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Doctoral training continues to grow in scale and scope in Australia, but has been subjected to far less design and improvement compared with other facets of higher education. Governments and universities engage in ongoing change which helps respond to opportunities and challenges but also leads to a proliferation of options and approaches. The current research study was seeded and shaped by the ambitious view that despite such refinement the doctorate remains in need of much bolder and deeper design, and particularly design with an education focus. This paper reports outcomes from a four-year national project which sought to articulate a doctoral design architecture. The paper discusses framing contexts and concepts, design and characteristics of the doctoral architecture, then implications for sectoral, institutional and individual practice. It concludes that this kind of architecture can provide a useful guide for growth. [ABSTRACT FROM AUTHOR]

Purpose: To compare the effects of morphine and methadone on length of hospital stay (LOS) or treatment (LOT) and adverse effects in infants with neonatal abstinence syndrome (NAS). Design: Systematic review. Sample: PubMed, Google Scholar, Cochrane library, CINAHL, IPA, American Academy of Pediatrics, and clinicaltrials.gov were systematically searched to identify randomized controlled trials (RCTs) and observational studies. comparing morphine and methadone for NAS. Outcomes: LOS, LOT, adverse effects. Results: One RCT, two cohort studies, and two chart reviews met inclusion criteria. Each had a low risk of bias. LOS ranged from 12.08 to 36 days with morphine and 21 to 44.23 days with methadone. LOT ranged from 7.46 to 22.9 days (morphine) and 13.9 to 38.08 days (methadone). Adverse effects were not reported. Clinical evidence comparing morphine to methadone for NAS treatment is limited and conflicting. A recommendation for one over the other cannot be made based on these outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The American Medical Association has reported that 2016 was the first year in which fewer than half (47.1%) of all practicing physicians owned their own practice. Across the United States, there has been consolidation of physicians and hospital and health systems, resulting in questions about the effect of this on healthcare expenditures. The aim of this study was to compare the expenditures per patient between hospital- and health system-affiliated physicians and independent physicians.Methods: The author used Virginia's new statewide all-payer claims database to analyze expenditures and quality for 3 years for hospital- and health system-affiliated physicians versus independent physicians. The database had all claims statewide for Virginians with individual or group commercial insurance coverage: 1.95 million patients in 2013, 2 million in 2014, and 2.1 million in 2015. The average annual expenditure for each physician was adjusted for average patient condition burden (risk) and differences in geographic input costs using regression analysis. Measures of primary care quality were obtained from the claims data using evidence-based measures from national health quality organizations.Results: Hospital- and health system-affiliated physicians had annual expenditures per patient ranging from 10.3% to 14.6% higher than independent physicians. Most of the measures of primary care quality were not significantly different.Conclusions: Virginia patients, employers, and managed care companies incurred higher per-patient expenditures with hospital and health system physicians than with independent physicians. [ABSTRACT FROM AUTHOR]

Introduction: Transitions are traditionally viewed as challenging for clinicians. Throughout medical career pathways, clinicians need to successfully navigate successive transitions as they become progressively more independent practitioners. In these guidelines, we aim to synthesize the evidence from the literature to provide guidance for supporting clinicians in their development of independence, and highlight areas for further research.Methods: Drawing upon D3 method guidance, four key themes universal to medical career transitions and progressive independence were identified by all authors through discussion and consensus from our own experience and expertise: workplace learning, independence and responsibility, mentoring and coaching, and patient perspectives. A scoping review of the literature was conducted using Medline database searches in addition to the authors’ personal archives and reference snowballing searches.Results: 387 articles were identified and screened. 210 were excluded as not relevant to medical transitions (50 at title screen; 160 at abstract screen). 177 full-text articles were assessed for eligibility; a further 107 were rejected (97 did not include career transitions in their study design; 10 were review articles; the primary references of these were screened for inclusion). 70 articles were included of which 60 provided extractable data for the final qualitative synthesis. Across the four key themes, seven do’s, two don’ts and seven don’t knows were identified, and the strength of evidence was graded for each of these recommendations.Conclusion: The two strongest messages arising from current literature are first, transitions should not be viewed as one moment in time: career trajectories are a continuum with valuable opportunities for personal and professional development throughout. Second, learning needs to be embedded in practice and learners provided with authentic and meaningful learning opportunities. In this paper, we propose evidence-based guidelines aimed at facilitating such transitions through the fostering of progressive independence. [ABSTRACT FROM AUTHOR]

