Understanding managed care: practice implications for NPs.

Highly effective nurse practitioners in managed care settings may understand the basic concept of managed care without appreciating how the context of managed care impacts their practice. This article discusses the concept of managed care within the context of 4 managed care strategies. In developing this paper, our goals were first, to describe contracts, incentives, management, and medical necessity as managed care strategies and second, to discuss some of the ways these strategies can significantly impact nurse practitioner practice. Illustrative practice examples are used to suggest that those nurse practitioners who understand managed care, both as a theoretical concept and as a context for practice, may find that they are better able to develop innovative ways to meet the needs of their patients.

Needs and challenges for health services research at academic health centers.

What are the institutional strategies used by academic health centers and other academic institutions to support and maintain the infrastructure that promotes health services research? Using the findings from interviews conducted in late 1998 with health services researchers at ten health services research centers of several types and from several geographic areas, and with the directors of ten health services research training centers, the authors address this key issue by examining four central infrastructure needs and challenges for health services research: (1) organizing core institutional resources (most centers received some level of core financial support from their parent organizations); (2) supporting career development of individual researchers (the more competitive health care system may diminish the ability of academic health centers and other institutions to give such support, but certain opportunities were noted); (3) supporting and enhancing training in health services research (such support comes from many different disciplines and organizations; the typical career path is in academic settings); and (4) establishing and supporting research partnerships (there are growing opportunities for such alliances). The authors reach a number of conclusions from their study, including the fact that there are a wide variety of models of successful health services research centers, with very different missions, organizational and interdisciplinary configurations, research and policy objectives, and collaborative relationships. Additional studies are needed to further specify those infrastructure elements that foster effective and productive health services research in academic health centers and other university settings.

An emerging public health perspective on domestic violence: implications for Wisconsin physicians and health care organizations.

In this article, we provide a brief discussion of the health and health care cost consequences of the problem of domestic violence, and a review of some key reasons why physicians may often fail to recognize the signs of this violence and abuse in their patients. In Wisconsin, a variety of agencies, educational institutions and communities are in the process of developing and refining educational initiatives or multidisciplinary response efforts which have medical care components or implications. Collectively, the experience being gained by these various efforts throughout Wisconsin provides a solid foundation from which to further develop and enhance a public health perspective for responding to domestic violence. It is suggested that this perspective can help inform the state's physicians and health care organizations on how they can improve their individual and organizational responses to the problem of domestic violence.

Wisconsin's future requirements for generalist physicians: is the state's training capacity sufficient?

The need for expansion of generalist residency training programs in Wisconsin is considered, using population-based considerations and projection models that estimate the future statewide supply of and requirements for generalist physicians. In 1990, Wisconsin's generalist physician-to-population ratio was relatively low, at 59 per 100,000 population. The supply of generalists per 100,000 population was also highly variable across broad geographic areas of the state, with 16 of Wisconsin's 25 Health Service Areas having ratios which fell below 59 per 100,000 population. These patterns may not automatically translate into the need for expansion of Wisconsin's generalist residency training capacity, however. The projection model indicates that, even with no expansion of graduate medical education capacity for generalist physicians, the statewide supply could grow to more than 70 generalists per 100,000 population by the year 2015. Expansion of the state's generalist training capacity would also not guarantee that any additional generalist physicians trained in the state would actually locate in areas where they would be most needed. Policy efforts to provide incentives for generalist physicians to locate in under-served areas should continue to be supported.

Functional status, symptoms of depression, and the outcomes of hospitalization in community-dwelling elderly patients.

OBJECTIVE: To assess the relationship between symptoms of depression at admission and postdischarge medical outcomes in hospitalized elderly patients. DESIGN: Prospective cohort study. METHODS: Patients screened for symptoms of depression at admission using the Geriatric Depression Scale underwent assessment 1 month after discharge to determine outcomes of hospitalization. SETTING: A 370-bed, acute care, community hospital. PATIENTS: A sample of 197 cognitively intact, community-dwelling elderly patients, aged 70 years and older, hospitalized with medical diagnoses, with expected lengths of stay of 48 hours or more. MAIN OUTCOME MEASURE: The Medical Outcomes Study Short-Form instrument was used to obtain data on 1-month postdischarge medical outcomes with respect to physical functioning, health status, and mental status. RESULTS: On admission, a total of 23.9% had symptoms of depression (Geriatric Depression Scale score, > or = 11) that were significantly related to preadmission functional status. In multivariate analyses, depressive symptoms at admission were significantly related to 1-month medical outcomes, independent of functional status. CONCLUSIONS: Findings suggest that depressive symptoms in hospitalized elderly may be reactive to physical disability and characterize a group of patients who have poorer functional status prior to admission. The effect of depressive symptoms on 1-month postdischarge medical outcomes, however, appears to be independent of and in addition to the effects of preadmission functional status.

Risk of falls after hospital discharge.

