AAMSE Trends Identification Report

Transcription

AAMSE
Trends Identification Report
2009
American Association of
Medical Society Executives
Trends Identification Report
2009
AAMSE Trends Identification Report 2009
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Task Force Members
Jon H. Sutton, MBA, Task Force Chair
Manager, State Affairs
American College of Surgeons
Barbara Greenan
Senior Director, Advocacy
American College of Cardiology
John S. Jordan, CAE, Board Liaison
EVP/CEO,
Pennsylvania Academy of Family Physicians
Matthew Katz, MS
Executive Director,
Connecticut State Med Society
Palmer Jones, Board Liaison
Executive Vice President
New Hampshire Medical Society
Michael Kulczyki, CAE
Executive Director
The Joint Commission
Gregory Bernica
Executive Vice President
Harris County Medical Society
Linda Lambert, CAE
Executive Director
American College of Physicians - New York
Jason Byrd, JD
Associate Director, Practice Mgmt and QI
American Society of Anesthesiologists
David McKenzie, CAE
Reimbursement Director
American College of Emergency Physicians
Bruce Balfe, Consultant
Elizabeth Schumacher, JD
Senior Attorney
American Medical Association
Bruce Butterfield, CAE, APR
President
The Forbes Group
Spencer Su Li, MPA
Director, International Activities
American Academy of Pediatrics
Fraser Cobbe
Executive Director
Florida Orthopaedic Society
Steve Smith, CAE
CEO/Executive Director
American Academy of Hospice & Palliative Medicine
Matthew Fitzgerald, MPH, DrPH
Associate Vice President for Quality
American College of Cardiology
James Swartout
Associate Executive Director
American Osteopathic Association
Donald Zeigler, PhD
Planning Director/Strategic Analysis
American Medical Association
Table of Contents
Medical Society Management, Finance and Communications................................. 4
Electronic Medical Records and Health Information Technology............................ 6
Access to Care and Health System Reform................................................................ 8
Changing Healthcare Workforce................................................................................ 10
Medical Society Membership as a Value Proposition.............................................. 12
Public Health Infrastructure and its Relationship to Healthcare Delivery............. 13
Quality of Care and Patient Safety............................................................................. 15
Payment Systems and Insurance Reimbursement Reform.................................... 18
Sources........................................................................................................................ 20
Additional reprints of this report are available to AAMSE members for $10.
For more information please email [email protected]
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Medical Society Management, Finance and Communications
Greg Bernica, Jason Byrd, JD, Spencer Su Li, MPA
Changes in the healthcare sector, including restraints on physicians’ income, decreasing hospital and practice operational
margins, mergers within the pharmaceutical, insurance and hospital industries, new technologies and new government
regulations have created challenges for medical societies. In addition, potential substantial health care reform and difficult
economic conditions pose enormous challenges for societies to position and prepare themselves. Societies and their
executives must demonstrate the tangible and intangible value of membership, develop new sources of non-dues income,
embrace a new era of collaboration and cooperation with a variety of organizations, and effectively communicate with
members in an information overload environment.
Trends:
• With increasing restraints on physicians’ income,
physicians are paying members dues and purchasing
medical society services based upon the perceived value
of membership and those services. It is more difficult
to raise dues when physicians’ fees are not increasing
unless physician members are convinced of the value of
their membership.
• Public education and communication will become a
key component of medical societies with the increased
emphasis on patient-centered care. Societies will develop
and/or enhance portions of their web site or separate web
portals to serve this purpose. This could increase the
value of membership as it represents an opportunity to
promote the respective professions.
• Mergers of pharmaceutical companies, insurance
companies and hospitals have increased their bargaining
clout for their share of health care dollars and reduced
sponsorships/advertising sources of non-dues income.
• Outside companies are developing products and services
to provide to society members that are in competition with
products and services that are or could be provided by
medical societies.
• Pharmaceutical, Office of Inspector General and
Accreditation Council for Continuing Medical Education
guidelines have become more stringent.
Medical
societies, such as the American College of Cardiology
and the American Psychiatric Association as well as
influential organizations as the Journal for the
American Medical Association and the Macy
Foundation have called for either the complete
elimination or significant reduction in the amount
of educational grant and fundraising opportunities
allowed by pharmaceutical and device
manufactures. Ethical questions and additional legislative
restraints on industry funding of educational offerings will
further erode sources of non-dues revenue for societies.
• More physicians are transitioning from private practice
to being employed. These physicians rely upon their
employer for services traditionally provided by medical
societies and may question the value of continuing their
membership in the society. With larger corporations
merging and acquiring physician practices and hospitals,
societies may face future competition with such
corporations.
