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The patient-centered medical home model of primary care has received considerable attention for its potential to improve outcomes and reduce health care costs. Yet little information exists about the model's ability to achieve these goals for Medicaid patients. We sought to evaluate the effect of patient-centered medical home certification of Louisiana primary care clinics on the quality and cost of care over time for a Medicaid population. We used a quasi-experimental pre-post design with a matched control group to assess the effect of medical home certification on outcomes. We found no impact on acute care use and modest support for reduced costs and primary care use among medical homes serving higher proportions of chronically ill patients. These findings provide preliminary results related to the ability of the patient-centered medical home model to improve outcomes for Medicaid beneficiaries. The findings support a case-mix-adjusted payment policy for medical homes going forward.

Medical school deanship in the US has evolved during the past 200 years as the complexity of the US health care system has evolved. With the introduction of Medicare and Medicaid and the growth of the National Institutes of Health, the 19th-century and first half of the 20th-century role of the medical school dean as guild master transformed into that of resource allocator as faculty practice plans grew in scope and grew as an important source of medical school and university revenue. By 2000, the role of the medical school dean had transformed into that of CEO, with the dean having control over school mission and strategy, faculty practice plans, education, research dollars, and philanthropy. An alternative path to the Dean/CEO model has developed-the System Dean, who functions as a team player within a broader health system that determines the mission for the medical school and the related clinical enterprise. In this paper, the authors discuss the evolution of the medical school dean with respect to scope of authority and role within the health care system.

Objective Determine the degree of congruence between several measures of adverse events. Design Cross-sectional study to assess frequency and type of adverse events identified using a variety of methods. Setting Mayo Clinic Rochester hospitals. Participants All inpatients discharged in 2005 ( n = 60 599). Interventions Adverse events were identified through multiple methods: (i) Agency for Healthcare Research and Quality-defined patient safety indicators (PSIs) using ICD-9 diagnosis codes from administrative discharge abstracts, (ii) provider-reported events, and (iii) Institute for Healthcare Improvement Global Trigger Tool with physician confirmation. PSIs were adjusted to exclude patient conditions present at admission. Main outcome measure Agreement of identification between methods. Results About 4% (2401) of hospital discharges had an adverse event identified by at least one method. Around 38% (922) of identified events were provider-reported events. Nearly 43% of provider-reported adverse events were skin integrity events, 23% medication events, 21% falls, 1.8% equipment events and 37% miscellaneous events. Patients with adverse events identified by one method were not usually identified using another method. Only 97 (6.2%) of hospitalizations with a PSI also had a provider-reported event and only 10.5% of provider-reported events had a PSI. Conclusions Different detection methods identified different adverse events. Findings are consistent with studies that recommend combining approaches to measure patient safety for internal quality improvement. Potential reported adverse event inconsistencies, low association with documented harm and reporting differences across organizations, however, raise concerns about using these patient safety measures for public reporting and organizational performance comparison.

Academic Health Sciences Centres (AHSCs) have long been viewed much as the historic battleship - possessing great force, power and bulk, but increasingly vulnerable to forays of lighter and more agile competitors. This commentary reviews the efforts of leaders of AHSCs in the United States to reposition their institutions at the centre of integrated delivery systems, partly as a result of greatly increased reliance on clinical revenue to support the historic teaching mission. While Lozon and Fox point to increased involvement of AHSCs in broad regional systems of care financed through a coordinated strategy, integrated systems in the United States may be fragmenting as marketplace-driven financial schemes actually discourage integrated care. From the perspective of organizational theory, the future seems to imply a diversification of organizational forms for the AHSCs in the United States, with a corresponding strategy of lessening reliance on clinical revenues through enhancement of research funding.

The objective was to investigate the effect of admission health status on hospital adverse events and added costs. Secondary data were from merged administrative and clinical sources for Mayo Clinic Rochester, Minnesota hospital discharges in 2005 (N = 60,599). This was a retrospective cross-sectional study of the effect of demographics, diagnosis group, comorbidity, and admission illness severity on adverse events, incremental costs, and length of stay (LOS) using the Agency for Healthcare Research and Quality Patient Safety Indicators and provider-reported events with harm. Estimates are derived from generalized linear models. Admission severity increased the likelihood of all types of adverse events (7.2% per unit acute physiology score for any event); 7 specific comorbidities were associated with increased events and 2 with decreased events. High admission severity increased incremental costs and LOS. Selected comorbidities increased incremental LOS but had no significant effect on incremental costs. Adverse event reporting should incorporate comorbidity and admission severity. Reimbursement incentives to improve patient safety should consider adjustment for admission health status.

Board accountability for quality and patient safety is widely accepted but the science for how to measure it is immature, and differences between measuring performance, identifying hazards, and monitoring progress are often misunderstood. Hospital leaders often provide scorecards to assist boards with their oversight role yet, in the absence of national standards, little evidence exists regarding which measures are valid and useful to boards to assess quality improvement. The authors describe results of a cross-sectional board study, identifying the measures used to monitor quality. The measures varied widely and many were of uncertain validity, generally identifying hazards rather than measuring rates. This article identifies some important policy implications regarding boards' oversight of quality and acknowledges existing limits to how we can measure quality and safety progress on the national or hospital level. If boards and their hospitals are to monitor progress in improving quality, they need more valid outcome measures.

