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Given the increasingly turbulent health care environment, the strategic adaptation of academic health centers (AHCs) provides an opportunity to investigate the effects of drastic change on a population of organizations. This article identifies and categorizes the adaptive behavior using existing strategic typologies, while exploring the implications for hospital managers.

With 85% of kids in the U.S. covered by insurance, and their number expected to rise to 80 million by 2020, children's hospitals aren't just playing games. They're building new campuses, expanding existing hospitals, and taking advantage of private donations and the "kid-care" program.

Has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors? This paper uses time-series cross-sectional methods on California hospital discharge data from 1986-1994 to show the association of hospital prices with measures of market concentration changed steadily over this period, with prices now higher in less competitive areas, even for non-profit hospitals. Regression results are used to simulate the price impact of hypothetical hospital mergers.

Hospitals are competing with each other for the limited financial resources available in the health care sector. Comparison of hospitals is legally required (BPf1V section 5) to improve financial efficiency in the health care sector and make competition between hospitals keener, while also objectivizing it. If comparison of the hospitals is really to enhance profitability or efficiency, and not just to reduce the prices for hospital stays regardless of quality, it must extend to far more than the global figures in the compilation summarizing performance and calculation and the hospital statistics (no. of cases, days of care, length of stay, case lump sums and special fees). Documentation of particular features of the patient population, the potentials of the hospital and description of the treatment processes yield valuable information on capacity and performance level. With rising costs, the danger is growing that the quality and risk dimension of the actual medical treatment will not be promoted with the same enthusiasm by those offering the service. Hospital audit does not only allow a check on the hospital's own situation with regard to performance, quality, efficiency and patient satisfaction, but can also provide a basis of structural planning. The fact is that all efforts made and steps taken by the responsible persons in the hospital to improve the quality of structures, processes and results can only be successful if they are also perceived by the patients, the doctors who refer them and the visitors. If hospital audit is restricted to the bed occupancy and the invoicing data, it is only realistic to expect cuts in performance level. This would be bad for the patient and, in view of the consequent costs, also for the overall costs in the health care sector. Against the backdrop of a future performance-related system of remuneration instead of the principle of covering one's own costs that has been in place hitherto, openness about treatment results gains in importance as a competition parameter for qualified hospitals.

Leland Kaiser, American healthcare futurist, said "the hospital is a human invention and as such can be reinvented at any time." In the future, our healthcare model will be reinvented to support a proactive healing environment based on providing patient, family and staff comfort. Facilities must be functionally planned as well as attractively designed with an aesthetic appeal and therapeutic environment. Tomorrow's health facility types will be created superseding the traditional inpatient and outpatient-reoriented hospitals. These new facilities will incorporate changing technologies, demographics and serve continually changing modes of operation.

Health care providers around the country face a growing threat from more limited service "niche" providers, often sponsored by specialty physicians. Mark Grube, vice president of Abendshien+Grube Associates, writes that hospitals and health systems may want to consider joint ventures with physicians to counter this trend.

Objective: To discuss the implications of the rapid transformation of the healthcare financing and delivery system for competition, social welfare, and antitrust policy., Principal Finding: Horizontal and vertical consolidations can enhance efficiency but can also be anticompetitive in markets characterized by entry barriers., Recommendation: Active enforcement of the antitrust laws is essential to ensure that competition in healthcare markets will lead to procompetitive, rather than anticompetitive effects. However, healthcare antitrust enforcement policy must be flexible enough to allow efficient new forms of organization and practice to emerge.

How can healthcare leaders stay ahead of the curve? What can they do to see what the future holds and to secure a place for their employees and their organizations? They must begin doing today what they need to do to survive tomorrow. Furthermore, they must take wise action today or there will be no tomorrow. This article looks into the future and connects it with what we must see and do today. The article begins with a glimpse of the future and with an exploration of what people really want from health and healthcare. Next, it examines what appear to be inexorable megatrends and healthcare trends that are sweeping through society. This leads us to consider the quality and value imperatives that must be faced to secure a stake in the healthcare delivery. We will discuss a model for managing care for individual patients and small populations by focusing on where patients, populations, and caregivers meet--at the front lines of patients care. We conclude with some advice on how to build sustainable organizations by exploiting the inevitable.

Timely anticipation of patient needs and fair pricing of services will ensure survival of the on-site hospital laboratory in the coming era of managed healthcare. Management education and efficient operation are the keys to a bright future.