• The Internet has become a necessary tool for medical
societies; though the Internet, by itself, is unlikely to be
a revenue producing vehicle, it should serve as a costeffective repository for the various revenue-producing
products developed by societies.
• The Internet and other technologies have the potential
to create both competitors and partners from around the
world.
• Email, web-based seminars, and other developing
technologies provide new opportunities to communicate
with members. Information overload, which has always
been a problem for busy professionals, has expanded
with the new technology. Societies will need to balance
ease of communication with necessity.
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• Natural and man-made disasters have substantially
impacted several medical societies and their members
over the last several years.
• Accounting scandals among elite corporations have
lead to more public and government scrutiny of financial
information and controls. Changing tax laws may cause
societies to modify their governing structure, including
composition and size of their Board of Directors, to
maintain their non-profit/charitable status.
• Negative economic conditions will put pressure on
sponsorship and advertising revenue.
Medical societies and their executives should:
• Understand the unique needs of each physician segment and match resources that address those needs. Focus
on needs that the medical society is uniquely qualified to meet and on resources for services that provide the most
value to the most members.
• Develop “member only” opportunities/services/pricing so there are tangible reasons to pay dues. Evaluate
opportunities for non-dues revenues and/or enhanced member services associated with advances in information
technology and services.
• Develop or enhance public portals to educate patients, consumers and others on the profession and its value
with content and/or technology to “pull” members and non-members to your website. Invest money or partner
to develop a web presence to meet members’ needs and demonstrate the value of the organization, including
“members only” section and personal customization for members.
• Educate members in seeking and obtaining sponsorships and grants.
• Pursue strategic partnerships/alliances as potential methods of developing new non-dues revenues or reducing
costs for producing programs or services. Societies need to establish criteria for selecting partners to ensure
common goals and values as well as financial stability. Develop win-win partnerships with sponsors and advertisers
so the society is a priority even when advertising budgets are reduced.
• Evaluate dues structure to ensure value equals or exceeds dues. Identify services that can be removed from the
dues structure and billed to the specific users and/or beneficiaries. Investigate means to assist group practices in
exchange for paying or promoting membership.
• Evaluate cost effectiveness of outsourcing administrative functions that are not core competencies of the society.
Implement tighter financial controls and provide total transparency on all financial transactions to the governing
board. Association boards will be expected to more closely monitor business, conflicts of interest, and financial
affairs of the association as part of their fiduciary responsibility.
• Determine how new Internal Revenue Service reporting requirements for non–profits will impact your organization.
• Customize communications to meet members’ specific needs and preferences. Determine how to differentiate
your messages. Continue the transformation to and enhancement of digital products offerings whenever possible.
Digital products are affordable to produce relative to traditional print media, and thus, afford opportunities to
disseminate large amounts of information at reduced costs. However, societies will need to be mindful of ensuring
they continue to reach portions of their membership who do not use the Internet.
• Develop a disaster plan that allows the society to continue to operate and communicate with members under
various disaster scenarios.
• Consider increasing the size and scope of their memberships by allowing for additional members related to the
profession traditionally represented by the society. However, with potential increasing memberships, societies will
need to personalize the member’s experience through the website (use of cookies or personalized home pages),
annual meeting and educational experiences.
• Effectively convey association policy messages to legislative and government bodies during potential health care
reform discussions. Educating and encouraging membership ownership and participation in this process will be a
primary key to success.
• Consider webcasting of meetings and educational offerings as societies and members reduce travel costs with the
struggling economy.
• Identify resources available in other countries that could be used to achieve the society’s global and/or domestic
mission, and establish partnerships with supporters in emerging economies.
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Electronic Medical Records and Health Information Technology
Linda Lambert, CAE, Babette Peach
Health Information Technology
Healthcare experts, policymakers, payors, and consumers consider health information technology to be an essential
element in transforming the healthcare industry. Given the current fragmented nature of health care, the need to integrate
new scientific evidence into the practice of medicine, the emergence of telemedicine activities including secure messaging
and eVisits, and the importance of practice transformation to achieve improved health outcomes, paper-based systems
are becoming obsolete. In theory, the benefits of HIT are evident; however adopting these technologies has been difficult
and slow. In January 2009, President-elect Barack Obama called for all U.S. residents to have electronic health records
within five years and that he would seek allocations of $50 billion over five years to support the adoption of standardsbased HIT systems and interoperable national health information network1
Trends:
• The federal government will continue to expand the
Office of the National Coordinator for Health Information
Technology (ONCHIT) and agencies such as eHealth
Initiative (eHI) will form multi-stakeholder collaborative to
promote use of Health IT and Electronic Medical Records.