OBJECTIVES: To determine the incidence of falls within the first month after hospitalization and risk factors associated with falling during this period. DESIGN: Cohort study with 1-month follow-up after hospital discharge. SETTING: 370-bed community hospital. PATIENTS: Consecutive sample of 214 patients, aged 70 years and over, hospitalized for medical illness more than 48 hours and discharged to the community. EXCLUSION CRITERIA: terminal illness, neurologic diagnosis, discharge to skilled nursing facility. MEASUREMENTS: Information was obtained at hospital admission, discharge, and 1 month after discharge. Initial assessment included demographic data, vision, mood, pre-admission function, and use of assistive device. Discharge assessment included length of hospital stay, use of assistive device, need for professional help after discharge, medications cognition, and functional status. Patients were assessed 1 month after discharge for history of confusion and falls. Main outcome measure was falls in the first month after discharge. MAIN RESULTS: Twenty-nine patients (13.6%) fell during the month after discharge. Major risk factors for falls included, at discharge, decline in mobility (P = 0.005), use of assistive device (P = 0.002), and cognitive impairment (P = 0.05), and after hospital discharge, self-report of confusion (P = 0.002). Patients who were functionally dependent and needed professional help after discharge had the highest rate of falls (20.2%). In contrast, only 8.4% of independent patients not requiring professional help fell (P = 0.01). CONCLUSIONS: There is a high incidence of falls after hospital discharge, particularly among patients who are functionally dependent. Further study is needed to determine to what extent acute illness and hospitalization may influence falls risk.

The value of the physician executive role to organizational effectiveness and performance.

With the growing importance of medical management as a component of health care delivery, it is important to understand the extent to which physician executives assist their organizations in the provision of health care that is efficient and of high quality. To date, research on the role of physician executives in large health care organizations has been limited. This research attempts to address some of the gaps in our understanding of the value of the role of the physician executive and explores the anticipated opportunities for expansion of that role as health care organizations attempt to respond to a rapidly changing health care environment.

Measurement of activities of daily living in hospitalized elderly: a comparison of self-report and performance-based methods.

OBJECTIVE: To determine the accuracy of self-reports of physical functioning by hospitalized elderly. DESIGN: Comparison of two measures. PATIENTS AND SETTING: Two-hundred forty-seven medical inpatients (mean age 78.7 years) hospitalized at St. Marys Hospital Medical Center, Madison, WI. MAIN OUTCOME MEASURES: Measures of five activities of daily living by self-report and by performance. RESULTS: The rate of agreement between self-report and performance ADL measures was the lowest in the areas of bathing and dressing where the agreement was 63% and 64%, respectively. When patients reported needing no help in these two tasks, they were measured lower 32% of the time for dressing and 42% for bathing. When patients reported needing help in an activity the agreement rate between patient and occupational therapist varied widely, from only 42% for toileting to 78% for bathing. The two factors which were statistically associated with poor agreement between the two ADL measurements were cognitive impairment (P less than 0.001) and a decline from the pre-hospital level of ADL functioning which had occurred during hospitalization (P less than 0.001). CONCLUSIONS: These data suggest that there may be significant differences between patient assessments and performance-based measurements of ADL functioning in hospitalized elderly at time of discharge. These differences may have implications for the collection of functional measurements for discharge planning or for geriatric research in the hospital environment.

Uncompensated and discounted Medicaid care provided by physician group practices in Wisconsin.

A survey of a sample of physician group practices in Wisconsin was undertaken to determine the amounts of charity care, bad debt, and discounted Medicaid care that were provided in 1988. Overall, the physician group practices in the sample reported dollar amounts of uncompensated care and discounted Medicaid care that averaged approximately 7.6% of their total billings for the year (1.6% of charity care, 3.0% of bad debt, and 3.0% of discounted Medicaid care). From the dollar totals reported, it was calculated that the individual physicians represented by this sample of group practices were responsible for, on average, +4300 of charity care, +9100 of bad debt, and +7500 of Medicaid discounted services, for a yearly per-physician total of +20,900 of uncompensated care and discounted care provided to uninsured and indigent patients. The results indicate that a majority of the group practices provided more charity care in 1988 than they had 5 years earlier and suggest that the burden of providing uncompensated care tends to fall disproportionately on those group practices that are also providing relatively high levels of service to Medicaid recipients.

Career paths of physician executives.

Survey data from a sample of physicians whose primary professional activity is administration were used to examine their previous administrative positions and career paths. Forty percent reported administrative positions in more than one type of health care organization, and time spent in administration increased with age and years in administration. Most responders with senior titles had four or more positions in a single type of organization or two positions in different types of organizations. These findings should be useful for further investigation on the physician executive role, as well as in career planning.

How much administration is today's physician doing?

The substantial changes in the organization and financing of health care services that have occurred in the United States over the past decade have helped to facilitate a growing role for physicians in health care management. These administrative roles for physicians are becoming increasingly important within many health care institutions with regard to such issues as cost containment and cost effectiveness, quality assurance and professional standards, and access to care. The growing complexity and diversity of the delivery system have created the need for more physicians to become involved in "orchestrat(ing)" the management of the medical-industrial complex."

Trends in physician availability in 10 urban areas from 1963 to 1980.

The overall growth in the physician supply has so dominated the public policy agenda that issues of physician distribution within urban areas have received little attention. In this study, we examined the changes in physician availability in the poverty and nonpoverty areas of 10 U.S. cities between 1963 and 1980. We found that the overall availability of patient care physicians increased in both poverty and nonpoverty areas, with greater growth in the nonpoverty areas. For office-based primary care physicians, however, there was a 45% decline in availability in the poverty areas and a 27% decline in the nonpoverty areas. We conclude that the overall increase in the physician supply may not adequately correct geographic and specialty maldistribution in urban areas. We suggest that special educational, service delivery, and financing strategies within urban areas continue to be needed to address problems of inequitable physician availability.