The objective of the present study was to identify altered pathways in breast cancer based on the individualized pathway aberrance score (iPAS) method combined with the normal reference (nRef). There were 4 steps to identify altered pathways using the iPAS method: Data preprocessing conducted by the robust multi-array average (RMA) algorithm; gene-level statistics based on average Z; pathway-level statistics according to iPAS; and a significance test dependent on 1 sample Wilcoxon test. The altered pathways were validated by calculating the changed percentage of each pathway in tumor samples and comparing them with pathways from differentially expressed genes (DEGs). A total of 688 altered pathways with P<0.01 were identified, including kinesin (KIF)- and polo-like kinase (PLK)-mediated events. When the percentage of change reached 50%, 310 pathways were involved in the total 688 altered pathways, which may validate the present results. In addition, there were 324 DEGs and 155 common genes between DEGs and pathway genes. DEGs and common genes were enriched in the same 9 significant terms, which also were members of altered pathways. The iPAS method was suitable for identifying altered pathways in breast cancer. Altered pathways (such as KIF and PLK mediated events) were important for understanding breast cancer mechanisms and for the future application of customized therapeutic decisions. [ABSTRACT FROM AUTHOR]

Background: Bangladesh is facing serious shortage of trained health professionals. In the pluralistic healthcare system of Bangladesh, formal health care providers constitute only 5 % of the total workforce; the rest are informal health care providers. Information Communication Technologies (ICTs) are increasingly seen as a powerful tool for linking the community with formal healthcare providers. Our study assesses an intervention that linked village doctors (a cadre of informal health care providers practising modern medicine) to formal doctors through call centres from the perspective of the village doctors who participated in the intervention. Methods: The study was conducted in Chakaria, a remote rural area in south-eastern Bangladesh during April-May 2013. Twelve village doctors were selected purposively from a pool of 55 village doctors who participated in the mobile health (mHealth) intervention. In depth interviews were conducted to collect data. The data were manually analysed using themes that emerged. Result: The village doctors talked about both business benefits (access to formal doctors, getting support for decision making, and being entitled to call trained doctors) and personal benefits (both financial and non-financial). Some of the major barriers mentioned were technical problems related to accessing the call centre, charging consultation fees, and unfamiliarity with the call centre physicians. Conclusion: Village doctors saw many benefits to having a business relationship with the trained doctors that the mHealth intervention provided. mHealth through call centres has the potential to ensure consultation services to populations through existing informal healthcare providers in settings with a shortage of qualified healthcare providers. [ABSTRACT FROM AUTHOR]

Background. Anaesthetists may fail to recognize and manage certain rare intraoperative events. Simulation has been shown to be an effective educational adjunct to typical operating room-based education to train for these events. It is yet unclear, however, why simulation has any benefit. We hypothesize that learners who are allowed to manage a scenario independently and allowed to fail, thus causing simulated morbidity, will consequently perform better when re-exposed to a similar scenario. Methods. Using a randomized, controlled, observer-blinded design, 24 first-year residents were exposed to an oxygen pipeline contamination scenario, either where patient harm occurred (independent group, n=12) or where a simulated attending anaesthetist intervened to prevent harm (supervised group, n=12). Residents were brought back 6 months later and exposed to a different scenario (pipeline contamination) with the same end point. Participants' proper treatment, time to diagnosis, and non-technical skills (measured using the Anaesthetists' Non-Technical Skills Checklist, ANTS) were measured. Results. No participants provided proper treatment in the initial exposure. In the repeat encounter 6 months later, 67% in the independent group vs 17% in the supervised group resumed adequate oxygen delivery (P=0.013). The independent group also had better ANTS scores [median (interquartile range): 42.3 (31.5-53.1) vs 31.3 (21.6-41), P=0.015]. There was no difference in time to treatment if proper management was provided [602 (490-820) vs 610 (420-800) s, P=0.79]. Conclusions. Allowing residents to practise independently in the simulation laboratory, and subsequently, allowing them to fail, can be an important part of simulation-based learning. This is not feasible in real clinical practice but appears to have improved resident performance in this study. The purposeful use of independent practice and its potentially negative outcomes thus sets simulation-based learning apart from traditional operating room learning. [ABSTRACT FROM AUTHOR]

Providers that care for disproportionate numbers of disadvantaged patients tend to perform less well than other providers on quality measures commonly used in pay-for-performance programs. This can lead to the undesired effect of redistributing resources away from providers that most need them to improve care. We present a new pay for- performance scheme that retains the motivational aspects of standard incentive designs while avoiding undesired effects. We tested an alternative incentive payment approach that started with a standard incentive payment allocation but then “post-adjusted” provider payments using predefined patient or provider characteristics. We evaluated whether such an approach would mitigate the negative effects of redistributions of payments across provider organizations in California with disparate patient populations. The post-adjustment approach nearly doubled payments to disadvantaged provider organizations and greatly reduced payment differentials across provider organizations according to patients' income, race/ethnicity, and region. The post-adjustment of payments could be a useful supplement to paying for improvement, aligning the goals of disparity reduction and quality improvement. [ABSTRACT FROM AUTHOR]

