Economics Of Medical Practice Research Articles

The Focused Musculoskeletal Factory

Rheumatology has evolved rapidly over the past 20years. The availability of numerous treatment interventions has dramatically altered patient outcomes and revitalized the specialty. At the same time, the economics of medical practice is challenging the practicing rheumatologist to seek more efficient and more attractive models of care delivery. These models of care must be attractive not only to rheumatologists and their patients but also to other interested parties as well, such as payers, government agencies, and accreditation bodies.

Measuring Changes in the Economics of Medical Practice.

For the latter third of the twentieth century, researchers have estimated production and cost functions for physician practices. Today, those attempting to measure the inputs and outputs of physician practice must account for many recent changes in models of care delivery. In this paper, we review practice inputs and outputs as typically described in research on the economics of medical practice, and consider the implications of the changing organization of medical practice and nature of physician work. This evolving environment has created conceptual challenges in what are the appropriate measures of output from physician work, as well as what inputs should be measured. Likewise, the increasing complexity of physician practice organizations has introduced challenges to finding the appropriate data sources for measuring these constructs. Both these conceptual and data challenges pose measurement issues that must be overcome to study the economics of modern medical practice. Despite these challenges, there are several promising initiatives involving data sharing at the organizational level that could provide a starting point for developing the needed new data sources and metrics for physician inputs and outputs. However, additional efforts will be required to establish data collection approaches and measurements applicable to smaller and single specialty practices. Overcoming these measurement and data challenges will be key to supporting policy-relevant research on the changing economics of medical practice.

Learning from the legal history of billing for medical fees.

When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients. At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures. Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.

Making a medical living: the economics of medical practice in the Cape c.1860-1910.

The economics of colonial medicine have been largely neglected. This chapter shall seek first to give an overview of the medical market in the Cape during the late nineteenth and early twentieth centuries, before turning to a fuller exploration of the nature of private and public practice, and their inter-relationship. The chapter will end with a case study of Dr William Darley-Hartley whose life exemplified some typical features of life in the Cape medical profession at this time.

A survival strategy for an academic psychiatry department in a managed care environment.

The changing economics of medical practice have had a profound effect on the educational, research, and service missions of academic departments of psychiatry across the country. The authors describe the development of a managed behavioral health care organization in their parent academic health system as a survival strategy for allowing their department to function in a managed care environment. They present a series of lessons learned in this effort to adapt to a highly volatile managed behavioral health care market: know how you fit into your market as well as your institution, form cooperative alliances within and outside of your institution, provide incentives to manage risk, focus on core competencies, innovate in your areas of strength, and collect data.

General practitioner health and well-being: from Brisbane to Los Angeles.