• Growth will be progressive – taking steps to adopt
segments of HIT such as e-prescribing and expanding to
full electronic medical records.
• Physicians will use point of service IT to most efficiently
serve their patients.
• States will seek to fill the gap of implementation as they
see the benefits.
• Payors and hospital systems will offer opportunities to
implement various phases of HIT in physician practices
in exchange for expectation of more efficient claims filing
and to collect data not only to determine the level of
services performed but to assess the quality of services
delivered and their adherence to standardized practice
measures.
Electronic Health Records
Electronic health records have the potential to improve the delivery of health care services. However, in the United States,
physicians have been slow to adopt such systems. A national study released in June 2008 by the New England Journal
of Medicine assessed physicians’ adoption of outpatient electronic health records, their satisfaction with such systems,
the perceived effect of the systems on the quality of care, and the perceived barriers to adoption and confirms previous
research:
Respondents:
• Four percent of respondents reported having a fully
functional electronic-records system, 13% reported
having a basic system.
• Of the small number of respondents who had a fully
functional system, 71% reported that their system was
integrated with the electronic system at the hospital
where they admit patients, as compared with only 56% of
respondents with a basic system.
• Among the 83% of respondents who did not have
electronic health records, 16% reported that their practice
had purchased but not yet implemented such a system at
the time of the survey. Additionally 26% of respondents
said that their practice intended to purchase an electronicrecords system within the next 2 years.
• Physicians who practice in groups of more than 50 were
three times as likely to have a basic electronic-records
system and more than four times as likely to have a fully
functional electronic-records system as were physicians
in groups of 3 or fewer. However, even in large groups,
only a small minority (17%) had a fully functional system,
and 49% had no electronic-records system at all.
• Electronic-records systems were more prevalent among
physicians who were younger, worked in large or primary
care practices, worked in hospitals or medical centers,
and lived in the western region of the United States.
• Rates of adoption did not differ significantly among
providers serving a high proportion of minority patients
or patients who were uninsured or receiving Medicaid, as
compared with other physicians.
1. ABC News Medical Unit, President-Elect Urges Electronic Medical Records in 5 Years, January 09, http://abcnews.go.com/Health/President44/
Story?id=6606536&page=1
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• Among the 17% of doctors with a fully functional or basic
electronic-records system, at least 97% reported using all
the functions at least some of the time.
• Among the small number of respondents who had fully
functional electronic-records systems, most physicians
reported the positive effects of the system on the quality
of clinical decisions (82%), communication with other
providers (92%) and patients (72%), prescription refills
(95%), timely access to medical records (97%), and
avoidance of medication errors (86%).
• Furthermore, 82 to 85% reported a positive effect on
the delivery of long-term and preventive care that meets
guidelines. For physicians with basic systems, the extent
of positive effects was generally smaller.
• Most of those with fully functional systems reported
averting a known drug allergic reaction (80%) or a
potentially dangerous drug interaction (71%), being
alerted to a critical laboratory value (90%), ordering a
critical laboratory test (68%), and providing preventive
care (69%).
• Ninety-three percent of physicians with fully functional
systems reported being satisfied with their electronicrecords systems overall. 88% of physicians with basic
systems reported being satisfied with their electronicrecords systems overall
• Eighty-eight percent of physicians with fully functional
systems reported an ease of use of the system when
providing care to patients. Eighty-one percent of
physicians with basic systems reported an ease of use of
the system when providing care to patients
• Ninety percent of physicians with fully functional
electronic-records systems were significantly more likely
to be satisfied with the reliability of their system than 79%
of those with basic systems
• Among physicians who did not have access to an
electronic-records system, the most commonly cited
barriers to adoption were capital costs (66%), not finding
a system that met their needs (54%), uncertainty about
their return on the investment (50%), and concern that a
system would become obsolete (44%).
• Factors that were most frequently cited as facilitators
of adoption were: financial incentives for the purchase
(Fifty-five percent among physicians with no electronic
health records and 46% among those with electronic
health records); and payment for use of an electronicrecords system (57% and 52%, respectively).
• About 40% of respondents with and without an electronicrecords system also reported that protecting physicians
from personal liability for record tampering by external
parties could be a major facilitator of adoption.
• Monitor federal and state legislation and policies regarding EMR/HIT.
• Become familiar with and advisers to oversight agencies at the federal and state levels to provide input and serve
as resources on IT issues that affect physician practices.
• Be able to analyze complex information (such as security and confidentiality rules) and to condense the information
in a way which make it easy for members to understand.
