Partnership synergy: a practical framework for studying and strengthening the collaborative advantage.

The substantial interest and investment in health partnerships in the United States is based on the assumption that collaboration is more effective in achieving health and health system goals than efforts carried out by single agents. A clear conceptualization of the mechanism that accounts for the collaborative advantage, and a way to measure it are needed to test this assumption and to strengthen the capacity of partnerships to realize the full potential of collaboration. The mechanism that gives collaboration its unique advantage is synergy. A framework for operationalizing and assessing partnership synergy, and for identifying its likely determinants, can be used to address critical policy, evaluation, and management issues related to collaboration.

Promoting collaborations that improve health.

There is growing interest and investment in health-related collaboration in the United States. In an environment characterized by increasingly complex health problems, substantial resource constraints, and a fragmented health system, public and private organizations as well as communities are recognizing that most objectives related to health and health care cannot be achieved by any single person or organization working alone. Partnerships that bring together diverse people and organizations have the potential for developing new and creative ways of dealing with today's turbulent environment. Despite its potential advantages, collaboration also presents daunting challenges. Further, documenting the effectiveness of partnerships in improving health and well-being has been difficult. Given the significant difficulties of collaboration and the lack of evidence of its effectiveness, questioning whether the investment in health partnerships is justified seems reasonable. In this paper we address this question by illustrating the connective power of collaboration. We describe how collaboration, by connecting individual-level services, broadening community involvement in population-based health strategies, and linking individual-level services and population-based strategies, can improve the health of communities. We then discuss activities that could assist partnerships in reaching their collaborative potential and conclude by presenting the most compelling reasons for pursuing collaboration.

The intensity of physicians' work in patient visits--implications for the coding of patient evaluation and management services.

BACKGROUND: Clinicians use visit codes to bill for services involving the evaluation of patients and the management of their care. The existing guidelines for coding and documenting these services, as well as proposed revisions, have been criticized as complex, clinically irrelevant, and costly. We investigated whether easily measured characteristics of physician-patient visits accurately reflect differences in the amount of work performed. Such characteristics might provide the basis for a simple and equitable physician-payment scheme. METHODS: We collected information about the amount of physicians' work, the time spent in encounters with patients, and characteristics of patients and visits for 19,143 physician-patient visits in the practices of 339 urologists, rheumatologists, and general internists. Physicians recorded the actual time involved in evaluating the patient and managing his or her care during each visit and estimated the work involved in relation to a standardized, hypothetical visit. We used multivariate linear regression to identify factors related to differences in the total amount of work and to calculate work and work intensity (work per minute) for different types of visits. RESULTS: The duration of the face-to-face encounter with the patient or family (encounter time) was strongly predictive of the total amount of work. Total work, however, did not increase in direct proportion to encounter time. Visits with shorter encounter times were more intense than longer ones, in part because the work involved in providing fixed services, such as review of records and entry of information, did not vary in direct proportion to the length of the face-to-face encounter. Work intensity was greater for new patients than for established patients, for patients referred by other physicians than for those who were not, and for patients with new rather than previously existing problems. CONCLUSIONS: A simple coding scheme based on time spent by the physician in the face-to-face encounter and a limited set of characteristics of the visit would accurately reflect total work in actual practice. A fee structure based on these factors and the inverse relation between work per minute and the encounter time would provide equitable payment while encouraging efficiency and discouraging "upcoding" of services.

Payment for diabetes care under the Medicare fee schedule.

The system Medicare uses to determine physician payment is inequitable to physicians who provide primarily evaluation and management (EM) services. This creates financial incentives that may discourage physicians from providing Medicare patients with care that meets the American Diabetes Association's standards. Under Medicare's resource-based fee schedule, which will be phased in beginning January 1992, payment for EM services should more accurately reflect the time, effort, and overhead costs involved in providing them. This article describes how physician payment will be determined under the Medicare fee schedule and examines the probable effects of changes in payment on the physicians who care for patients with diabetes and the quality of services they provide.

Realizing the potential of practice pattern profiling.

In January 1992, the Physician Payment Review Commission held a conference to learn about the appropriateness of present uses of profiling of practice patterns, and to identify what will be required to realize the full potential of this technique in the future. The conference addressed the data needs of profiling, the development of valid and relevant profiles, the impact of profiles on medical practice, and controversies surrounding public access to profiling information and the uses to which profiling has been put. This paper, based in part on that conference, reviews the basic concepts that underlie profiling and describes the roles that profiling can play in quality improvement, assessment of provider performance, and utilization review. It uses case studies to illustrate the types of problems that have arisen in actual usage and discusses what will be required to resolve them. The final section describes the roles that profiling can play in achieving the goals of health care reform, and concludes with what is needed in data and infrastructure development to improve the quality and usefulness of profiling.