In the late 1940s, William Carlos Williams, family physician and author, began his short story “The Practice” with the following paragraph that captured the human splendor of medicine1: It's the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life. I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives; when they were being born, when they were dying, has always absorbed me. He went on to say that the full-time practice of medicine never interfered with his writing but rather served as his “very food and drink.” Clearly, this American general practitioner (GP) saw his practice as a vocation, a life-fulfilling calling. Half a century later, Hartwig and Nichols report on a study of GPs half a world away in Brisbane, Australia, that suggests that for many, medicine is no longer a vocation—a form of food and drink—but rather a stressful job. In response to a survey that found that health and well-being were major concerns for its more than 800 physician members, the Brisbane North Division of General Practice commissioned a study to explore the issues. It found that many GPs would leave the profession if they could, have high stress and low morale, delay use of or refuse medical services when they are sick, and are more likely to suffer mental health problems and marital discord than the general population they serve. The major causes of stress included time pressures to see patients, too much work for too little pay, government bureaucracy, paperwork, and unrealistic expectations by demanding patients. Is general practice a job in Brisbane but a vocation elsewhere? Or are our colleagues elsewhere in the world experiencing the same loss of morale? More than 1,000 family physicians in the Netherlands, many dressed in pajamas, recently traveled to The Hague to tell Parliament that they were overwhelmed with work and gravely underpaid.2 They pleaded for a reduction in their 70-hour week and for more resources to hire additional staff. In California, dominated by managed care and low capitation rates, one repeatedly hears that physician morale is at an all-time low. Physicians speak daily about the workloads and bureaucratic hurdles imposed by managed care. Many bright premed students at UCLA have deferred going to medical school, electing to try a job with a “dot.com” company. I suspect we are experiencing a world epidemic of stress among primary care physicians. Why does this matter? The well-being of a nation's physician workforce affects the quality of care that it can provide. The Brisbane study reported that tension and frustration among GPs led to increased prescription rates and referrals, poorer continuity of care, and decreased satisfaction among patients. As family physicians suffer, so do their patients. What should be done? The Brisbane GPs suggested a number of supportive strategies, including practice management support, assigned locums to ensure time off, and an advocacy network for local GPs. The goal is to develop an alternative model of a healthy GP with high morale and job satisfaction, resulting in high-quality patient care. Sources of satisfaction included problem solving, procedural work, research and teaching, and financial security. An American study of 330 family physicians showed a strong correlation between personal values of benevolence—defined as “preservation and enhancement of the welfare of people with whom one is in frequent close contact”—and job satisfaction.3 Benevolence could be protective for physicians. We must also understand that the medical world is changing rapidly, that it is undergoing both a biomedical transformation and an economic upheaval as costs soar. We are woefully unprepared for the challenges we face. Rather than mourn what has been lost, we need to become adept at working in the new economic, bureaucratic culture of health care.4 As Relman says, physicians need better and more training in the “politics, philosophy, and economics of medical practice.”5 Physicians in the United States have become double agents, struggling to negotiate the opposing practices of controlling costs and caring for patients. The essence of doctoring needs to be redefined in this new setting. Doing something you love almost always outweighs the associated costs. Most primary care physicians in the world entered the practice believing, as did William Carlos Williams, that this was a noble calling—indeed, a vocation. We must not lose sight of the fact that we are lucky to be in a profession in which we do well for ourselves by doing well for others.

From the University of Washington to Washington University: a personal journey

A human sternum with an imbedded arrowhead (Fig 1) from Patagnoia presents a dramatic image fit to make several points regarding life, medicine, and surgery. Things are not always what they seem (the arrow enters the inner side of the sternum and therefore crossed the chest). Life was as fragile then as it is today. New forms of trauma have replaced, but not completely, the arrow, and new diseases, witness acquired immunodeficiency syndrome, continue to arise or be recognized. Although the interval from then to now is great, the messages are timeless. My message is not timeless but focuses on two generations of physicians (dad and me), a decade of change, and the next generation. In less than a decade profound changes in the structure and economics of medical practice have surpassed those of the preceding 150 years. As I look back on my 32 years of practice that came after 13 years in education, training, and military service after college, I thought it might be appropriate to reflect on these changes and how they may affect physicians in the future. I was fortunate to have a father who practiced medicine in a blue collar community of ten thousand people, that was built around a United States naval ship yard. I was well aware of my father’s profession from an early age but did not participate in it as some sons might. I was occasionally exposed to the “evils of socialized medicine” through conversations between my father and other physicians. I also learned that the American Medical Association was solidly against this form of medical practice, which I did not fully comprehend. At that time it seemed a far off possibility and not particularly threatening even as I considered pursuing medicine as a career. It was during college that I decided that medicine would be a good career, for several reasons. I had a personal health problem that I wanted to research and correct for myself and others. There seemed to be a good market for physicians. Providing care was satisfying to one’s own mind and was associated with respect from the community. And if one were diligent and even modestly successful one would not starve. Medical school taught me enough to engender a new respect for my dad, who delivered babies, set fractures in his office, and then developed the x-rays of the same between pediatric patient visits, performed major abdominal or gynecologic operations in the morning before heading to the office, managed to make house calls at mundane as well as odd hours, and speak with patients on the phone in midst of family dinners (the phone was in its place beside the kitchen table where we ate). At that time I could recall Sunday drives in the country when father would point out a farmhouse where he had delivered a baby, where he had treated a patient with heart failure, or relate that he had to back his model-T Ford up the hill to another house as low gear did not provide enough power to make the grade. Mother told me how wonderful it was when the bridge was built across Port Washington Narrows in 1932 so that instead of a 10minute ferry ride it was a short drive across the bridge to make a house call and it saved a 1-hour drive home when dad missed the last ferry in the evening. These vignettes from the practice of a solo practitioner engaged in the great American fee-for-service tradition that existed from the founding of our country until recently are uncommon today except in very rural or remote areas. Occasionally my dad would mention that some patients had no money or not enough to pay for services, which never seemed to be a problem for him. The only vexation that I perceived was on occasion when such a patient would become unusually demanding of his time, such as a lengthy phone call while we were eating. Some less-well-off patients, but also those who did pay, were grateful in other ways by bringing something from the garden, the beach, the water, or something crafted by hand and dropped off at the office or our home. In my clinical years at the University of Washington Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14 1998.

