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Many changes have occurred in the financing and organization of health care services in recent years. Medicare's prospective payment system, a major financing innovation implemented by the federal government, is continuing to evolve in response to demands that costs be controlled while quality of care and access are ensured.
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Rural hospitals are actively pursuing various strategic alternatives to confront the dramatic changes taking place in the delivery, organization, and financing of healthcare. One of these strategic alternatives is involvement in provider-sponsored managed care organizations. Studies have argued that this form of managed care would enhance public trust and might improve the performance of hospitals. The changing healthcare environment has also increased the importance of the competence and composition of hospital boards. This article examines the effect of the governing board's composition on rural hospitals' involvement in provider-sponsored managed care organizations. The study sample consisted of 140 rural hospitals in Iowa and Nebraska whose CEOs responded to a survey conducted by the Center for Health Services Research at the University of Iowa between June and December 1997. The principal finding was that the likelihood of a hospital owning any form of managed care organization increases with the number of community leaders and health professionals on the board. The number of business leaders had no effect on the likelihood of involvement in such an arrangement. Other factors that affected the likelihood of owning a managed care organization were the health status of the population and ownership type. Key recommendations to managers are to (1) revisit the hospital board's composition before actively pursuing a strategic action, (2) examine the compatibility of the type of strategic activity pursued with the background of board members and the interests of the populations they represent, and (3) use the governing board as a resource in determining which new strategic activities to undertake.
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OBJECTIVES: Evaluating the impact of recommendations based upon health technology assessment (HTA) represents a challenge for both HTA agencies and healthcare policy makers. This research sought to understand factors affecting the uptake of HTA recommendations to support decision making with respect to the introduction of three health technologies. METHODS: Using a multidimensional framework, based upon a combination of theoretical models, a case study was conducted. A total of twenty-eight semistructured interviews were done with physicians from fifteen hospitals and other stakeholders in Catalonia. Interview content was analyzed iteratively and classified according to theoretical dimensions and contextual factors. RESULTS: At the sociopolitical level, factors related to the organization and financing of the health system were found to affect the utilization of HTA recommendations. At the healthcare organization level, existing collaborations between the hospital and the HTA agency favored the integration of recommendations into practices. Formalism in the organization also influenced the utilization of HTA recommendations. At the professional level, the high degree of autonomy of specialists, the importance of peers and collegial control, and the definition of professional roles and responsibilities influenced physicians' willingness to integrate HTA recommendations into their practice. CONCLUSIONS: This study offers a comprehensive framework to understand the complex dynamics that affect adoption of health technologies in organizational and professional practices. The findings suggest some avenues to promote the integration of HTA recommendations into practices and, thus, increase the utilization of scientific evidence to support decision making in health care.
Understanding how different health care systems are organized and financed is rarely taught in medical school. In 1997, several U.S. and European medical schools formed an ongoing, innovative, and collaborative exchange program to enable their medical students to gain an insight into the dynamics of another country's health care system. One student from each participating institution completes a month-long rotation at a host medical school under the supervision of a faculty mentor. Selected target diagnoses serve as the basis for comparative case studies. To enable the student to effectively study the host country's health care system, each is assigned a patient with the preselected specific diagnosis. The students view the patient's care within the context of the host country's delivery system rather than being limited to the clinical diagnosis and treatment of the disease. Matching the student with a patient permits the student to see how medical care is delivered and financed in the host country. Each student is required to prepare a written report focusing on costs; organization and delivery of care; quality and outcomes of care; politics, culture, and ethics; and learning. The case studies permit comparisons of health care systems among the participating U.S. and European Union countries, as well as opportunities for institutional and individual learning.