A health insurer in Michigan, through its Physician Group Incentive Program, engaged providers across the state in a collection of financially incentivized initiatives to transform primary care and improve quality. We investigated physicians' and other program stakeholders' perceptions of the program through semistructured interviews with more than 80 individuals. We found that activities across five areas contributed to successful provider engagement: (1) developing a vision of improving primary care, (2) deliberately fostering practice-practice partnerships, (3) using existing infrastructure, (4) leveraging resources and market share, and (5) managing program trade-offs. Our research highlights effective strategies for engaging primary care physicians in program design and implementation processes and creating learning communities to support quality improvement and practice change. [ABSTRACT FROM AUTHOR]

The article focuses on the collaboration of small primary care practices to control their operation and remain competitive in the U.S. The departure of physicians from independent practice is attributed to the changing financial health care model. The areas involved in clinical integration include physician leadership, patient care management and monitoring system. Information on management services organizations (MSOs) and the independent physician/practice association is provided. INSETS: PRACTICE INTEGRATION TIPS;KEY QUESTIONS TO ASK BEFORE INTEGRATING.

Background: Physician's dissatisfaction is reported to be increasing, especially in primary care. The transition from fee-for-service to outcome-based reimbursements may make matters worse. Purpose/Objective: To investigate influences of provider attitudes and practice settings on job satisfaction/dissatisfaction during transition to quality-based payment models, we assessed self-reported satisfaction/dissatisfaction with practice in a Rochester (New York)-area physician practice association in the process of implementing pay-for-performance. Subjects/Methods: We linked cross-sectional data for 215 survey respondents on satisfaction ratings and behavioral attitudes with medical record data on their clinical behavior and practices, and census data on their catchment population. Factors associated with the odds of being satisfied or dissatisfied were determined via predictive multivariable logistic regression modeling. Results/Conclusions: Dissatisfied physicians were more likely to have larger-than-average patient panels, lower autonomy and/or control, and beliefs that quality incentives were hindering patient care. Satisfied physicians were more likely to have a higher sense of autonomy and control, smaller patient volumes, and a less complex patient mix. Efforts to maintain or improve satisfaction among physicians should focus on encouraging professional autonomy during transitions from volume-based to quality/outcomes-based payment systems. An optimum balance between accountability and autonomy/control might maximize both health care quality and job satisfaction. [ABSTRACT FROM AUTHOR]

Pay-for-performance, public reporting, and accountable care organization programs place pressures on physicians to use health information technology and organized care management processes to improve the care they provide. But physician practices that are not large may lack the resources and size to implement such processes. We used data from a unique national survey of 1,164 practices with fewer than twenty physicians to provide the first information available on the extent to which independent practice associations (IPAs) and physician-hospital organizations (PHOs) might make it possible for these smaller practices to share resources to improve care. Nearly a quarter of the practices participated in an IPA or a PHO that accounted for a significant proportion of their patients. On average, practices participating in these organizations provided nearly three times as many care management processes for patients with chronic conditions as nonparticipating practices did (10.4 versus 3.8). Half of these processes were provided only by IPAs or PHOs. These organizations may provide a way for small and medium-size practices to systematically improve care and participate in accountable care organizations. [ABSTRACT FROM AUTHOR]

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and 90 to 2,700 participating physicians. The sites had varying degrees of experience with performance-based payments; however, all formed collaborative new relationships with payers and created shared savings agreements linked to performance on quality measures. Each organization devoted major efforts to physician engagement. Policy makers now need to consider how to support and provide incentives for the successful formation of multipayer ACOs, and how to align private- sector and CMS performance measures. Linking providers to learning networks where payers and providers can address common technical issues could help. These sites' transitions to the new payment model constitutes an ongoing journey that will require continual adaptation in the structure of contracts and organizational attributes. [ABSTRACT FROM AUTHOR]

Background: Previous studies have documented the effect of collaboration among physicians on the effectiveness in delivering health services and in producing better patient outcomes. However, there is no systematic empirical study suggesting the underlying relationship between the collaboration network of physicians and its effect on hospitalization cost and readmission rate. In this study, we explore the effect of different attributes (i.e. degree centrality, betweenness centrality, network density and network distance) of physician collaboration network (PCN) on hospitalization cost and readmission rate. Method: We analyse health insurance claim data set of total hip replacement (THR) patients to construct PCN and to test the effect of its network attributes on hospitalization cost and readmission rate. We consider patient age as moderating factor, which could affect the relation of the PCN attributes with hospitalization cost and readmission rate. Results: We find that degree centrality (i.e. level of involvement) and network density (i.e. level of connectedness) of PCN are negatively correlated with hospitalization cost and readmission rate. In contrast, betweenness centrality (i.e. capacity to control the flow of information) is found positively correlated with hospitalization cost and readmission rate. Distance (i.e. embeddedness of actors in a network) is found positively correlated with hospitalization cost but negatively correlated with readmission rate. We do not notice any significant impact of patient age on the relation of PCN attributes with hospitalization cost and readmission rate. Conclusion: The results show that the structure of PCNs is related to indicators of hospital costs and quality (readmission). In their respective hospitals, health-care managers or administrators may follow our research findings to reduce cost and improve quality. [ABSTRACT FROM PUBLISHER]