Sharps disposal in the operating room: current clinical practices and costs.

In the evolving medical environment, fiscal constraints on medical practice are becoming the norm. The new days of austerity have revived interest in the economics of medical practice. Economic measures, however, should not impinge on the quality of patient care. Waste disposal, in particular, is an area without any direct patient benefit but which carries both short- and long-term ecological costs. Much of how we dispose of waste is dictated in the United States by the Joint Commission for the Accreditation of Hospital Organization, Occupational Safety and Health Administration, state regulations, and individual hospital protocols. In an attempt to elucidate the waste in waste management, we examined the use of standard operating room sharp boxes. Full sharp boxes from three different operating sites were randomly saved. Boxes were weighed and opened, and contents were separated into appropriate sharps: loose needles, scalpels, syringes with uncapped needles, and other. Weight and volume assessments were performed on the nonsharps. True sharp values were derived from nonsharps data. Less than 50% of the contents were appropriate for sharps disposal, with empty glass vials constituting the greatest percentage by weight of nonsharps material. We believe that encouraging the appropriate use of sharps boxes is a potential source for savings. Sharp boxes were randomly saved from university operating rooms and analyzed for content. The full boxes contained 14% appropriate sharps by weight and <50% appropriate sharps by volume. The largest fraction of nonsharps weight was found to be glass.

Obstacles to Attracting Physicians to Underserved Communities

In his article, Thomas Weil notes correctly that attracting physicians to certain historically underserved inner-city and rural communities appears to be an intractable social and public policy dilemma. He suggests that this problem may be amenable to solution if health networks interested in capitalizing on those markets provide leadership in building systems of care in those communities. He posits that the existence of such systems might attract physicians to establish practices in underserved communities, provided that the networks also provide financial incentives. Implicit in Weil's thinking is that physicians will be unlikely to establish practices in the target communities, unless viable systems of care are in place. On this point, we believe he is correct. At issue, however, is whether establishing systems of care in historically underserved urban and rural communities, while necessary, will prove sufficient to attract physicians to those communities. Weil suggests that over the years policymakers have implemented three specific strategies to address this problem: (1) increase the number of U.S. medical school graduates; (2) allow graduates of non-U.S. medical schools to enter the country for residency training and practice; and (3) establish the NHSC. He concludes that individually and collectively, those policies failed to accomplish the stated goal. Weil's analysis is only partially true. While there is no question that the policies he describes did not solve the problem of geographic maldistribution of physicians, it is important to recognize that only the last one of the three was intended to do so. With the limited space available for this commentary, we cannot review in detail the history of the policies referenced, but we would assert that increasing the number of U.S. medical school graduates and allowing graduates of non-U.S. medical schools to enter residency programs in this country were not policy initiatives intended primarily to provide physicians for inner-city and rural communities. It is therefore not surprising that the programs established to implement these policies did not resolve the problem of medically underserved communities. By contrast, the NHSC was established specifically to fill this need. However, this program has never been funded by the federal government at the level required to place physicians in all of the communities of need. Moreover, the NHSC has been plagued over the years by congressionally mandated changes in the program's goals and objectives. Regardless of how one interprets the relevant policymaking events of the past quarter century, the fact remains that certain urban and rural communities in which residents lack ready access to physician services continue to exist. If one hopes to create systems of care to remedy this situation, one must first identify and understand the reasons that more physicians have not chosen to establish permanent practices in those communities. Decisive Factors We believe that three major factors determine whether an individual physician is likely to establish a practice in an urban innercity or rural community that has historically been without a physician: 1. the physician's specialty; 2. the economics of medical practice in the community; and 3. the living conditions in most medically underserved communities in relation to the legitimate lifestyle aspirations of most physicians. Let us consider each factor in turn. First, the greatest need in medically underserved communities is for physicians who practice primary care medicine. Accordingly, physicians trained as family physicians, general internists, or general pediatricians (the kinds of physicians who generally practice primary care medicine) are virtually the only physicians likely to consider practicing in these communities. Furthermore, given the broad range of primary care services (e.g., routine obstetrical care) that physicians must be prepared to provide in underserved areas, family medicine physicians are much more likely than general internists or general pediatricians to succeed in relatively isolated practice (particularly in rural communities). …