• Find physician members who are early adopters and solicit their participation in the development of policy, to serve
as resources/advisors to collaborative and to serve as mentors for other physicians.
• Be strong advocates for proper alignment of the financial benefits of HIT adoption. Those practices that bear the
cost of systems adoption should receive proper compensation from the “payors” that will actually achieve the cost
savings.
• Establish relationships with Certification Commission for Healthcare Information Technology (CCHIT) certified
vendors to assist members with the best services relating to HIT adoption.
• Advocate for responsible public policy that promotes interoperability for records between all health providers and
systems, including physician practices, hospitals, pharmacies, nursing homes, equipment vendors, payors and
patients.
• Monitor the collection, use and reporting of data via report cards to ensure the information is valid and useful.
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Access to Care and Health System Reform
Michael Kulczycki, CAE, Linda Lambert, CAE, John Jordan, CAE, Jon Sutton, MBA
The issue of access to care and health system reform has taken center stage among policymakers and Congress
throughout the 2008 U.S. election. With the change in administration, there is strong momentum for health reform
initiatives such as system reform, a focus on public health, tax credits for small business, reductions in overall cost of care
(fiscal responsibility), improvements in patient safety and quality, and implementation of health information technology. In
addition, many members of Congress with a traditional interest in health care have released their own plans, promising a
vigorous debate for the next few years. Various groups including business, labor, health care, consumers, and others are
also driving the debate and have developed their own reform plans. These often focus on quality and cost, and represent
a variety of financing proposals for single and pluralistic payment plans.
System reform and access to care are complex issues with a multitude of factors. While some of these are addressed in
greater detail in other parts of this report; the following trends should be mentioned:
Trends:
• There are 45 million uninsured and 25 million underinsured
Americans1, with a real interest to find some way to make
health coverage available to them all. Both the president
and Congress are serious about making sure that everyone
has some type of coverage, which will be a major part of
any health system reform plan enacted. It is likely that until
a plan is passed, the numbers of uninsured will increase
as the economic recession continues to result in millions
of lost jobs and employee-sponsored health plans.
• There are not enough physicians available to provide
medical care to everyone, and training programs will not
be able to keep up with the increasing demand for services
-- particularly as the US population ages. Shortages exist
in both primary and specialty care, with rural areas the
first to be impacted especially with regard to trauma and
emergency care. As primary care physicians, general
surgeons, and other specialists move into retirement, it
will be increasingly difficult for rural hospitals to adequately
staff their facilities, potentially resulting in the closure
of small community hospitals in areas where they are
critically needed.
• Pressure will be put on Congress to substantially increase
funding for medical education and residency training to
address the primary care and specialist shortages.
• The patient-centered medical home (PCMH) is an
approach to provide comprehensive, coordinated
healthcare for patients. It facilitates a partnership between
the individual patient, their personal physician, and when
appropriate, the patient’s family (Joint Principles of the
Patient-Centered Medical Home, Feb 2007). Since
numerous demonstration projects have just gotten started,
it will be a year or two before data is available to determine
the overall feasibility/viability of the concept. Questions
also remain about the details of the PCMH, particularly
related to physician payment mechanisms, availability (or
not) of new funding, how systems of care will work, who is
eligible to be the medical home provider, and so on.
1.
• The serious shortage of primary care physicians and
other physician specialties is well documented2. Studies
and solutions will be tested in an effort to create an
adequate physician workforce.
• Quality and patient safety will continue to be a cornerstone
of health system reform proposals. The adoption of
evidence-based guidelines and pathways, as well as
promotion of those guidelines and pathways into clinical
practice, will accelerate implementation of standards of
care and cost efficiencies.
• More patients (whether insured, uninsured, or
underinsured) will take advantage of the basic care
provided in retail clinics or urgent care centers, driving
expansion of these facilities into various settings. Large
corporations may consider opening similar clinics within
their own buildings in order to reduce health insurance
costs, provide basic lab testing, and implement well-care/
preventive care programs.
• Particularly for the uninsured or underinsured, the
number of people participating in medical tourism will
expand. More overseas hospitals will become accredited
by The Joint Commission and other accrediting
agencies, drawing highly-trained medical professionals
to their facilities. Insurance companies and self-insured
employers will take advantage of cross-border care
providers to save money.
U.S. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2007, August 2008
2. Asletine, Robert H., Jr., PhD and Katz, Matthew C., MS and Geragosian, Audrey Honig, Connecticut Physician Workforce Survey 2008: Final
Report on Physician Perceptions and Potential Impact on Access to Medical Care, September 2008
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• Manage the expectations of their diverse memberships with regard to various facets of health system reform plans.
