in their mission, vision, and values. They should collaborate with many other organizations and people--such as schools, churches, police, and businesses--to build partnerships that extend beyond the healthcare sector into the total community. Healthcare organizations should provide some resources and funds to improve the health of their served populations, and they should view this commitment as an investment (especially if there are capitated lives) rather than as an expense. They should also obtain public and private grant funds and leverage the resources of their collaborative partners to improve their local environment, heredity, lifestyles, and medical care services. Finally, leaders can advocate and support public policy that would improve the four forces that shape health.

Physician motivation, satisfaction and survival.

Physicians are working harder today and enjoying it less. What has happened to create such dissatisfaction among those in one of the most autonomous professions? What can be done to address the anger, fear and unhappiness? This article is an analysis of the factors influencing human motivation. Maslow's hierarchy of needs--physiological, safety/security, social/affiliation, esteem and self-actualization--is used to suggest ways physicians can satisfy their needs in turbulent financial and professional times.

Mastering health care executive education: creating transformational competence.

The effective health services executive needs to continue to develop analytical, technical and behavioral skills to anticipate and meet the changing requirements of the health care industry. Those leading the field of health administration will need to be competent in achieving transformations. Lifelong learning is a necessity. As the structure and knowledge of the field change, so must the ways of exchanging information about health and medical care. Distance learning is a strategy for lifelong learning that can be used to continue one's education. In order to be successful in positioning a health care organization in the competitive world, investment in continued education to update strategic thinking and the analytical competency of executives and managers is imperative. Academic programs able to respond to the educational needs of the health care industry have a dedicated faculty who understand corporate culture and competitiveness in the health care marketplace and are able to offer effective adult education using cutting-edge computer technology for distance learning.

HMO survival: determination of optimal size.

The concept of prepaid health care as embodied by health maintenance organizations (HMOs) provides variety in the provision and coverage of health care benefits. This is important in the development of a diverse and appropriate health care system for the US. HMOs were developed to provide a cost-effective, alternative form of health care delivery and financing to ensure access and continuity. HMOs can achieve this only by sustaining organizational viability. A survivor analysis modelling technique is employed to analyze the optimal size of HMOs by region model type and profit status over the period from 1977 through 1986. A determination of an optimal size category establishes a survival criterion for HMOs. A minimum enrollment of at least 25,000 members should be achieved as quickly as possible. This minimum standard can be used as a guide for initial success, however a higher enrollment in the 40,000 to 60,000 member range appears necessary for longer-term survival.

Access and outcomes of elderly patients enrolled in managed care.

OBJECTIVE: To determine differences in access to care and medical outcomes for Medicare patients with an acute or a chronic symptom who were enrolled in health maintenance organizations (HMOs) compared with similar fee-for-service (FFS) nonenrollees. DESIGN: A 1990 household telephone survey of Medicare beneficiaries who reported joint pain or chest pain during the previous 12 months. SAMPLE: Stratified random sample of HMO enrollees (n = 6476) and comparable sample of FFS Medicare beneficiaries (n = 6381). ACCESS AND OUTCOME MEASURES: Care-seeking behavior, physician visits, diagnostic procedures performed, therapeutic interventions prescribed, follow-up recommended by a physician, and symptom response to treatment. RESULTS: After controlling for demographic factors, health and functional status, and health behavior characteristics, HMO enrollees with joint pain (n = 2243) were more likely than nonenrollees (n = 2009) to have a physician visit (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.03 to 1.38) and medication prescribed (OR, 1.35; 95% CI, 1.14 to 1.60). Patients with chest pain who were enrolled in HMOs (n = 556) were less likely than nonenrollees (n = 524) to have a physician visit (OR, 0.50; 95% CI, 0.30 to 0.82). For both joint and chest pain, HMO enrollees were less likely to see a specialist for care, have follow-up recommended, or have their progress monitored. There were no differences in complete elimination of symptoms, but HMO enrollees with continued joint pain reported less symptomatic improvement than nonenrollees (OR, 0.72; 95% CI, 0.59 to 0.86). CONCLUSIONS: Reduced utilization of services for patients with specific ambulatory conditions was observed in HMOs with Medicare risk contracts, with less symptomatic improvement in one of the four outcomes studied.

The hospital response to Medicare's Prospective Payment System: an econometric model of Blue Cross and Blue Shield plans.

This paper presents an empirical analysis of the impact that resulted from phase-in of Medicare's Prospective Payment System (PPS) on hospital utilization and payments for the Blue Cross and Blue Shield (BCBS) plans. A pooled cross-sectional time series econometric model was specified and estimated using quarterly hospital utilization and payments of the BCBS plans over the period 1980 to 1987. The results indicate that the implementation of PPS was significantly associated with a lower rate of hospital admissions, days and deflated inpatient payments for the BCBS plan members under age 65. A 1% increase in the proportion of hospital days reimbursed under PPS resulted in a .032% decrease in BCBS plan admissions per 1,000 members, a 0.017% decline in days per 1,000 members and a 0.016% decline in deflated inpatient payment per 1,000 members. The reductions in hospital utilization resulted in lower payments by BCBS plans to participating hospitals suggesting a positive spill-over effect of PPS for private insurers. This research underscores the importance of interaction between federal health policy and the private health insurance market.

Do health maintenance organizations work for Medicare?

Since 1985, the Health Care Financing Administration (HCFA) has encouraged health maintenance organizations (HMOs) to provide Medicare coverage to enrolled beneficiaries for fixed prepaid premiums. Our evaluation shows that the risk program achieves some of its goals while not fulfilling others. We find that HMOs provide care of comparable quality to that delivered by free-for-service (FFS) providers using fewer health care resources. Enrollees experience substantially reduced out-of-pocket costs and greater coverage. However, because the capitation system does not account for the better health of those who enroll, the program does not save money for Medicare.

How the elderly fare in HMOs: outcomes from the Medicare competition demonstrations.

Because of concern about the effects of prepaid care on outcomes for elderly enrollees in health maintenance organizations (HMOs), a prospective study of access to care and functional outcomes was performed. HMOs with Medicare risk contracts in January 1985 (N = 17) were selected from ten communities and were matched for comparison with ten similar communities where no Medicare HMOs were in operation. Random samples of HMO enrollees (N = 2,098) and fee-for-service (FFS) nonenrollees (N = 1,059) were assessed at baseline and at follow-up one year later (HMO = 1,873, FFS = 916) to observe access to care and functional outcomes. At baseline, nonenrollees had more bed days and poorer functional status than HMO enrollees. While fewer HMO enrollees experienced declines in functional status between baseline and follow-up (e.g., patient's ability to function declined in one or more activities of daily living: HMOs at 5.3 percent versus FFS at 8.5 percent, p < .01), after controlling for other factors with logistic regression, enrollment status was not significantly associated with functional decline. Self-rated health, history of hospitalization, age of 80 or older and baseline functional status were predictive of decline in function. After controlling for baseline differences, HMO disenrollees also experienced similar functional declines at follow-up compared to continuously enrolled beneficiaries. These findings suggest that Medicare beneficiaries who belong to HMOs experience comparable rates of functional decline to those experienced by beneficiaries in the FFS sector with similar initial levels of function and health status. Together with results showing no significant difference in medical visits according to various symptoms, we conclude that access and quality of care delivered by HMOs is comparable to that provided in FFS settings.