Book Review: The Economics of Medical Practice, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911

Book Review: The Economics of Medical Practice, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911

The Patient-Physician Relationship

The patient-physician relationship is under siege. I believe there are two sources that underlie the distress experienced by many patients and physicians in their interactions with each other. First, there is an intensification of the tension between the science and the art of medicine. Second, there are severe strains related to the rapid changes in the economics of medical practice. Concern about tensions between the science and the art of medicine is hardly new. In the first paragraph of his landmark 1927<i>JAMA</i>article, Francis Peabody noted that the most common criticism of young physicians of that era was that "they are too 'scientific' and do not know how to take care of patients."²A physician can hardly be "too scientific" in the sense of having an understanding of a disease and the knowledge necessary to diagnose and treat it successfully. What Dr Peabody meant almost 70 years ago,

Professional burnout among head and neck surgeons: results of a survey.

Burnout may develop in highly productive, hard-working individuals from all walks of life. Extending working hours under stressful circumstances may produce a sense of frustration resulting in emotional exhaustion, loss of empathy for patients, and a decreased sense of personal accomplishment. The membership of the American Society of Head and Neck Surgery and the Society of Head and Neck Surgeons was surveyed by mail relative to burnout. A total of 395 head and neck surgeons responded. Mean age was 48 years. The average individual worked an average of 66 hours per week. More than 70% of work was devoted to patient care of which 30% to 50% was devoted to the management of head and neck cancer. A total of 128 (34%) individuals responded that they felt "burned out." Only 27%, however, indicated frustration with disease, whereas 67% indicated frustration by government and 58% indicated frustration by the economics of medical practice. Most respondents enjoy their work, nevertheless, the stress of extending working hours dealing with severely ill patients, and the increased need to deal with government and economic issues is of concern to the community of physicians practicing head and neck surgery. Discussion about and confrontation with these issues are appropriate to facilitate and enhance an individual's ability to continue to function productively in this environment.

Health care in transition. Consequences for young physicians. Council on Long-Range Planning and Development

Individuals planning for a career in medicine must weigh a number of factors into their decisions. Increasingly, they must understand the nature of the socioeconomic environment of health care, including the extent of competition with other physicians and other health professionals; the degree of autonomy from health care institutions, government, and third-party payers; the impact of demographic or technological changes; and the economics of medical practice. This report analyzes the environment of medicine, emphasizing those elements that will be most important to medical students and resident physicians. It focuses on three stages of a physician's career: obtaining a medical education, beginning to practice medicine, and maintaining a viable practice.

Future trends in the economics of medical practice and care

A revolution is taking place in the American health care industry. The basis for these changes is the rapid escalation of health care costs to nearly 11% of our gross national product. The changes have caused a controversy regarding whether cost containment reduces the quality of medical care. Our present system was built on the premise that the highest quality of health care could be delivered to all fairly and without any form of rationing. This has led to a massive growth in facilities and the number of physicians. In simple economic terms the market factors in the environment should have lowered the cost of care. However, the cost of care has increased even more rapidly than expected. It seems likely that older economic principles must be abandoned to control costs. Price competition, preferred providers and more efficient hospitals must all be encouraged. Overutilization of care must be discouraged by proper incentives, and overpricing by physicians may require fixed cost reimbursement. Two-tiered health care delivery will develop and small segments of the population may receive a lower quality of care. Rationing of care may be a simple alternative.