The science of psychology spans the three Research Councils of Canada. It includes the biological determinants of behaviour, such as the study of basic brain processes, memory, thought, perception (NSERC), the contribution of human behaviour across the continuum of health and health care (CIHR), and factors related to the workplace and society at large (SSHRC). Psychology is one of the few disciplines with such a broad scope of scientific interests, which allows it to act as a meeting ground and synthesizing agent for research from all three councils and from many other disciplines.
Though the concept of employee assistance programs (EAPs) is widely accepted throughout business and industry, few hospitals have established similar channels for dealing with workers whose personal problems cause work-related problems. Among the reasons for the health care profession's lack of involvement in this area are: lack of information about costs and benefits of EAPs; the hospital's multidisciplinary environment in which standards of employee competence and behavior are set by persons from many disciplines; hospital working hours; and health care workers' attitudes about their vulnerability to illness. St. Benedict's Hospital, Ogden, UT, however, has confronted the question of how to demonstrate Christian concern for its employees. St. Benedict's EAP, the Helping Hand, which was created in 1979, combines progressive disciplinary action with the opportunity for early intervention in and treatment of employees' personal problems. When a worker with personal problems is referred to the EAP coordinator, he or she is matched with the appropriate community or hospital resource for treatment. Supervisors are trained to identify employee problems and to focus on employee job performance rather than on attempting to diagnose the problem. St. Benedict's records during the program's first three years illustrate the human benefits as well as the cost savings of an EAP. Of 92 hospital employees who took part in the EAP, 72 improved their situations or resolved their problems. The hospital's turnover rates declined from 36 percent to 20 percent, and approximately $40,800 in turnover and replacement costs were saved.
As hospitals attempt to survive in today's new competitive environment, they will find that the traditional organizational structure does not work. This structure can be characterized as a three-legged stool. Governance, management, and medical staff existed in relative harmony, with each able to attend to its own distinct, separate responsibilities. The medical staff regulated itself, the governing board had no serious difficulties in coping with the institution's finances, and the CEO was concerned solely with the physical plant and hospital personnel. In a riskless economic environment, this three-legged stool could remain stable. In the coming years,however, a hospital will need a clear-cut, identifiable leader if it is to survive. To centralize authority primarily in the CEO's hands will be a difficult step for nonprofit hospitals, particularly those sponsored by religious institutions, because of their tradition of operating much as a charitable social agency rather than a business. But this step must be taken, even to the extent of naming the CEO as chairman of the board, for a leader is required who has the authority to make quick decisions in the competitive marketplace. Timeliness is of strategic importance in such an environment, and governing boards increasingly will find it impossible to make timely decisions on a collective basis. Moreover, CEOs will have to coordinate the activities of management, medical staff, and the governing board. They will need to play a strong role in ensuring that target levels in DRG costs are met, and they will need the authority to mediate in issues in which the hospital's economic interests are pitted against physicians'.(ABSTRACT TRUNCATED AT 250 WORDS)
Clarence Herbert, 55, stopped breathing following routine surgery in August 1981. Though a respirator restored his breathing, the lack of oxygen had caused severe brain damage, and Mr. Herbert was in a coma. Whether he could recover beyond a vegetative state was not known. Two days after her husband was placed on the respirator, Mrs. Herbert authorized the withdrawal of all life-support means. Mr. Herbert died six days later. Charges of murder by deprivation of treatment against the two attending physicians were dismissed in a lower court, a decision that was upheld in the state appeals court. Because court accounts are unclear, it is impossible to judge whether withdrawal of treatment was moral in this case. This case, however, raises a question about life-sustaining treatment in general. What is the moral criterion for withdrawal: quality of life or quality of treatment? The quality-of-life principle removes the obligation to take life-sustaining measures when a person's life does not or will not meet certain standards. Quality of treatment permits the withdrawal of even minimally burdensome treatment if it is considered useless. Though the California case appears to rest on these principles, withdrawing treatment from a person in a permanent coma, such as Mr. Herbert, implies that the quality of life is so low that life is not worth preserving, if the patient has no potential for conscious life, others have no duty to preserve it. This judgment may be acceptable in a terminal case when treatment truly is useless; however, withdrawing treatment that is useful in prolonging life cannot be justified.
