Associate degree in health care administration

IN THIS ARTICLE...

As we move into the 21st Century, the U.S. health care system faces tremendous challenges such as care for an aging and increasingly diverse population, escalating costs and limited resources. Government, consumers, hospitals and the insurance industry are positioning themselves for the future. Physicians need to do the same. Physicians must come to the table and assert leadership by working collaboratively with major stakeholders. Examine some steps that need to be taken to help shape the future of medicine.

IN THE PAST 100 YEARS, the health sector in this country experienced considerable growing pains as it evolved from a craft-based profession to a multi-billion dollar industry.

This growth was fueled by substantial government subsidy and encouraged by strong public support. But more recently, concerns about escalating costs led to increasing oversight and regulation by third-party payers.

The United States has one of the most costly health care systems in the world, yet it fails to cover nearly one in six citizens. Perhaps even more troubling is that health outcomes, such as immunization and infant mortality rates, are worse than in most industrialized nations.

How to provide affordable care for our population remains one of the biggest questions. Some argue that the U.S. should adopt a national health system, similar to the United Kingdom's or Canada's.

Critics say such systems offer substandard care characterized by long delays and under funding. Many Americans also oppose the heavy tax burden associated with such plans. They don't have confidence that the government can deliver an efficient single-payer plan. The U.S. health care system will almost certainly remain a market-driven enterprise for the near future.

Even if THE U.S. economy remains strong, the health care industry will face tremendous financial pressures in the coming decade. Third party payers will continue to restrict payments in an effort to control expenses. At the same time, more intensive and complex services will be needed as the population ages and becomes more diverse.

How will health care handle this increased demand?

Major stakeholders must be willing to look beyond individual interests and work together to exert a positive influence over the future. This requires a consensus to resolve the tensions between the needs of the individual patient and those of the population.

* We need to determine what part physicians will play in health care reform.

* We need to realign clinician and provider missions.

* We need to partner with consumers.

For the purposes of this discussion, clinicians are defined as health professionals involved in direct patient care, providers are health care entities such as hospitals, and consumers comprise patients and those representing their interests, such as employers. Physicians are discussed separately from other clinicians because they usually function independently from health providers such as hospitals.

The role of physicians in health care reform

Physicians play a key role in shaping the health care system.

While we continue to direct the efforts of clinical team members in patient care, our culture and training failed to prepare us to lead the entire health care system.

Physicians are increasingly seen as workers responsible for producing work units.

We face unprecedented scrutiny of service utilization and productivity.

In addition, most specialties experienced considerable cuts in income levels.

And worst of all, consumer confidence is shaken by widely publicized rates of medical errors and perceived financial conflicts of interest influencing medical decisions. Despite our best efforts, care often seems fragmented, superficial and inefficient.

Managed care wasn't the magic bullet. Physicians reacted in a variety of ways to health care reform through managed competition.

* Most consolidated practices in order to share rising overhead costs. But shrinking payments led to financial conflicts and bitter competition.

* Some physicians chose to embrace corporate medicine, assuming executive roles in the system.

* Others took salaried positions, hoping to buffer themselves from the administrative burdens. But working conditions for salaried physicians are sometimes so undesirable that they make a push to unionize.

* And some physicians left the practice of medicine altogether.

Physicians must come together as a group if we want to participate in shaping the future of health care. Our patients need our proactive advocacy. To assume leadership, we must be willing to meet new mandates for cost and accountability.

And we must look beyond care of the individual patient, share our knowledge and collaborate with other stakeholders in caring for the population as a whole.

Realigning clinician and provider missions

In the past, clinicians and providers shared a mission of excellence in patient care.

As long as payments were made on a fee-for-service basis, the two groups worked in complementary and mutually beneficial ways.

More recently, financial pressures caused conflicts between clinicians and providers.

In response to market forces, complex partnership and ownership arrangements arose between providers, clinicians and even payers. Disagreements center on cost and efficiency, quality and safety. Third-party payment schemes reinforce this environment of divergent incentives.

Clinician and provider missions must be realigned to put patient care first. This would allow both sides to focus on value, while factoring in both cost and quality. Consider this scenario:

Mrs. Jones is hospitalized for an infected diabetic foot ulcer. Her insurance company pays the same amount of money to the hospital whether she is there for two days or five days. The hospital prefers to discharge her quickly and provide less expensive home health care with appropriate medication and nursing services.

Mrs. Jones' physician, Dr. Smith, is paid a professional fee for each day that he sees her in the hospital. This fee is higher than what he receives from either an office visit or oversight of home health care.

Mrs. Jones' diabetes was so out of control when she was first admitted that an endocrinologist was asked to consult. This specialist feels that Mrs. Jones should stay in the hospital for at least seven days.

Because she lives alone, Mrs. Jones wants to stay in the hospital until the ulcer heals completely. That would take at least a month. Her daughter, who takes care of her mother, would like that, too.

It's easy to see how financial incentives could play a role in Dr. Smith's decisions. On the other hand, it's unfair to accuse Dr. Smith of responding only to the economics of the situation. He must also factor in the patient's own wishes, those of her daughter and the specialist's opinion.

Under managed competition, clinicians must make similar decisions every day, often involving far more complex circumstances. With so many variables to consider; it's no wonder there is little consistency between the medical practices.

Scientific approach

Clinicians and providers must agree on the best ways to deliver value.

An objective, scientifically derived set of standards could allow us to balance cost with quality to achieve value. While such standards exist in evidence-based clinical guidelines, they are difficult to implement.

Advances in biomedical science continue to develop at astonishing rates. The science of managing health lags behind. We continue to rely on inconsistencies that characterize the so-called "art" of medical management rather than objective "science."

In our scenario, the hospital and Dr. Smith could make use of clinical guidelines to determine a reasonable benchmark for Mrs. Jones's length of stay, given her age and other medical conditions.

A care map determines the care she receives while in the hospital and through home health. This care map is accessible to her and everyone involved in her care, so that her progress can be charted and adjusted accordingly.

Mrs. Jones and her daughter might feel the decision making process is more transparent and less arbitrary. They may then be more comfortable transitioning to home care.

The most compelling reason for advancing the science of health management is that it eliminates financial conflicts of interest. Using objective standards, clinicians can be held accountable for costs. Providers are accountable for delivering quality care.

Rigorously prepared and systematically implemented sets of clinical guidelines make it easier for people to do the right thing most the time. Unfortunately, such health management tools are expensive to develop, implement and maintain.

Modern information technology can simplify these tasks, but few can afford to invest a great deal of capital in computer systems during harsh economic times.

Failure to advance the science of health management isn't anything new.