Patient-centered, accountable care has garnered increased attention with the passage of the Affordable Care Act and new Medicare regulations. This case study examines a care model jointly developed by a provider and a payer that approximates an accountable care organization for a Medicare Advantage population. The collaboration between Aetna and NovaHealth, an independent physician association based in Portland, Maine, focused on shared data, financial incentives, and care management to improve health outcomes for approximately 750 Medicare Advantage members. The patient population in the pilot program had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide unmanaged Medicare populations. NovaHealth's total per member per month costs across all cost categories for its Aetna Medicare Advantage members were 16.5 percent to 33 percent lower than costs for members not in this provider organization. Clinical quality metrics for diabetes, ischémie vascular disease, annual office visits, and postdischarge follow- up for patients in the program were consistently high. The experience of developing and implementing this collaborative care model suggests that several components are key, including robust data sharing and information systems that support it, analytical support, care management and coordination, and joint strategic planning with close provider-payer collaboration. [ABSTRACT FROM AUTHOR]

With the passage of the Affordable Care Act (ACA) in 2010, broad agreement has been reached on the need for fundamental reform of healthcare delivery and payment systems. Accountable care organizations (ACOs) have become one of the most discussed provisions of the ACA, and Medicare's Shared Savings Program (SSP), the incentive program tied to ACOs, has the potential to change the delivery of healthcare. The SSP will attempt to improve the quality of care while reducing the growth in expenditures by encouraging the formation of ACOs. The SSP is voluntary, and organizations that wish to participate will encounter advantages and disadvantages in its adoption. This article provides hospital administrators with basic information about the ACO requirements set forth by the Centers for Medicare & Medicaid Services and helps frame decision making about hospital participation in ACOs. [ABSTRACT FROM AUTHOR]

This paper describes how the Melbourne East General Practice Network supports general practice to enable quality of care, it describes the challenges and enablers of change, and the evidence of practice capacity building and improved quality of care. Primary care is well known as a place where quality, relatively inexpensive medical care occurs. General practice is made up of multiple small sites with fragmented systems and a funding system that challenges a whole-of-practice approach to clinical care. General Practice Networks support GPs to synthesise complexity and crystallise solutions that enhance general practice beyond current capacity. Through a culture of change management, GP Networks create the link between the practice and the big picture of the whole health system and reduce the isolation of general practice. They distribute information (evidence-based learning and resources) and provide individualised support, responding to practice need and capacity. [ABSTRACT FROM AUTHOR]

Introduction. This is a study of the process of diagnosis in family medicine (FM) in four practice populations from the Netherlands, Malta, Serbia and Japan. Diagnostic odds ratios (ORs) for common reasons for encounter (RfEs) and episode titles are used to study the process of diagnosis in international FM and to test the assumption that data can be aggregated across different age bands, practices and years of observation. Methodology. Participating family doctors (FDs) recorded details of all their patient contacts in an episode of care (EoC) structure using the International Classification of Primary Care (ICPC). RfEs presented by the patient and the diagnostic labels (EoC titles) recorded for each encounter were classified with ICPC. The relationships between RfEs and episode titles were expressed as ORs using Bayesian probability analysis to calculate the posterior (post-test) odds of an episode title given an RfE, at the start of a new EoC. Results. The distributions of diagnostic ORs from the four population databases are tabled across age groups, years of observation and practices. Conclusions. There is a lot of congruence in diagnostic process and concepts between populations, across age groups, years of observation and FD practices, despite differences in the strength of such diagnostic associations. There is particularly little variability of diagnostic ORs across years of observation and between individual FD practices. Given our findings, it makes sense to aggregate diagnostic data from different FD practices and years of observation. Our findings support the existence of common core diagnostic concepts in international FM. [ABSTRACT FROM PUBLISHER]

In the constant attention paid to what drives health care costs, only recently has scrutiny been applied to the power that some health care providers, particularly dominant hospital systems, wield to negotiate higher payment rates from insurers. Interviews in twelve US communities indicated that so-called must-have hospital systems and large physician groups--providers that health plans must include in their networks so that they are attractive to employers and consumers--can exert considerable market power to obtain steep payment rates from insurers. Other factors, such as offering an important, unique service or access in a particular geographic area, can contribute to provider leverage as well. Even in markets with dominant health plans, insurers generally have not been aggressive in constraining rate increases, perhaps because the insurers can simply pass along the costs to employers and their workers. Although government intervention--through rate setting or antitrust enforcement--has its place, our findings suggest a range of market and regulatory approaches should be examined in any attempt to address the consequences of growing provider market clout. [ABSTRACT FROM AUTHOR]