As in a number of other low- and middle-income countries, the health sector in Vietnam is transforming with a rapid shift from fully state run and financed health care towards more private financing and delivery of health care. This development has been particularly noticeable in the largest city in the country, Ho Chi Minh City, where a majority of physicians now are practising in private clinics and where the private health care sector is an increasingly popular option for people. While the private sector is an important part of the health care system in Vietnam, few data are available on the characteristics and quality of private health care services. This case study describes some aspects of the re-emerging private health care sector in Ho Chi Minh City, Vietnam, from the view of 27 private and non-private physicians. The paper explores physicians' reasons for going private, physicians' notions of patients' health care preferences, and physicians' views on potential influence of financial incentives on characteristics of private health care. The characteristics of private health care are discussed in relation to a context of private health care characterised by a fully patient-financed fee-for-service payment system, weak regulatory mechanisms, and a public health care system (government-run and-financed health care) that operates under resource constraints. Issues to consider when attempting to steer private health care in Vietnam in a direction where it can optimally contribute to public health, are discussed while considering the interplay between authorised private practitioners, private pharmacies, the informal private sector, and the public health care sector.

Turf issues exist largely because of emerging endovascular technologies. Vascular surgeons must develop skills with catheters, guidewires, and imaging techniques. Turf battles will result from unrestrained competition. Center/partnerships between vascular surgeons and interventional radiologists will minimize these turf battles and facilitate cross-training, which will improve the functioning of both specialists. These center/partnerships will, therefore, provide the best, most cost-effective care. Finally, all specialists who are interested in vascular disease must recognize the dangers of overproduction of competing specialists. More importantly, their leaders and specialty societies must make a serious effort to deal with this problem fairly.

The Turkish health system has been undergoing a radical reform process since the early 1990s. Reform proposals, based on purchaser/provider split, self-governing hospitals (ultimately leading to full privatization), compulsory health insurance etc., are expected to have a profound effect on hospital management. In such an environment, hospital administrators' views on the domains and issues that will come to the fore in the year 2000 gain importance. In this paper, results of a study undertaken among hospital administrators are presented. The study aimed to find the views of hospital administrators on issues likely to gain prominence in the year 2000 and the skills, knowledge, and abilities required to tackle these issues. It was concluded the autonomous status of hospitals, privatization, competition, and health trusts will become the central domains in the year 2000 in hospital administration. Innovation and following technological developments were considered most critical.

Applying Porter's model of competitive forces to health care, stakeholder concepts are integrated to analyze the future of medical groups. Using both quantitative survey and qualitative observational data, competitors, physician suppliers, integrated systems new entrants, patient and managed care buyers, and hospitals substitutes are examined.

The comparative literature on health care reform has identified a convergence upon market models as nations respond to similar economic, technological, social, and demographic pressures. In this article I first challenge the conventional view by comparing "market" reforms of the late 1980s and early 1990s in the United Kingdom, the Netherlands, and Sweden. Though these nations did indeed converge upon the instrument of the market incentive, there was considerable divergence in the content and aims of their reform strategies. These nations designed their respective markets to make different tradeoffs among competing values. While all three exploited the principle of provider competition, they appointed different actors to judge the contest: the cost-conscious public authority in the United Kingdom, the quality-conscious patient in Sweden, and the optimizing consumer in the Netherlands. I argue that these countries were thus using common market tools to promote different health policy goals. Distinguishing these reforms further is the fact that--particularly in the Netherlands--there was a gap between market plans and the reality of implemented change. I then ask why nations responded so differently to such similar objective pressures. My contention is that this divergence reflects, in part, the different ideological orientations of the ruling party or coalition in each nation. Yet divergence is also the result of differences in both the design of political institutions and the structure of the pre-reform health system in each country.

As market forces have continued to push healthcare systems toward greater efficiency and lower costs, providers have begun asking for help in balancing ethical concerns. Several organizations are responding by establishing programs to provide guidelines for ethical decisionmaking. Health System Leader talked with these pioneers about their progress, the thinking that went into establishing these programs, and their recommendations for others beginning to tackle this need.

Examines the process of change in hospitals that has emerged following the introduction of the health quasi-market in 1991. Blends empirical evidence with Greenwood and Hinings' archetype and tracks of change concepts to analyse the process which is labelled quasi-market transformation (QMT). Argues that, before 1991, hospitals tended to operate within structures and systems underpinned by an interpretive scheme. Represents these similarities of configuration as the directly-managed (DM) hospital archetype. When change initiatives challenged this configuration, the outcomes were negotiated and resulted in "adjustmental" change. In contrast, shows the introduction of the quasi-market to have involved the first transformation of the DM archetype's interpretive scheme, systems and structures. Analyses four years of transition to reveal that QMT has been interpreted differently within hospitals. However, presents data to suggest that many hospitals now display significant similarities in terms of configuration. Represents these similarities within the emerging Trust hospital archetype.

