How other members of the top management team see the nurse executive.

This study compared how top-level organizational groups within Veterans Affairs Medical Center (VAMC) top management teams perceived nurse executives' participation in strategic decision making. Nurse executives' perceptions of their own involvement in strategic decision making generally agreed with the views of both chiefs of staff and directors. However, the associate director's perceptions of the nurse executive's involvement often differed significantly with those of the nurse. Nurse executives will be better prepared to function effectively within the top management team if they are aware of patterns in how they are perceived by other members.

Decision-making activity and influence of nurse executives in top management teams.

This study assesses the impact on decision-making when introducing the nurse executive into the top management team (TMT) in Veterans Affairs Medical Centers. Results indicate that nurse executives formally elevated to the TMT were no more likely to perceive greater involvement in decision-making than non-TMT nurse executives or nurses informally appointed to the TMT. However, nurse executives in all categories perceived themselves as more involved in strategic decisions than other TMT members.

HMO marketing and selection bias: are TEFRA HMOs skimming?

The research evidence indicates that health maintenance organizations (HMOs) participating in the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) At-Risk Program tend to experience favorable selection. Although favorable selection might result from patient decisions, a common conjecture is that it can be induced by HMOs through their marketing activities. The purpose of this study is to examine the relationship between HMO marketing strategies and selection bias in TEFRA At-Risk HMOs. A purposive sample of 22 HMOs that were actively marketing their TEFRA programs was selected and data on organizational characteristics, market area characteristics, and HMO marketing decisions were collected. To measure selection bias in these HMOs, the functional health status of approximately 300 enrollees in each HMO was compared to that of 300 non-enrolling beneficiaries in the same area. Three dependent variables, reflecting selection bias at the mean, the low health tail, and the high health tail of the health status distribution were created. Weighted least squares regressions were then used to identify relationships between marketing elements and selection bias. Subject to the statistical limitations of the study, our conclusion is that it is doubtful that HMO marketing decisions are responsible for the prevalence of favorable selection in HMO enrollment. It also appears unlikely that HMOs were differentially targeting healthy and unhealthy segments of the Medicare market.

Selection bias in TEFRA at-risk HMOs.

The issue of selection bias was investigated using data from 22 HMOs who are enrolling Medicare beneficiaries under Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) at-risk contracts. The study differs from previously published analyses of this issue in that it deals with the current Medicare risk program (TEFRA) rather than with earlier Demonstration Programs; as an indicator of selection bias, it utilizes beneficiary functional health status at enrollment; and it examines selection not only at the mean of the health status distribution, but at the two tails (very disabled, very able) as well. For each of the participating HMOs, the functional health status of recent Medicare enrollees was compared with that of a control group of randomly chosen fee-for-service beneficiaries. None of the HMOs experienced adverse selection, whether measured in terms of overall (mean) health status of enrollees or in terms of the proportion of the very disabled population that chose to join. Nine of the 22 HMOs were considered to have experienced favorable selection on the basis of the mean health status of new enrollees. In addition, ten more HMOs were found to have experienced favorable selection in one or both tails of the health status distribution. Although a specific cause for the observed enrollment patterns is not identified, speculation is made on factors that may or may not contribute. Evidence suggests that beneficiary self-selection is probably a more important explanation of these patterns than purposeful actions of HMOs to discourage enrollment by sicker beneficiaries (i.e., "skimming").