Today's rapid rate of technology change introduces both opportunities and challenges for psychologists. A Technology and Practice Questionnaire was sent to 1000 psychologists in independent practice, half of whom were contacted by e-mail and the other half by U.S. mail. A total of 237 of the 433 deliverable surveys sent by U.S. mail were returned (54.7% response rate), but only 49 of the 458 deliverable surveys sent by e-mail (12.9% response rate). Respondents were asked to rate the frequency of 51 behaviors in their practice and to indicate whether the behavior is ethical. The results suggest a relatively low rate of technology use among independent practitioners and a high degree of ethical uncertainty regarding the use of various technologies in practice. Implications for training and practice are considered. [ABSTRACT FROM AUTHOR]

The Health and Social Care Act 2008 places a legal responsibility upon healthcare organisations to provide a clean environment where infection risks are minimised. From April 2010, the regulation of both the NHS and the independent healthcare sector will, for the first time, fall under the same legislative framework. Nuffield Health (NH) is an independent healthcare provider with 30 acute hospitals. Strategic management of infection prevention is led by the NH Director for Infection Prevention. Management at the hospital level is led by the matron/Director for Infection Prevention and Control supported by trained infection prevention link practitioners (IPLPs). High-quality infection prevention across a large geographical area presents many challenges and IPLPs have been used to both monitor and improve the quality of infection prevention using national audit tools and acting as role models to influence practice. Audit results over 4 years demonstrate yearly improvements and low rates of healthcare-associated infections. [ABSTRACT FROM AUTHOR]

This paper highlights the issue of independent midwives practising without professional indemnity insurance. The paper explains the history of the provision, decline and now absence of insurance for midwives who practise independently. Despite the government's commitment to professional indemnity insurance cover for all health professionals working independently and not covered by the Clinical Negligence Scheme for Trusts, an exception has been made for independent midwives. The paper questions how the government can maintain its commitment to choices for maternity care yet permit midwives to care for pregnant women and attend at the birth of a baby without requiring insurance. There is no mandatory requirement to insure by the Nurses and Midwives Council (NMC). Without a mandatory requirement to insure the only advice given to midwives by the NMC is that they should inform their patients of the insurance position. The way in which information should be given is not stated and the practice is not consistent. Little information on the implications of lack of insurance is provided to parents considering retaining an independent midwife for the birth of their child. This situation leaves parents and children exposed to a situation where there is a clinical negligence claim no possibility of obtaining damages from an uninsured Defendant of limited personal means. [ABSTRACT FROM AUTHOR]

Copyright of Journal of the Cukurova University Institute of Social Sciences is the property of Cukurova University Institute of Social Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article presents information on the Medicaid programs in New York. Health maintenance organizations (HMOs) are regulated by the New York State Health Department and they provide health care and perform the function of third-party payers. It is stated that HMOs are multidisciplinary, and they provide comprehensive health care coverage for all aspects of medical care and hospitalization. HMOs also offer dental treatment through contracts with independent practice associations (IPAs).

The article reports on the Dental Managed Care Plans. Dental Managed Care Plans are developed to improve health care delivery and to help control health care costs. Their important aspect is the transfer of financial liability by the patient and third-party payer to the dentist. They are also contracted with several medical companies participating provider organizations (PPO), individual dental practices and independent practice associations (IPA) to provide dental services to their members.

Copyright of Canadian Family Physician / Médecin de Famille Canadien is the property of College of Family Physicians of Canada and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The association between the organizational structure of physician groups and health care quality has never been evaluated empirically. Objective: To examine whether integrated medical groups (IMGs) provide higher-quality primary care than individual practice associations (IPAs). Design: Cross-sectional study. Setting: PacifiCare, a large health maintenance organization. Participants: Approximately 1.7 million enrollees of PacifiCare cared for by 119 California physician groups between July 1999 and June 2000. Measurements: The percentage of eligible PacifiCare enrollees who received mammography, Papanicolaou smear screening, chlamydia screening, diabetic eye examination, an asthma controller medication, or a β-blocker after acute myocardial infarction. Results: Physician groups identified as IMGs, compared with those identified as IPAs, had higher rates of mammography (relative risk, 1.15 [95% CI, 1.01 to 1.33]), Papanicolaou smear screening (relative risk, 2.29 [CI, 1.53 to 3.42]), chlamydia screening (relative risk, 2.17 [CI, 1.04 to 4.55]), and diabetic eye screening (relative risk, 1.55 [CI, 1.28 to 1.88]). Leaders of IMGs were more likely to report using EMRs (37% vs. 2%; P < 0.001) and quality improvement strategies, but these characteristics explained little of the quality differences between IMGs and IPAs. Limitations: Organizational characteristics, including group type, were reported by physician group leaders and not directly assessed. Patient characteristics that could have accounted for some of the observed differences also were not assessed. Conclusions: Patients cared for in IMGs generally received higherquality primary care than those cared for in IPAs. Having an EMR and implementation of quality improvement strategies did not explain the differences in quality. These findings suggest that physician group type influences health care quality. [ABSTRACT FROM AUTHOR]