Competitive practices and the prospective payment system are among factors challenging Catholic health care facilities' commitment to serve the poor and elderly and to provide individualized care. To concentrate their mission on services to the marginated and thus alienate other payer groups through inability to compete in either services or price is fiscal suicide. Sponsors and CEOs of Catholic facilities are exploring creative solutions to this dilemma: Revising the mission statement. The facility may restate its goals--e.g., to provide an "adequate" level of care and technology, rather than "the best care possible;" Changing delivery methods to focus on outreach services, ambulatory care centers, surgicenters, etc.; Finding new ways of providing charity care through endowment, trust, foundation, and unrelated business income. Corporate restructuring to generate income and protect the facility's asset base is being widely studied. Because many congregations sponsor several institutions, Catholic health facilities are well positioned to enter multi-institutional systems and participate in networking as a means to save money and to market services. Catholic health care facilities must form a nationwide system of influence in the growing public policy debate about access to and rationing of health care. Before these issues are resolved; Catholic facilities will continue to feel pressure to provide services beyond their means. The chief executive officer has four particular tasks during this period: To use an entrepreneurial approach to generate funds to support the facility's mission activity; To guide the board of trustees to accept multi-institutional arrangements; To raise legislators' and citizens' awareness of the institution's fiscal challenges; To motivate the institution's staff to provide individualized, compassionate care in spite of the depersonalizing effects of DRGs.(ABSTRACT TRUNCATED AT 250 WORDS)
Measuring costs and revenues on a diagnosis related group (DRG) basis allows health care managers to define product lines, identify market shares, and examine the effects of case mix and physician behavior on profitability. It also enables public agencies to predict bed needs and evaluate certificate-of-need applications. The large number of DRGs, however, and other managerial considerations may discourage the use of DRG-based budgeting and planning. To save time and enhance data usefulness, financial officers may consolidate the DRGs into fewer groups. Revenue, for example, can be estimated by grouping the DRGs into 23 major diagnostic categories or by clustering them according to cost weight or into one group. Comparisons of payment rates and costs will identify the DRGs that lose money and will determine whether departmental costs are excessive. Strategic planning units formed from the 468 DRGs will help health care managers analyze and project performance. Product lines for this purpose may be clustered according to major diagnostic category, physician specialty, or clinical department. Since a potentially enormous amount of DRG-based clinical and financial information could be generated, hospitals should create data committees to ensure that managers receive only the information they need.
Pathways, and adolescent family life demostration program at St. Ann's Infant and Maternity Home in Hyattsville, Maryland, which initiated activities in March, 1983, served 268 clients in its 1st year. 59% were 17 years of age or under. A 5-year grant from the Department of Health and Human Services Office of Adolescent Pregnancy Programs provided for residential care for pregnant adolescents lacking family to assist them in the last phase of pregnancy; a day program offering accredited educational services and community vocational resources, training in parenting skills, individual and family counseling, and prenatal care for teenagers; an aftercare residence for adolescent mothers and their infants with an intensive program of vocational and parenting education; and a community outreach program offering health care, counseling, family life education, adoption, and other services. The program differs from previous programs at St. Ann's in 5 main ways: 1) substantial care is available to teenage mothers after delivery 2) educational services have been expanded for mothers living at home and attending during the day 3) a more comprehensive counseling program with more intensive family focus in included 4) the program is raching out into the community with a range of services to adolescents seeking assistance, regardless of race, religion, or financial status, and 5) an evluation program has been developed to monitor the operating program, the adolescents receiving services, and their children. The National Center for Family Studies at the Catholic University of America has assisted in staff training and service delivery design. Follow-up studies on clients who have left the program are only beginning. Counseling plans are formulated to fit individual needs, but all residents participate in group therapy sessions led by a psychiatrist and social worker. The infants' fathers and the adolescents' parents recieve services when possible. Although the grant finances the basic program, additional funds are contributed by foundations, United Way, program service fees, and public agencies. Client fees are based on a sliding scale which ranges from 30-100% of the acutal cost of care. Maximum enrollment in the program is 8 mothers and babies in the Aftercare Program, 25 adolescents in the residential program, 10-16 in the day programs, and 40-50 in the coumunity outreach program.