Available information does not indicate either that quality has deteriorated as price competition has increased or that quality has improved. To reward plans for providing what consumers want, public and private policies have crucial roles in the following areas: mandating minimal requirements for plans; funding research to improve knowledge and methods related to quality-of-care assessment; publication of quality-of-care information; selective contracting and regionalizing of services; and payment for physician services. Learning what degree of trade-off between cost versus quality and other benefits is acceptable to consumers will be an iterative process that informs future policies to safeguard the quality of care.

The transformation of the health-care industry holds great economic potential for laboratory diagnostic testing providers who understand the five market forces driving change and who are shaping their own roles in the emerging market. Because of these trends, provider-based laboratories (PBLs) are competing with independent laboratories (ILs) for the latter's traditional client base--outpatients and nonpatients. PBLs will continue to service acute care patients while becoming more IL-like in logistics, sales, customer service, and marketing. Forced to compete on price, ILs have engaged in mega-mergers and will try to break into acute care via joint ventures. The ILs will need to choose their markets carefully, solidly integrate with parent organizations, and find ways to be profit centers. Consumers' demands also are forcing change. Consumers want accurate, legible bills and simplified eligibility determination and registration. They want an emphasis on prevention and wellness, which means that diagnostic testing must address early identification and monitoring of high-risk groups. To realize cost-efficiencies under whole-life capitation, laboratory networks must be part of a completely integrated health-care system. The laboratory of the future will be multicentered, without walls, and with quick access to information through technology.

With Columbia/HCA Healthcare Corp. sitting on the sidelines, a newly aggressive not-for-profit hospital sector is stepping up its merger and acquisition activity. Since Richard Scott resigned as Columbia's chief on July 25, the company hasn't announced a single acquisition. Meanwhile, during that span, 40 not-for-profit systems have announced deals involving 50 hospitals.

While purchasing giants Premier and VHA jockey for market share, signs show they're looking for competition in all the wrong places. Some of their own members, having merged into powerful regional systems, say they've built up the buying muscle capable of getting better deals from suppliers.

The nature of the American health care marketplace is in a state of flux and refinement. The recent attempt by the federal government to change the health care system has brought these issues to the forefront of public and private discourse. This research endeavor examines if these discussions influenced health care decisions by some of the nation's most influential decision makers.

This article identifies the strategic types in the hospital industry based on the hospital's use of Porter's generic strategies in their pure and hybrid forms. The article also examines differences in performance of hospitals across strategic types. Results indicate that hospitals that follow a focussed cost leadership strategy, in general, have superior performance on a variety of performance measures, while hospitals that use a combination of cost leadership and differentiation perform the poorest. Implications of findings for hospital administrators are also discussed.

Localism predominates in purchaser-provider relationships, with markets strictly limited in practice. Block contracting predominates, largely to enable purchasers to bring pressure to bear on providers' costs and outputs. The administrative costs of operating the purchaser-provider split have led to a clear growth in the overall administrative costs within the NHS. Locality commissioning may conflict with the need to reorganise clinical services.

Context: Growth in health care market competition and the concomitant increasing dependence of academic health centers on clinical revenues may require medical school faculty to increase patient care activity, perhaps at the expense of research and teaching. However, the relationship between health care market competitiveness and the activities and attitudes of medical school faculty has not been established., Objective: To examine the relationship between market competitiveness and the activities and attitudes of medical school faculty members., Design: Mailed survey of 3394 life-science faculty in the 50 universities that received the most funding from the National Institutes of Health in 1993., Setting: Medical schools in research-intensive universities., Participants: A total of 2167 faculty responded to the survey (response rate, 64%). We analyzed the responses of 1671 medical school research faculty located in markets of differing health care competitiveness, ranging from least competitive (stage 1) to most competitive (stage 4) markets., Main Outcome Measures: The number of publications in refereed journals in the last 3 years, the average number of hours per week of teaching contact, whether faculty in clinical departments had patient care responsibilities, and measures of departmental community, cooperation, and conflict., Results: Clinical researchers in stage 1 and 2 markets published more scientific articles than those in stage 3 markets (14.5 vs 12.6, P=.04) or in stage 4 markets (14.5 vs 12.0, P=.03). Among 96 young faculty (professional age-<10 years) in clinical departments, 11 (44%) of those in stage 1 and 2 markets had patient care duties compared with 32 (56.1%) of young faculty members in stage 3 markets (P=.04) and 12 (85.7%) of those in stage 4 markets (P=.01). The percentage of senior faculty in clinical departments (n=691) with patient care responsibilities did not differ significantly by market stage. Compared with faculty in less competitive markets, faculty in stage 4 markets perceived lower levels of departmental cooperation and higher levels of conflict., Conclusions: Increased competitiveness of health care markets seems to hinder the capacity of academic health centers to conduct clinical research and to foster the careers of young clinical faculty.