With purchasers' increasing frustration with healthcare costs, more innovative approaches to performance-based reimbursement are in demand. Establishing pay- for-performance programs has become a popular strategy for reorienting payments from rewarding volume to rewarding adherence to performance measures. However, while performance on quality measures has improved, no reports exist about the return on investment (ROl) of pay-for-performance programs. This article compares the overall costs of implementing and maintaining a pay-for-performance program with the resulting cost trend savings for diabetes care for a health maintenance organization's (HMO's) population. The program was a five-year partnership (2000-2004) between a health plan and an independent practice association (IPA) for the HMO product. It reported performance scores on quality, patient satisfaction, and practitioner efficiency at the individual physician level. Physician performance reporting began in 1999, and payment for that performance began in 2002. The cost of the program was $1,150,000 yearly. Savings for diabetes alone in 2003, the first post-intervention year, were $1,894,471. Second-year (2004) savings against the two-year rolling trend were $2,923,761. For 2003, the resulting ROl was 1.6:1, and for 2004, it was 2.5:1. To our knowledge, this article is the first report of a positive ROl for an HMO-based pay-for-performance program, and it begins to answer the question of whether the investment in such programs is worth the effort. [ABSTRACT FROM PUBLISHER]

This article examines Federal Trade Commission (FTC) policy - in particular, the agency's controversial 1996 statements on clinical integration - toward joint negotiations for nonrisk contracts with health plans by physicians organized into independent practice associations (IPAs) and (with hospitals) into physician-hospital organizations (PHOs). The article concludes that the policy is consistent with antitrust principles, consistent with current thinking on the use of organized processes to improve medical care quality, specific enough to provide guidance to physicians wanting to integrate clinically, and general enough to encourage ongoing innovations in physician organization. The FTC should consider stronger sanctions for IPAs and PHOs whose clinical integration is nothing more than a sham intended to provide cover for joint negotiations, should give the benefit of the doubt to organizations whose clinical integration appears to be reasonably consonant with the statements, and should clarify several ambiguities in the statements. Health plans should facilitate IPA and PHO efforts to improve care by rewarding quality and efficiency and by providing clinically integrated organizations with claims information on individual patients. Though creating clinically integrated organizations is difficult and expensive, physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patients. [ABSTRACT FROM AUTHOR]

Few nurses have the experience of developing an independent practice. This ethnographic study explores the process and challenges of becoming an entrepreneur as described by nurses developing independent practices in community care gerontologic nursing. The process included developing a legal contract, marketing strategies, and reimbursement amounts and strategies. Major barriers to implementing this role identified by the nurses included ignorance and confusion by others about their role, financial issues related to an uncertain income, time management, and legal concerns especially around delegation. These were experienced and dedicated nurses who were also risk-takers and enjoyed the independence of practicing nursing because they believed it was meant to be practiced. Suggestions for research, education, and practice are included. [ABSTRACT FROM AUTHOR]

: BackgroundHealth promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown.: MethodsThis research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%.: ResultsOverall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan.: ConclusionsPhysician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally. [Copyright &y& Elsevier]

Discusses the advantages of traditional solo practice as an alternative for family physicians. Cottage industries and careers as the business equivalent of solo physicians; Existence of a health care delivery model that will work equally well in all circumstances; Provision of the highest quality of acre at the lowest cost from solo practices or groups operating functionally as solo practices under one roof; Minimization of human error; Maximization of long-term profits. INSETS: SPEEDBAR;KEY POINTS;SPEEDBAR;SPEEDBAR

With numerous medical groups and individual practice associations (IPAs) in California now reporting operating losses—and many approaching financial insolvency—the question arises why physician organizations are in such a tenuous situation. One line of thinking is that the problem is attributable to the market dominance of the major health plans and their ability to impose actuarially unsound low capitation rates on professional providers. This article describes four other reasons for the current plight of physician organizations: (1) a physician-centric approach to IPA governance, (2) lack of qualified staff within key operating units, (3) management reporting that is insufficient to support utilization analysis and health plan negotiations, and (4) a highly charged political process for determining physician reimbursement. IPA survival will ultimately depend upon whether IPAs are perceived by their physician members and leaders as true business operations or just as another income source. [ABSTRACT FROM AUTHOR]

BACKGROUND • Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but litile is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and lioth health care expendiaires and the risk of avoidable hospitalizations. METHODS • We used cross-sectional analyses of claims data from an independent practice association-style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients. RESULTS • Alter adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in die highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5% - 13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile. CONCLUSIONS • Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admmited for avoidable hospitalization conditions. [ABSTRACT FROM AUTHOR]

