Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.

Measuring contributions to the clinical mission of medical schools and teaching hospitals.

This is the final report of a panel convened as part of the Association of American Medical College's (AAMC's) Mission-based Management Program to examine the use of metrics (i.e., measures) in assessing faculty and departmental contributions to the clinical mission. The authors begin by focusing on methods employed to estimate clinical effort and calculate a "clinical full-time equivalent," a prerequisite to comparing productivity among faculty members and departments. They then identify commonly used metrics, including relative-value units, total patient-care gross charges, total net patient fee-for-service revenue, total volume per CPT (current procedural terminologies) code by service category and number of patients per physician, discussing their advantages and disadvantages. These measures reflect the "twin pillars" of measurement criteria, those based on financial or revenue information, and those based on measured activity. In addition, the authors urge that the assessment of quality of care become more highly developed and integrated into an institution's measurement criteria. The authors acknowledge the various ways users of clinical metrics can develop standards against which to benchmark performance. They identify organizations that are sources of information about external national standards, acknowledge various factors that confound the interpretation of productivity data, and urge schools to identify and measure secondary service indicators to assist with interpretation and provide a fuller picture of performance. Finally, they discuss other, non-patient-care, activities that contribute to the clinical mission, information about which should be incorporated into the overall assessment. In summary, the authors encourage the use of clinical productivity metrics as an integral part of a comprehensive evaluation process based upon clearly articulated and agreed-upon goals and objectives. When carefully designed, these measurement systems can provide critical information that will enable institutional leaders to recognize and reward faculty and departmental performance in fulfillment of the clinical mission.

The Balanced Budget Act of 1997: its impact on U.S. teaching hospitals.

The Balanced Budget Act of 1997 had a profound impact on the financing and organization of many health care services. The Act disproportionately affected U.S. teaching hospitals, leading to substantial budget reductions in many institutions and the threat of cuts in major programs and services that teaching hospitals provide to communities. This paper examines the overall financial and organizational impact of the Balanced Budget Act on teaching hospitals and considers its effect on residency education. It also discusses to what degree the Balanced Budget Refinement Act of 1999 will mitigate these effects and posits other solutions to the serious financial issues facing teaching hospitals in the United States.

Organizational models of medical school relationships to the clinical enterprise.

The authors analyzed existing relationships between medical schools and clinical enterprises in order to develop models of these relationships. The conceptual framework for the models uses three variables to assess the nature of the relationships: (1) high academic control-high clinical enterprise control; (2) high academic influence-low academic influence; and (3) self-contained system-open system (i.e., the extent to which the resources needed for clinical education are provided by the relationship between the clinical enterprise and the medical school). The authors present four conceptual models of the relationship between the medical school and the clinical enterprise: (1) The "single ownership; owned integrated system" is characterized by a closed clinical delivery system owned or controlled by the academic institution. (2) The "general partner" organization emphasizes an open clinical environment in which the medical school forms alliances with clinical entities, and the school is a dominant partner. (3) The "limited partner" organization operates with an open clinical delivery system that the school relates to through affiliations and contractual relationships, and the school is a less dominant partner. (4) The "wholly owned, subsidiary" organization operates in a controlled clinical environment in which the medical school is a subsidiary of the larger integrated delivery system. Each model is presented in its pure organizational form, then augmented with descriptions of the different ways that the medical school and other components may relate to each other. Also, the advantages and disadvantages of each model for the medical school are discussed. The authors emphasize that no model is superior to the others; instead, the best choice for a medical school depends on the history, local circumstances, and leadership of the school and other organizations. The authors' intent is to assist the leaders of medical schools as they design strategies for the future relationships of their institutions.

Preserving the mission.

Teaching hospitals and medical schools are changing with the times, but the authors argue that other players in the delivery system--government, insurers, hospitals, and health systems--must share in the effort to preserve the nation's medical education and research infrastructure.

Competition versus regulation: its effect on hospitals.

While factors other than competition and regulation influence hospital's behavior, these two strategies have dominated the health policy debate. To examine the impact of these two competing strategies on patients and hospitals, the authors examine experiences in Baltimore, which has followed a regulatory strategy since the early 1970s, and Minneapolis/St. Paul, which has pursued a competitive strategy during the same time frame. Compared with the national average, both strategies had only a minor impact on containing hospital costs per capita, but they influenced hospital productivity, cost per discharge, and utilization in different ways.