[Hospital group practice].
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This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training.
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Underperforming hospital-sponsored group practices can achieve reasonable financial performance without sacrificing morale among the group's physicians and office staff if six key elements for success can be implemented. These key elements involve formalizing physician leadership and governance, clearly allocating risk, communicating expectations regarding pay for performance, providing meaningful information, keeping overhead expenses under control, and putting an experienced management team in place. Implementing these six elements can help struggling hospital-sponsored group practices achieve a successful turnaround.
Many hospital-affiliated group practices have had significant problems. Failures are common. Sturdy Memorial Associates, a hospital affiliated group practice functioning out of twelve sites in the greater Attleboro area in Massachusetts, has been a success. Two senior managers discuss the history and the reasons why.
Group practice arrangements can underlie a hospital's strategy to recruit physicians and ensure steady patient volumes. Because physicians largely control where their patients are treated, many hospitals are considering ways to more closely align practitioners with their programs and services. Models for developing group practices range from asking young physicians to join an established practice to helping merge the practices of a retiring physician and an established practitioner.
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Many hospital executives see the emergence of medical group practices as a threat to their autonomy. However, the degree of future success of hospitals and group practices may depend on their willingness and ability to develop common goals and strategies.
Henry Ford Hospital, a 1,000-bed institution in central Detroit, is being developed into a "center of excellence" with expansion of ambulatory care to suburban satellite clinics. A hospital-based HMO has been started in an effort to cut costs, decentralize care, and provide an alternative to Blue Cross. It has been successful and is now being considered as a solution to Michigan's Medicaid problems. Background and analysis follow.
Each physician group, network, or management services organization developed as part of an "integration" strategy over the past decade is unique. The current status of each of these entities is based on a variety of factors, including the local health care economy and environment, the sponsoring organization, and the entity's leadership. Much of the current news concerning integration initiatives is negative, and significant operating losses and the disillusionment of the participants have been reported. It is important to study the failures, however, for despite the unique factors impacting each one there are universal lessons to be learned in every case. This article chronicles the causes of one integrated group practice's breakup after five years of operation and the process undertaken to return the physicians to small independent practices.
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Initiation of a hospital-based faculty group practice to replace part of a general medical clinic was evaluated in a quasi-experimental design. Practice setting (where patients received their primary care) was the independent variable. The group practice, unlike the traditional clinic, emphasized primary care by providing 24-hour, seven day/week access by telephone; continuity between inpatient and ambulatory care (all patients admitted as private patients of group practice attending physicians) and coordination of care. Resource use, including visits to the primary care site, the emergency room and specialty clinics, and tests ordered at each site were tracked for one year by chart review. Multivariate analysis showed that, contrary to expectations, group practice patients had no fewer emergency room or specialty clinic visits, although they did make more visits to the practice. With respect to tests, practice patients had almost two more tests ordered in the primary care site than clinic patients, although there was no concomitant reduction in tests ordered at other sites. The authors conclude that ambulatory care resource use is an insufficient measure of the effect of a change in practice setting.
Federal reimbursement systems, state constitutional amendments, and fiscal responsibilities are driving physicians and hospitals into alliances that were unheard of a decade ago. How those alliances are established is critical to the success of those new affiliations. James Unland explores several forms of physician groups and physician-hospital alliances. The "Group Practice Without Walls," "The Mutual Service Corporation" and others are explored in this article. In a world of changing health-care programs, Unland states there is a middle ground where group-practice ownership and control are shared. The exact type of structure, ownership, and control will depend upon many factors. Unland makes a point-by-point evaluation of a hospital-group alliance that integrates numerous medical practices into a single operational entity.
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