The final rules for the first year of Medicare's prospective payment contain a number of crucial revisions of the interim rules: Payment standards. Because of a revised estimate of inflation, the adjusted federal standardized payment amounts have been reduced about $12. Update factors. Revised inflation updating factors will be applied to the hospital-specific portion of payment rates and will reflect a lower (0.1 percent) budget-neutrality adjustment. Outliers. For the three-year transitional period, additional payments for outlier patients will be based entirely on a smaller percentage of the federal payment amounts. Permissible charges to beneficiaries. Hospitals may charge beneficiaries for custodial care and medically unnecessary services before the day-outlier threshold is passed if the hospital or its utilization review committee determines that the beneficiary no longer needs inpatient care; this determination is confirmed by the attending physician or external medical review entity; and the patient is notified of the determination and potential charges. Periodic interim payment. This payment may be adjusted semiannually, or more frequently at a hospital's request. Biweekly payments will be made for items reimbursed on a reasonable-cost basis.
Preferred provider organizations (PPOs) have caused concern because they raise the question whether providers can establish mechanisms to control the price of medical care without violating antitrust laws. The U.S. Supreme Court recently decided in Arizona v. Maricopa County Medical Society that the practices of a physicians' organization which set fee schedules by majority vote constituted price fixing because "independent competing entrepreneurs" made the agreements. The decision implies that PPOs must carefully structure collective efforts to set prices in order to avoid unlawful agreement among competitors. To avoid antitrust exposure, hospitals may independently determine prices and contract individually with providers, or they may act as brokers for individual physicians, establishing fees and claims-processing procedures and then contracting with physicians who agree to these requirements. Setting fees independently may be difficult, however, since hospitals need to know what payment physicians will accept. Thus some physician involvement is probably inevitable. No antitrust liability results, however, if individual physicians are sampled in an information-gathering process but do not collectively set fees. In addition, a PPO that is structured as a partnership or other joint arrangement involving true risk sharing should withstand antitrust challenge. In recent business review letters, the Department of Justice approved two different PPO structures: A Hospital Corporation of America subsidiary would contract (nonexclusively) with providers, hospitals, and third party payers to treat the third party payers' beneficiaries at discounted rates. The charges would be negotiated individually with each physician and hospital. A management consultant firm would act as an intermediary between providers and third party payers, negotiating patient discounts but not participating in fee setting. A PPO need not be structured in every respect like these programs. Individual situations vary, and with sound antitrust advice, PPOs can avoid legal pitfalls.
The master indenture enables members of multiinstitutional health care systems to finance capital programs and expansions by borrowing on the basis of systemwide revenues and assets. Participation in a master indenture financing may be structured in two ways. In a restricted group, only the parent organization issues notes, and only the parent is directly liable for the debt. To ensure that each member's revenues flow to the parent, the latter must have sole member status and be permitted to approve subsidiaries' debts, budgets, amendments to articles and bylaws of incorporation, and selection of trustees. Each entity's articles and bylaws must permit it to support the system members' common charitable purpose. In contrast, members of an obligated group have direct joint and several liability for master indenture notes. If one subsidiary misses a payment, the parent can call for payment from other obligated group members. Limitations on a member's obligation to support system debt in case of insolvency or bankruptcy may be included in the master indenture provisions. Whichever structure is selected, the amount of debt that can be incurred is based on the institutions' combined financial statements. The master indenture thus allows financially weak institutions to benefit from the credit strengths of stranger system members and permits the parent organization to control members' access to capital markets.
To meet spiraling costs, tax-exempt hospitals increasingly are operating businesses unrelated to direct patient care. Knowing which activities may be open to challenge by the Internal Revenue Service (IRS) is essential to avoid the unrelated business income (UBI) tax. Three criteria must be met for an activity to be taxable as UBI: It must constitute a trade or business; It must be regularly carried on; and It must be unrelated to the organization's exempt purpose. The Internal Revenue Code and IRS rulings clearly exclude the following areas from UBI taxation: Activities performed by unpaid volunteers (e.g., hospital auxiliaries' fund-raising dinners and bazaars and the operation of thrift stores); Operations conducted for the convenience of the organization's members, students, patients, or employees (e.g., gift shops, cafeterias, coffee shops, parking lots, lounges, vending machines, pharmaceutical sales to inpatients and emergency room outpatients, and research activities for students' benefit; The sale of merchandise that has been received by gift (e.g., flea markets, baked goods sales, book sales, and rummage sales); Investment income such as dividends, interest, annuities, royalties, certain rents, and capital gains from the sale of investment assets; Gifts or contributions made directly to the facility; and Bingo games that are conducted commercially. Areas which may be subject to UBI taxation, or in which there have been controversial or contradictory court rulings, include: Pharmaceutical sales to the public or private physicians' patients; and Laboratory services provided to private physicians for treating their patients. IRS private letter rulings, though not precedential, have excluded from UBI taxation the x-ray income from a hospital's branch facility and rental income from property leased for use as a clinic or medical office building that is substantially related to the hospital's exempt functions. Private letter rulings have subjected to UBI taxation the income for a professional standards review organization's private review activities and debt-financed income from property that is not substantially related to the organization's exempt purpose.