Context: Independent practice associations (IPAs) are developing new methods of physician reimbursement to balance the objectives of encouraging individual productivity and clinical cooperation. The economic literature on payment incentives, derived from nonhealth industries, predicts that methods blending elements of fee-for-service and capitation will outperform exclusive reliance on either form of payment.Objective: To identify emerging payment methods within IPA physician groups that contract with managed care organizations.Design and Setting: Case studies of 7 large IPAs in the San Francisco, Calif, metropolitan region that served 826000 health maintenance organization (HMO) patients during the summer and fall of 1998.Main Outcome Measure: Payment methods of IPAs for primary care physicians, specialists, and physicians grouped by specialty department within the overall IPA structure.Results: All the IPAs contracted with multiple HMOs for the full range of primary and specialty care physicians' services but paid member physicians using methods that blended elements of fee-for-service and subcapitation. For primary care, most IPAs used monthly capitation adjusted for patient age, sex, and selected diagnoses, supplemented with fee-for-service payment for a wide range of visits and procedures, including patient visits in subacute, skilled nursing facility, emergency department, or home settings; for preventive care services; for office procedures requiring expensive supplies; and, most importantly, for borderline primary care procedures that either could be performed directly or referred to specialty care. All the IPAs paid specialty departments on a capitated basis and delegated to the departments responsibility for allocating the budget among individuals. Allocation mechanisms for individual specialists included adjusted fee-for-service, referral-based capitation, and blends of both.Conclusion: Our results and case studies indicate that IPAs are developing payment methods that blend elements of fee-for-service and capitation in innovative ways for primary care and specialty physicians. [ABSTRACT FROM AUTHOR]

Background: As managed care organizations (MCOs) continue to expand into the care of the chronically ill, the concept of providing cost-effective care with a preventive approach is vital for primary care providers (PCPs) to embrace. Diabetes is an ideal disease to incorporate this concept.Methods: We reviewed the literature using MEDLINE. We used the American Diabetes Association (ADA) Provider Recognition Program guidelines as the foundation for MCOs to establish a diabetes disease management program.Results: The implementation of disease management protocols, the use of computerized management systems, and the team approach can provide cost-effective diabetic care.Conclusions: To compete in the managed care market, it is vital for providers to link with their Independent Practice Associations (IPA), the ADA, and MCOs to implement standard protocols and negotiate for adequate reimbursement. [ABSTRACT FROM AUTHOR]

Abstract: The quality of ambulatory care received by Medicare recipients who enrolled in health maintenance organizations (HMOs) was compared to the care received by fee-for-service (FFS) Medicare recipients, in a quasi-experimental, non-randomized design. Both samples were drawn from the four major geographic areas in the country, and included two types of HMO practices: staff/group models, and independent practice associations (IPAs). A panel of expert physicians developed criteria for evaluating ambulatory care, and medical record abstractions using these criteria were performed on 1,590 outpatient records: 777 FFS and 813 HMO (441 staff/group, 372 IPA). While individual items of medical histories and physical examinations were performed most often for staff/group HMO patients and least often in FFS patients, odds ratios (OR) for performance in staff/group HMO patients were particularly large for health maintenance items: tonometry (OR = 8.4), mammography (OR = 2.7), pelvic examination (OR = 5.3), rectal examination (OR = 2.9), fecal occult blood test (OR = 3.3). The results suggest that recommended elements of routine and preventive care are more likely to be performed for Medicare enrollees in staff/group HMOs than in FFS settings. (Am J Public Health 1990; 80:411-415.) [ABSTRACT FROM AUTHOR]

Abstract: The Health Care Financing Administration (HCFA) initiated the Medicare Competition Demonstrations in 1982 in anticipation of congressional intent to establish a national program. Interim results on the 1984 service use and cost experience of the health maintenance organizations (HMOs) and competitive medical plans (CMPs) participating in the demonstrations indicate that Medicare enrollees in the demonstration experienced a median of 1,951 hospital days per 1,000 person years, 57 per ¢ of the median of 3,432 days per 1,000 in the local markets from which the plans drew enrollment. Independent practice association (IPA) HMOs experienced higher hospital use rates than staff and group model HMOs. These comparisons are not adjusted for various risk factors, the absence of which were likely to favor the demonstration plans. Plans with lower hospital service use were federally qualified and had been operating for more than five years. The median total annual revenue per enrollee across all plans was $2,312, compared to median annual expenses per enrollee of $2,250. The distribution of median annual expenses per enrollee by major category of expense was: institutional expenses ($1,038/enrollee), medical expenses ($720/enrollee), supplemental services expenses ($154/enrollee), and administrative and other expenses ($295/enrollee). Future analysis, using beneficiary-level data, will examine the impact of the demonstration and the nature and extent of evident biased selection and will compare the quality of care in the demonstrations to that in the fee-for-service sector. (Am J Public Health 1988; 78:937-943. INSET: Joint Federal Effort to Assist Recruitment of Disadvantaged.... [ABSTRACT FROM AUTHOR]