Medicare surgical global fees: the relationship between included services and payment.

This paper documents how extensively the component services Medicare carriers include in their global fees vary for four common operations. Although payment for each of the operations also varies substantially among Medicare carrier areas, differences in the extent of services included in the surgical global fee do not contribute to explaining the variations in payment. The recently enacted Medicare fee schedule based on resources can rationalize the current pattern of payments, but only if a uniform global service policy is implemented.

Secretory dysfunction in parathyroid cells from a neonate with severe primary hyperparathyroidism.

We report a patient with neonatal severe primary hyperparathyroidism whose parathyroid cells were markedly refractory to regulation by calcium in vitro. He showed life-threatening hypercalcemia (4.8-5.2 mM vs. normal of 2.1-2.7 mM). A sibling had been treated previously for an identical disorder. At age 6.5 months, four hyperplastic parathyroid glands were removed, and portions of one were immediately grafted into the forearm. Serum calcium again became elevated post-operatively and then fall to the normal range after excision of grafted parathyroid tissue. Dispersed parathyroid cells from the first operation showed no suppression of PTH secretion by 2 mM calcium; however, there was normal maximal suppressibility at 4 mM calcium with half-maximal suppression at 2.53 mM (the calcium set point). This contrasts with much lower set points previously established for suppressible cells from normal (1.02 +/- 0.10 mM, mean +/- 1 SD), from primary hyperplastic (1.10 +/- 0.14 mM), or from adenomatous (1.26 +/- 0.14 mM) parathyroid glands. The strikingly high set point may not be unique because a small number of glands previously classified as nonsuppressible (by the criterion of failing to suppress below 50% maximum at calcium concentration up to 2-3 mM) might have shown similarly high set points if tested at higher calcium concentrations. We conclude that an unusual abnormality of PTH secretory control accounts, in large part, for both the marked hypercalcemia and for its refractoriness to surgical treatment in this patient.

Work in progress: abnormal parathyroid glands. Comparison of nonselective arterial digital arteriography, selective parathyroid arteriography, and venous digital arteriography as methods of detection.

Nonselective arterial digital arteriography (NSADA), selective parathyroid arteriography (SPA), and venous digital arteriography (VDA) were compared as methods of detecting parathyroid enlargement in 14 patients with primary hyperparathyroidism undergoing preoperative localization following unsuccessful neck surgery. All 14 had SPA and NSADA, consisting of contrast injections into the ascending aorta, innominate artery, and left subclavian artery; 7 also had VDA. Surgery was performed in 9 patients, and 2 additional glands were confirmed by fine-needle aspiration and venous sampling. Parathyroid glands could not be located in 3 patients, who were not re-explored. SPA demonstrated 11/13 abnormal glands (85%). NSADA detected 7/13 (54%), and there were 2 false positives. VDA showed 5/6 glands detected by NSADA (83%); the seventh patient did not have VDA. The overall quality of VDA was inferior to NSADA. Although NSADA and VDA are less sensitive than SPA, they are safer and easier to perform and should be the initial vascular screening procedures following unsuccessful parathyroid surgery.

Endogenous substrates for cAMP-dependent phosphorylation in dispersed bovine parathyroid cells.

Agonists that increase intracellular cAMP in bovine parathyroid cells ((l)-isoproterenol (ISO), dopamine, prostaglandin E2) as well as cAMP analogs (dibutyryl cAMP and 8-bromo-cAMP) stimulated the phosphorylation of 2 endogenous proteins with apparent molecular weights of 19K and 15K. The time course and concentration-dependence of ISO-stimulated phosphorylation in these cells correlated well with known effects of ISO on intracellular cAMP and PTH release. ISO-stimulated phosphorylation of these two proteins was rapidly reversed by (l)-propranolol. Although 2 mM extracellular calcium inhibited ISO-stimulated PTH secretion, it did not significantly affect the phosphorylation of the 19K and 15K bands. These results are consistent with a physiologic role for the phosphorylation of these proteins in agonist-stimulated PTH secretion in bovine parathyroid cells.