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In the last decade, medical group practices have readily adapted to the prospective payment system and managed care environment. In this article, Thomas Weil, Ph.D., speculates on the possibility and impact of equal access and universal coverage, i.e., national health insurance.
Influenced by the need to be competitive in an environment plagued by an oversupply of physicians, medical groups must give serious attention to major trends in terms of strategic planning. Group practice can benefit from the experience of other businesses which have survived in their respective marketplace. To assist medical groups in their strategic planning efforts, three health-care consultants offer predictions of future conditions in medical group practice.
Entry into private practice can be rewarding for nurses who are willing to risk personal, financial, and professional security. Among the problems faced by the nurse in this new role is the administration of the practice, since few, if any, adequate models exist. This article describes the struggle of nurses in one private nursing practice, Creative Health Services, to meet their needs for individual freedom within an organization that is regulated sufficiently to maintain its viability.
The growth of a family practice goup is presented as a case study. Enlarging size and increasing functions require organizational change--from solo to collegial to bureaucratic to political systems. Organizational theory distinguishes between the characteristics and functions of individual, collegial, bureaucratic, and political organizations. Different styles and strategies are appropriate at different stages.
The leadership efforts in this complex process emphasize the importance of communication, education and buy-in to implement advanced access in a group practice network. These key components, along with timely feedback, staff support and necessary resources, are especially significant when the end point and the benefits are not immediately apparent to those directly affected by the change. Once these elements are in place, however, any practice has the ability to establish advanced access, increase its patient base and improve its economic performance.
The purposes of this article are to identify all the variables that impact productivity in a group practice, contrast the administrator's and physician's definitions of productivity, discuss current measurement tools and outline the steps in a traditional productivity project. The article identifies key variables that management must address: physician education, goals, feedback and rewards that are critical to the success of any productivity undertaking. Upon completion of this article, the reader will be able to understand the differences in the way administrators and physicians view productivity and be able to identify the vital areas that must be addressed in any effort to increase productivity. While the article focuses on the academic setting, the principles are applicable in any group practice.
OBJECTIVE: To establish the degree of continuity of care in general practice. DESIGN: Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING: Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS: 776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES: Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS: In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS: Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health's recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.
Multiskilled health practitioners (MSHPs) may be used to reduce costs and increase the availability of services for group practices. There are a variety of possible competency combinations for MSHPs, many of which are unique to the needs of specific health care facilities. Examples of MSHPs as well as employer and employee perceptions of multiskilled needs relevant to health care delivery and applications to the group practice setting are presented.
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This article examines physician compensation models in medical groups and the factors affecting physician compensation and their impact on individual physician behavior and group practice performance. Four categories of physician compensation models are identified: (1) production-based compensation, (2) salary, (3) group-based compensation unrelated to individual physician productivity, and (4) capitation-based compensation. The statistics and the economic incentives of different compensation methods are presented. Finally, the impacts on health resources consumption, charges in medical group procedures for utilization and care management, and quality of care are discussed.
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A belief exists about the advantages of group medical practice over solo practitioners. The paper through a survey of 105 group practices examines a number of organisational and operational factors. The results suggest that practices are not always organised in a way to maximise the benefits of group operation but are still characterised by an individualistic approach.
Although there is a growing surplus of physicians in the United States, predictions are that the use of physician assistants (PAs) in group practice will continue to grow during this decade. Patient accessibility is the most important reason. Based on a recent survey, findings concerning the current and future utilization of PAs in group practice are presented.
Seven general surgeons in a prepaid group practice previously shown to have a mean operative work load of 9.2 hernia equivalents (HE) per week were found to have a standardized mean daytime working week of 56.2 hours, exclusive of evening activities of which 50.7 hours were devoted to professional activities. The surgeons also devoted a mean of 6.7 evening hours per week to professional activities for a mean net professional week of 57.4 hours. Comparisons with a population of previously studied community surgeons revealed that the prepaid group surgeons were able to produce a surgical output more than double that of the community surgeons while devoting only one and a half as much time to professional activities. Economies in the utilization of surgical manpower in the prepaid group appear to stem from: 1) restriction of practice setting to a single geographic location, 2) restriction of patients to surgical patients, 3) reduced surgeon waiting time in the office, and 4) the utilization of paraprofessional personnel for selected operative assisting. These economies were achieved while the prepaid group surgeons were observed to average more time per patient visit both on rounds and in the office than the community surgeons.
The aim was to assess the orthodontic treatment service provided by 6 orthodontists in a group practice in Malmö. One hundred cases were randomly selected from the model store. The Index of Complexity, Outcome and Need (ICON) was used to assess the need, complexity of the problem, outcome, the degree of improvement and whether the completed case was acceptable or not. The reliability of the examiner using the ICON was assessed using Root Mean Square. Logistic regression analysis was employed to explore the variables related to acceptability of the finish and duration of treatment. The younger the patient at the start of treatment the lower initial ICON score, with short treatment duration were associated with an acceptable finish. Three out of 100 cases were deemed as not requiring orthodontic treatment and 36 cases were classified as very difficult to treat. Nevertheless, 71 cases out of the 100 exhibited acceptable finishes with 27 indicating substantial or great improvement. 6 cases finished treatment with ICON scores greater than 43 indicating need for orthodontic treatment. The treatment on average took 22 months. An objective appraisal of the quality of orthodontic care in a group practice in Malmö has been undertaken. Seventy-one cases were completed with acceptable occlusions. The Index of Complexity, Outcome and Need appears to be a valuable tool to assess the multiple facets of orthodontic provision.
In order to explore the utilization and medical cost of patients with different insurance coverage in group practice centers, we collected patient data in three centers from September 1, 1987 to February 28, 1988. We classified the payments as self-payment,partial-reimbursement and total-reimbursement. There were 42,234 visits by 8,111 patients. The average frequency of visits within 6 months was 6.1 in total-reimbursement patients, 5.2 in partial-reimbursement patients and 2.6 in self-payment patients. We found that the frequency of visits increased with age in patients with total-reimbursement and partial-reimbursement. On the other hand, the frequency decreased after the age of 65 in patients with self-payment; whether it was related to the economic problems of the elderly needs further study. The highest medical cost per visit was NT$. 343 in total reimbursement patients, followed by NT$. 281 in partial-reimbursement patients. The lowest cost was NT$. 208 in self-payment patients. Yet, the highest ratio of total drug cost by total medical cost per visit was 73.7% in partial-reimbursement patients followed by 63.6% in total-reimbursement patients. The lowest ratio was 56.7% in self-payment patients. Although the partial-reimbursement system could not decrease the ratio of total drug cost by total medical cost per visit, it would be beneficial in group practice centers to decrease the patients' visits and the medical cost per visit. Therefore, this system should be executed in the future.
We followed a cohort of 7,666 individuals enrolled continuously for five years in a prepaid group practice in Columbia, Maryland. Incidence rates of all diagnosed mental disorders were estimated at approximately 3.7 per cent, lower for adolescents and children (about 3 per cent), higher for adult males aged 20-49 (4.3 per cent), and highest for adult females (5.8 per cent). Diagnoses are primarily for acute mental disorders and show a tendency to recur at fairly high rates.
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