Innovation in health administration education stimulates administrators and faculty to identify unmet educational needs within the health sector. In 1997, the inaugural class of the Master of Medical Management (MMM) at Tulane University graduated, signaling an individual achievement for all graduates and an accomplishment in innovation and collaboration in health administration education. Tulane University, in partnership with The American College of Physician Executives (ACPE), designed a unique health administration degree to meet the distinctive needs of physicians serving in executive and managerial roles or seeking to serve in such roles in the future. Since 1997, there are nearly 700 MMM graduates who hail from Carnegie Mellon, Tulane University, and the University of Southern California. ACPE administered a survey to 500 MMM alumni in the fall of 2005. The response rate was 47% (235 of 500). The findings from this survey describe the reasons why physicians decided to enroll in the MMM, their experiences as MMM students, and their perceptions of how the MMM had an impact on their careers. Moreover, in this article, recommendations are offered related to the design and delivery of innovative educational programs for emerging disciplines within the health sector.

OBJECTIVE Attempts to provide information to consumers about patient safety on specific hospitals have conflicted with organization self-perceptions and led to confusion among the general public. This article presents organizational theory framework and criteria to classify organizations as single versus multiple reporting entities. PARTICIPANTS AND METHODS Operational definitions are presented. A case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System is used to demonstrate their utility. The study includes analysis of an employee survey on employee satisfaction and patient safety climate in 2004 among nurses and physicians at the 2 Mayo Clinic hospitals in Rochester, Minn. RESULTS AND CONCLUSIONS The criteria for a single organization are more strongly supported for the Mayo Clinic hospitals located in the same city than for hospitals in the same system but separated geographically. Although there is debate about the measurement of organizational culture, employee surveys provide some evidence of a commonality across hospitals in the same city. The case study comparing institutions both within and across state boundaries in the Mayo Clinic Health System demonstrate the utility of the proposed criteria.

Great governance is an effective and efficient process to develop policies that set the strategic directions for the healthcare enterprise, and then help assure that resources are assembled and allocated for the successful implementation of the plans, in compliance with the ethical and regulatory framework of the industry. Given the growing legal and political emphasis on governance, it is crucial that undergraduate and graduate health administration programs adequately prepare students in the fundamental aspects of governance. This paper will present the ten building blocks of effective governance as well as other theories and frameworks applicable to teaching governance in a healthcare management program.

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.

This study compares the perspectives of eighteen managed care executives and twenty-four faculty practice executives on critical policy issues related to the managed care marketplace. Market sites studied in 1994 included four major metropolitan areas: Minneapolis–St. Paul, Los Angeles, Philadelphia, and Atlanta. These markets were selected as being representative of communities with descending degrees of managed care involvement, but with significant market activity. Study participants from both managed care systems and faculty practices examined five policy issues: (1) the importance of including academic medical centers in current and future health care plans for marketing purposes; (2) the provision of clinical services that are unique to the academic medical center, that is, unavailable elsewhere in the community; (3) the degree of financial supplement that employers might pay for including an academic medical center; (4) future restructuring of organizations to sustain the educational mission of academic faculty within a viable delivery system; (5) satisfaction of managed care providers with graduates of academic medical centers, as measured by the clinical skills of graduate physicians. The study findings showed little support among managed care plans for paying supplements to include faculty practices in a health care network. Most study participants from managed care systems and academic faculty practices identified limited competencies that are unique to academic centers. Moreover, managed care organizations were only willing to undertake limited restructuring at best to include faculty practices within their networks. General concern about the preparation of resident physicians (especially those in primary care disciplines) for practice within contemporary managed care organizations existed among managed care informants. The results of the study indicate that as traditional funding sources for medical education are reduced, schools require greater integration with managed care plans to enable academic medical centers and their faculties to continue promoting clinical enterprise.

The conflict between the elderly and organized medicine over "mandatory assignment" and "balance billing" is a significant public policy issue. Considerable ideological importance has been attached to this conflict by both sides, despite the relatively modest proportion of total revenue for physician services received through balance billing in payment for care of Medicare beneficiaries. The positions of these two coalitions are examined as well as the efforts of the Physician Payment Review Commission (PPRC) to craft a public policy response. Three alternative resolutions--those adopted by Congress in 1989 on the recommendation of the PPRC, the Canadian solution, and actions taken on a state level--are then contrasted. The concentrated impact on the elderly of balance billing practices is considered as a problem, especially for elderly of limited income and resources. Justification of the practice is typically provided by the profession on the ideological grounds of preservation of professional autonomy rather than economic gain, which also reflects the current relatively limited use of balance billing; a significant majority of all claims submitted in the United States are now assigned to physicians. A continuation of the gradualist strategy of the PPRC is endorsed as the most appropriate short-range solution to these problems, which diminish in significance with a more comprehensive national health financing scheme.