In developing inpatient and home hospice services in a subacute care setting, Villa Mercy chose to forego traditional hospice models in favor of a strong medical model. It confronted six basic issues in its pioneering effects. 1. Goal formulation. Villa Mercy provides for inpatient admissions whenever appropriate, but also aims to enable patients to stay at home as long as possible and to educate health professionals and the community on hospice care and the dying process. 2. Medical model functions. A hospice core team--composed of a hospice medical director, a chaplain, a social worker, a pharmacist, and registered nurses--meets weekly and assesses each patient's progress. Each core team member follows a specific role in meeting the patient's physical, psychological, social, and spiritual needs. 3. Pain and symptom management. Specific guidelines are followed in observing and listening to the patient, administering pain medication and controlling dose increases, working with patients who are in chemotherapy or drug therapy, and dealing with symptoms caused by the drug regimen. 4. Inpatient versus home care issues. the staffs of both components must coordinate their efforts and feel comfortable with moving patients from one component to the other. 5. Reimbursement channels. Title 18, Blue Cross, and other commercial third party payers have provided coverage at Villa Mercy. Tightening Health Care Financing Administration (HCFA) regulations, however, will make funding more difficult for providers operating under HCFA guidelines. 6. Volunteers. Volunteers are an essential part of the facility's hospice services and receive 20 hours of intensive classwork over a 10-week period before working with a patient and family.
Because of the development of multihospital systems and the establishment of diagnosis related groups, hospitals increasingly will establish matrix organizations for their corporate structures. St. Luke's Hospital adopted the matrix concept in the mid-1970s, utilizing program administrators for each specialty service or "clinical center of excellence." Such centers have been developed in digestive diseases, cardiovascular and pulmonary medicine, orthopedics and rheumatology, ophthalmology, and behavioral health. The program administrator's functions are diverse: To serve as primary liaison between physicians and the hospital; To project levels of program utilization and patient and physician satisfaction, to identify areas requiring administrative and marketing emphasis, and to develop the program's marketing plan; To develop, implement, and evaluate the program's strategic, operational, and financial plans; To recruit physicians to practice at St. Luke's and to cultivate referrals from outside physicians; To participate in selecting members of all board and medical staff committees relating to the particular specialty area; and To determine the need for new programs within the specialty area and to develop services. As indicated by a medical staff survey, most physicians at St. Luke's believe that the program administrator system has improved communication with the hospital administration, that the program administrator is able to respond effectively to physician requests and problems, and that the quality of patient care has been enhanced. A great majority said they would recommend the system to other hospitals.
As pressure mounts to contain Medicaid long term care spending, short-range "quick fixes" must be avoided. Three such false solutions in particular have shortcomings that may actually exacerbate long term care's financial dilemma because they are based on inadequate definitions of the problem. Two of these proposals--legislation to broaden family responsibility toward institutionalized elders on Medicaid and expanded state power to put liens on such elders' real property--err by trying to mandate "caring" and are predicated on a misunderstanding of the "spend-down" problem. The other proposal--to provide tax incentives to family members who care for elders--requires a large administrative apparatus, assumes an elasticity of supply that may not exist, and could disrupt the "gift relationship" on which family exchanges are often based. What is needed is a strategy with short term, intermediate, and long term objectives that move toward an insurance approach. The short term plan should lay the groundwork for intermediate strategy and control costs by changing rate-setting methods and putting limits on facility construction. The intermediate plan should change the problem's definition from one of merely controlling Medicaid long term care expenditures to one of efficiently managing state resources for the elderly through the development of state financing and local delivery systems that target older persons in greatest need. An effective means of doing this is through the creation of social/HMOs, which have five key features: integration of service responsibility and authority; flexibility in organizational design; balanced clientele; pooled prepaid funding; and financial risk for the provider organization. Finally, the long term strategy should transfer much of the long term care financial burden from individuals and state Medicaid agencies to insurance mechanisms. Many individuals would thus avoid impoverishment caused by health care spending and Medicaid would greatly reduce its caseload. Insurance coverage is an appropriate funding mechanism, moreover, in that relatively few persons will ever incur high costs.