In all likelihood, new money for physician payment will be limited, and competing interests (such as specialty vs.
specialty and inpatient vs. ambulatory care spending) could end up dividing medicine at a time when it most needs
to be united. Staff may need to be the “voice of reason” with leadership and membership to achieve meaningful
reform.
• Encourage appointment of health system reform committees to be able to provide rapid responses to proposals so
that the medical society/physician community may be properly represented.
• Work with members to advocate for health system reform, access to care for all, and to work as advocates
for patients. Not only should this involve advocacy training and relationship building, but also regular targeted
communication with medical society members and legislators/policymakers.
• Determine member needs regarding selection and implementation of health information technology (HIT). Medical
societies that can assist their members with valuable information on HIT products and services will have a
competitive advantage in the membership marketplace.
• When reform is passed, devote considerable resources to informing and educating the membership about the
reform, its implications for practice and encouraging them to be involved in shaping the new system.
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Changing Healthcare Workforce
Bruce Butterfield, CAE, APR, David McKenzie, CAE, Matthew Katz, MS
The current and foreseeable shortage of physicians and other healthcare workers has some of its roots in declining
birthrates a generation ago. Consequently, the “Gen X” generation, born after 1964, is the smallest generational cohort
– 46 million compared with 77 million Baby Boomers and nearly 80 million Millennials (the children of the Boomers, born
after 1980). This smaller cohort means that college enrollments are on a slide that will continue through the second
decade of the 21st Century. While the U.S. Department of Health and Human Services (HHS) says that the number of
full-time physicians will increase by about 12 percent between 2005 and 2020, demand for them will be nearly double that
as a result of the size and health care needs of the Baby Boom generation.
As a result, the U.S. must rely increasingly on a foreign-born and foreign-trained healthcare workforce at a time when
post 9/11 security concerns and current economic conditions make it difficult to enter and work in America. Legal and
administrative costs of obtaining a permanent work visa can approach $20,000 with no guarantee of being granted,
and the Immigration and Naturalization Service sends home nearly half-a-million foreign-born. Other Western countries
face the same skills shortage but impose fewer immigration restrictions, which puts the U.S. at a great disadvantage in
attracting these workers.
Trends:
• Due to sharp cuts in medical school support in response
to the projected oversupply of physicians in the late
1970s, no new medical schools were opened in the U.S.
from 1982 to 2005. With the domestic supply of new
doctors fixed, while a larger and older patient population
continued to demand more care, much of the increase in
the supply of physicians has come from outside the U.S.
Today, nearly a quarter of all practicing licensed surgeons
in the U.S are foreign born and educated or U.S. citizens
trained abroad.
• In addition, the growing proportion of women physicians
is expected to exacerbate the doctor shortage. The
proportion of new medical school graduates who are
women has risen from just ten percent in 1980 to close to
half of all graduates today. So far, women have exhibited
a tendency to retire slightly sooner, spend fewer hours
providing patient care, and are less likely to work in rural
areas2. As their share of the over-55 workforce grows
from one in eight today to one in four by 2020, the rate of
retirements is expected to accelerate.
• According to American Medical Association (AMA)
estimates, a third of all “active physicians,” those who
work 20 or more hours per week, will be 55 years old
or older by 20101. By 2020, their share of total active
physicians will top 40%. Although physicians tend to
retire later than most workers (more than 40% of all
male doctors between the ages of 70 and 75 are still in
the workforce, compared to only 20 percent of all male
workers), older physicians are also more likely to work
fewer hours. Because of this factor the number of fulltime equivalents (FTEs) practicing physicians is actually
lower than these numbers would suggest.
• These projections by HHS are alarming in their stark
contrast to anticipated increases in demand. The aging of
the population, overall economic growth, and anticipated
medical breakthroughs and technological advances are
expected to increase the demand for medical services
well in excess of supply trends.
• Until now, the number of recent medical school graduates
and immigrants with medical degrees had offset declines
from retirements. The U.S. Department of Health and
Human Services (HHS) expects the balance will tip in
the next decade as the acceleration in retirements will
outnumber medical school graduates whose numbers
have changed little from year to year since the 1982
establishment of a moratorium on new medical schools
in the U.S. due to the anticipated surplus of doctors.
• While much angst has been expressed about the loss of
U.S. jobs, the healthcare sector continues to be strong with
an unemployment rate of 3.1 percent3. Chronic shortages
of nurses continue unabated. The HHS estimates that
by 2020 the number of registered nurses will have fallen
short of demand by 29% or 800,000 unfilled positions.