A previous study of low-income enrollees in a closed-panel health maintenance organization (HMO) and a Blue Cross/ Blue Shield (BC/BS) plan showed that the effect on the use of health services of the age, sex, health status, previous health care use, race, and family size of the enrollees was different in the two plans. We have replicated this study using the same provider plans but studying a different group of white collar, middle class enrollees. A third plan, an experimental independent practice association (IPA), was also available for analysis. Utilization was defined as use (yes/no) and the quantity of use for those who used services (in standardized dollars). Significant interactions were detected between plan and all of the independent variables, but race. The use of services in the HMO was least affected by enrollees' characteristics (age, sex, race, health status, prior use, family size) and use was most sensitive to patient characteristics in BC. In some respects, the IPA was more like the HMO and in other respects more like the BC/ BS plan. [ABSTRACT FROM AUTHOR]

We examine scale and scope economics among Group and IPA Health Maintenance Organizations (HMOs) over the period 1988 to 1991 using a national sample of HMOs. We allow for the multiproduct nature of HMO production by estimating the cost of producing a member month of non-Medicare and Medicare coverage, and we examine the effect of HMO market structure on costs. We find that HMOs benefit from scale economies. There are scope diseconomies associated with providing both non-Medicare and Medicare products. Group HMOs in more competitive markets have lower costs but IPA costs are not affected by competition. [ABSTRACT FROM AUTHOR]

Context: Medical groups are growing and merging to improve efficiency and bargaining leverage in the competitive managed care environment. An increasing number are affiliating with physician practice management (PPM) firms that offer capital financing, expertise in utilization management, and global capitation contracts with health insurance entities. These physician organizations provide an alternative to affiliation with a hospital system and to individual physician contracting with health plans.Objective: To describe the growth, structure, and strategy of PPM organizations that coordinate medical groups in multiple markets and contract with health maintenance organizations (HMOs).Design: Case studies, including interviews with administrative and clinical leaders, review of company documents, and analysis of documents from investment bankers, the Securities and Exchange Commission, and industry observers.Setting: Medical groups and independent practice associations (IPAs) in California and New Jersey affiliated with MedPartners, FPA Medical Management, and UniMed.Outcome Measures: Growth in number of primary care and specialty care physicians employed by and contracting with affiliated medical groups; growth in patient enrollment from commercial, Medicare, and Medicaid HMOs; growth in capitation and noncapitation revenues; structure and governance of affiliated management service organizations and professional corporations; and contracting strategies with HMOs.Results: Between 1994 and 1996, medical groups and IPAs affiliated with 3 PPMs grew from 3787 to 25763 physicians; 65% of employed physicians provide primary care, while the majority of contracting physicians provide specialty care. Patient enrollment in HMOs grew from 285503 to 3028881. Annual capitation revenues grew from $190 million to $2.1 billion. Medical groups affiliated with PPMs are capitated for most professional, hospital, and ancillary clinical services and are increasingly delegated responsibility by HMOs for utilization management and quality assurance.Comment: Physician practice management organizations and their affiliated medical groups face the challenge of continuing rapid growth, sustaining stock values, and improving practice efficiencies while maintaining the loyalty of physicians and patients. [ABSTRACT FROM AUTHOR]

We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasi-experimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child-care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients. [ABSTRACT FROM AUTHOR]

Health maintenance organizations (HMOs) are providing an increasing proportion of medical care in the United States. Characteristics of these organizations such as cost containment, incentives to reduce spending by practitioners, and barriers to access for clients raise significant ethical concerns. This paper considers how these features of the HMO withstand ethical scrutiny and what may be done to prevent abuse. Generally, the challenges to the moral integrity of physicians practicing in HMOs are neither intractable nor in all cases unique, although special arrangements may have to be made to ensure that ethical standards are upheld. Independent practice associations pose particular problems. Finally, whether or not an HMO is a for-profit enterprise is a significant consideration. [ABSTRACT FROM AUTHOR]

The article presents information about alternative delivery systems (ADS), a network of health care providers that offer full coverage of services in exchange for a set premium. The author explored the three primary forms an ADS can take which includes prepaid group association, preferred provider organization and individual practice association. A comparison between the primary features of the three ADS and with those of traditional fee-for-service indemnity insurance is presented by the author. The involvement of agreements in ADS among otherwise independent providers was mentioned in the article.

The article presents the second part of a discussion on compulsory health insurance and its relevance for independent doctors in West Germany. Regulations and laws for state and non-state physicians are addressed. Personal responsibility and freedom of doctors as well as their relationship with their patients when working independently from the state is examined.