According to Nursing Management magazine, 55% of
nurses plan to retire between 2011 and 2020. Meanwhile,
the U.S. Bureau of Labor Statistics (BLS) projects that
one million new and replacement nurses will be needed
by 2016.
1. American Medical Association (AMA), Physicians Characteristics and Distribution in the United States, 2001 & U.S. Bureau of the Census, Current
Population Survey, 2001
2.
The Forbes Group, Plotting the Future of Cytopathology, May 2007
3.
U.S. Bureau of Labor Statistics, TABLE: Unemployed persons by occupation, industry, and duration of employment, March 2009
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• Additional strain on nursing availability is coming from the
explosion of retail medicine. While nurses often question
long hours and poor working conditions in hospitals,
medical clinics in pharmacy locations and other retail
locations, headed by nurse practitioners, give nurses
regular hours and significant autonomy depending on
state scope of practice laws.
• Another consequence of the growing labor shortage is the
expanded scope of practice for health care professionals
as a means of addressing access-to-care problems.
Nurse practitioners, physical and occupational therapists,
and other allied health care professionals are growing in
independence from physicians’ oversight.
• Allied health care practitioners are outpacing higher
specialties two or three to one. This means that there
will be even keener competition across health care
disciplines for skilled workers. Several states have passed
legislation allowing pharmacists limited ability to evaluate
and manage drug regimens as well as dispense drugs.
These non-physician professionals may be perceived as
competition to some private practice physicians but are
increasingly being utilized and valued in large organized
medical practice settings.
• According to the Bureau of Labor Statistics
(BLS) employment projections, professionals are
increasingly becoming employees of or contractors to
multidisciplinary practices while health care professionals
and paraprofessionals are becoming independent
entrepreneurs and business owners.
• Interestingly, a dynamic cross-border flow of medical
labor is emerging. While the Caribbean is a major
exporter of physicians and nurses to the U.S., it is a major
importer of physicians from the Middle East1. This “trade”
in medical providers, supported by private investment
and public development policies, is beginning to lead to
regional specializations. South and Central America are
developing several centers of excellence in cosmetic
surgery and dentistry.
• East Asia and India are focusing on becoming the provider
of choice for various treatments of heart disease and
other circulatory diseases. The Scandinavian countries
already have established a reputation for excellence in
geriatrics. Japan, not surprisingly because of its fastaging population, is also becoming a key resource in
community-based elder care. This trend in specialization
may be too new to fully assess how it may influence
future labor flows.
• Cross-border trade in health care services will balloon,
according to the World Health Organization (WHO),
which estimates that it will reach $1.25 trillion before the
end of the next decade. Part of that increase will be in
medical travel, which is expected to double by 2012 and
is beginning to be covered by insurers.
• Create or partner in the development of cultural “intelligence” and sensitivity training.
• Determine how to work with hospitals and healthcare providers in other countries to take advantage of more crossborder delivery of services.
• Decide how to address the increasing involvement of non-physicians in the delivery of primary care in terms of
membership and services.
• Create more interactive and unstructured opportunities for involvement of younger physicians who demand more
work-life balance. Aside from gender issues alone, younger physicians tend to demand more of a life style balance
preferring to work fewer hours per week than previous generations.
• Prepare for significant changes in healthcare delivery.
1.
Migration Information Source, The Global Tug-of-War for Health Care Workers, December 2004
11
Medical Society Membership as a Value Proposition
Steve Smith, CAE, Jim Swartwout, Barbara Greenan
A successful medical society must do more than simply provide resources, programs, services and representation through
advocacy in order to attract and retain members. Decisions to join or renew are increasingly based upon whether the
membership experience offers considerable value, unique access and sustainable support.
There is growing concern expressed by medical society leaders that today’s physicians are less interested in joining
organizations or must choose between societies due to limited time and resources. This can lead to declines in membership,
particularly as physicians are able to find what they need from other sources.
Trends:
• High value is placed on services and resources that assist
physicians in addressing and managing issues associated
with increasingly complex practice management
challenges as well as other business-related manners.
• Physicians continue to view associations as the
appropriate mechanism for representation to the
government and public.
• Although the professional liability crisis appears to have
abated in the press, physicians continue to be concerned
over liability exposure.
• E-learning modules and systems that guide, assess,
deliver and track CME with links to Maintenance of
Certification requirements are highly utilized and
increasingly integrated across platforms and providers
offering attractive “one stop” for members.
• Effective communication to members is delivered in a
clear, concise and timely manner and targeted to specific
knowledge and practice needs. Increasingly, information
is being delivered through digital mediums that include
interactive components.
• Healthcare professionals are increasingly turning to less
formal social networks and virtual resources for ongoing
collaboration, consultation and connections.
• Medical societies provide critical career and leadership
development opportunities for physicians from residency
through retirement which is an important “value added”
benefit.
• Collect and assess data from various member segments to ensure an appropriate mix of products and resources
are available.
• Strengthen communities and connections within all member segments, ensuring that strong linkages and
opportunities for interaction exist – virtually as well as in person – among all key constituent groups.
• Members are looking for resources, tools and products that are current, customizable and portable.
• Consider offering virtual membership or “pay-as-you-go” fee structures as opposed to the traditional annual
membership fee to appeal to a broader and more transient market.
• Provide “real time” support or accessible information and response.
• Engage members through surveys and interactive learning that extends beyond a single event or session.
• Gather and report data that shows the financial and professional benefits of membership in simple and compelling
terms.
• Demonstrate the society not only represents the needs and interests of its membership, but also proactively scans
the environment to alert and address emerging issues of importance to the field.
12
Public Health Infrastructure and its Relationship to Healthcare Delivery
Donald Zeigler, PhD
The public health infrastructure is made up of state and local public health organizations and staff that deliver the essential
public health services to every community and the information and communication systems used to collect and disseminate
population data. While approximately 3,000 federal, state and local governmental agencies have a role in the public health
system, no single organization or governmental agency has complete responsibility for public health goals in this country1.
Increasingly, public health addresses determinants of health, the behavioral and environmental forces that cause 70%
of avoidable mortality. Public health focuses on population health, behavioral risk factors, and the establishment of a
publicly-funded medical safety net. Public health overlaps and complements the health care delivery systems that pursue
biological mechanisms of disease, pharmacology, diagnostics, and therapeutic procedures for individual patients2,3. 45678
Trends:
• The major public health issues of the next decade are
emerging infectious diseases (e.g., influenza, monkeypox,
Dengue, drug resistant staph and TB, West Nile and
food-borne illnesses); chronic diseases; emergency
preparedness; climate change; injury mitigation; public
health research; public health infrastructure; and health
reform (including evidence-based quality care for all
persons and involving moving from a sickness to a
wellness system4).
• State-level public health preparedness is inadequate. Not
all states have adequate plans to distribute emergency
vaccines, antidotes and medical supplies. Not all states
have statutes that allow for adequate liability protection for
health care volunteers during emergencies. Some states
lack compatibility in their disease surveillance system
with that of the CDC. Some states have not purchased
antivirals to use during a pandemic flu and lack sufficient
capabilities to test for biological threats6.
• Public health is on the front lines of the country’s defenses
to prevent or contain major disease outbreaks, including
those caused by an act of bioterrorism, or to provide
wide-scale treatment to the survivors of major disasters1.
• Despite the extreme health challenges, the complex web
of public health practices and organizations is in disarray1.
• The bond between medicine and public health has
weakened in the late 20th century5.
• Extreme weather and climate events are projected
to affect agriculture, forestry and ecosystems, water
resources, industry, settlement, and every mode of
transportation. Extreme weather and rising sea levels
would have adverse effects on infrastructure, including
destruction of hospitals, primary health centers and
homes. Every mode of transportation in the United States
would be affected.
• In addition to fragmented responsibilities, there is a
lack of clear roles among state, local and federal health
agencies. There are no minimum standards, guidelines
or recommendations for levels of capacity or service
required of state and local health agencies.
• Most public health agencies are seriously understaffed
and have serious needs to upgrade the skills of their
employees. Worker qualifications have been eroding
over time.
1. US Department of Health and Human Services. Understanding and improving health. In: Healthy People 2010. 2nd ed. Washington, DC: US Dept
of Health and Human Services; 2000.
2.
McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993
3.
McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff. 2002
4. Benjamin G (Feb 29, 2008). Leading US Health Challenges: The coming decade. Coalition for Health Funding Hill Briefing, Washington, DC.
Available at: www.aamc.org/advocacy/healthfunding/obesityamerica.htm
5.
Davis R. Marriage counseling for medicine and public health: strengthening the bond between these two health sectors. Am J Prev Med. 2005
6. Committee on Climate Change and US Transportation, National Research Council (2008). Potential Impacts of Climate Change on US
Transportation: Special Report 290. Washington, DC: Transportation Research Board; 2008
7.
Ready or not?: protecting the public’s health from diseases, disasters, and bioterrorism. Trust for America’s Health
8.
Beitsch LM, Brooks RG, Glasser JH, Coble YD. The medicine and public health initiative: ten years later. Am J Prve Med 2005
13
• Collaborate with the public health community on issues of population health and emergencies, e.g., cooperate with
other governmental agencies and other associations to help physicians to acquire training and to be able to identify
and mobilize health professionals before and during an emergency.
• Provide training and resources for physicians to be able to diagnose and treat illnesses caused by exposure to
biological, chemical or radiologic agents.
• Facilitate training of physicians on:
o addressing changes in disease patterns from globalization, climate change and major weather events;
o public health and community resources; and
o the ways that healthcare professionals can play leadership and advocacy roles in communitywide health
initiatives.
• Provide training and resources so that physicians are able to integrate effective clinical preventive services
(screening, counseling, preventive medication) and community services (group education and community
resources, policy change, environmental change), e.g., tobacco and obesity, to address fully the opportunities for
prevention1.
• Medicine and public health officials need to work together to ensure adequate funding for care of patients and
whole populations2.
• Advocate for support of the public health infrastructure and prevention activities through public initiatives including:
o
o
o
o
o
o
increasing taxes on tobacco, alcohol and sweetened soft drinks;
smoke-free workplaces;
tobacco settlement funds for public health and fitness programs in schools.
adequate supplies of vaccines for patients
adequate funding for public health programs at all levels; and
support for safety-net programs, e.g., addressing social determinants of health, universal access to care,
prevention services, and disease management.
• Encourage public health and preventive medicine physicians to have a greater role in medical associations2.
• State and county medical societies should establish public health committees if they do not already have them and
expand their involvement and their members’ involvement in public health activities2.
• Medicine and public health officials should work together to bolster funding of each sector2.
• Bioterrorism and disaster preparedness, the growing burden of chronic diseases, health disparities, patient safety,
and healthcare access for the uninsured are urgent matters requiring effective collaboration between medicine
and public health7.
• Medicine and public health are both under financial siege.
14
Quality of Care and Patient Safety
Bruce Balfe, Matthew Fitzgerald, MPH, DrPH
Quality
The science of quality improvement as applied to health care was introduced in the late 1980s. The approach is simple
in its quasi-experimental design (typically lacking a control group) involving careful observation through performance
measurement, the introduction of some tool, strategy or system expected to increase the quality of care, followed again by
careful measurement to quantify the impact of the interventions. The principles of quality improvement have been more
traditionally applied to manufacturing processes and their application to the highly complex world of healthcare delivery
has been challenging. However over the past 20 years, health care quality improvement has evolved from an innovation
for early adapters to an organizational imperative, almost universally practiced by hospitals. In the current environment of
public reporting, pay-for-performance and increased accountability for quality and value, a rigorous application of quality
improvement is increasingly becoming a standard component of hospital administration. Other delivery modalities are
beginning to engage in quality improvement but have not yet reached the sophistication of acute care facilities. The
ambulatory care environment is particularly challenged by the rigors of quality improvement, and hence have been the
slowest to adopt it.
Defining and measuring the quality of medical care has been rapidly evolving over the past several decades. Initially
the concept of defining and measuring quality was met with considerable resistance from health care providers but as
measurement validity, precision and frequency increased so has acceptance. More recently, this concept has begun to
transform continuing medical education programs, from a traditional didactic approach emphasizing credentialing and
documenting attendance to programs where measuring actual performance and outcomes and the change therein are a
key component.
In recent years, national attention has been focused on the quality delivered by our healthcare system. For example
according to the Dartmouth Atlas “Tracking the Care of Patients with Severe Chronic Illnesses”, patients with chronic
illnesses receive very different care, depending upon where patients live and which hospital or health care system the are
loyal to. For example, the frequency of referrals to medical specialist per Medicare enrollee may vary by a factor more
then five depending on your location. Spending on patients with serious chronic illness varies by a factor of nearly three.
Trends:
• Increasingly, measuring actual performance and
outcomes will be the goal of quality of care systems.
A transition period will likely include a mix of input and
process measures as well as outcome measures since
outcome measures are harder to develop, get consensus
on, and implement.
• However, in order to be useful in a system-wide
approach there also needs to be general agreement
across specialties on format and what constitutes a good
performance measure. Umbrella organizations such as
the AMA need to play a strong role in developing and
maintaining the standards for performance measures.
• Traditional measures based on education and training
credentials and performance in continuing education
will continue but will be a baseline rather than an end
point in the quality of care arena. Increasingly, continuing
medical education will be referred to as continuing
professional development to encompass the broader
context of quality of care.
• Implementing quality standards is easier in institutional
settings. Hospitals and large group practices will find it
easier to implement quality standards on a broad scale
because they have the infrastructure and resources to
implement them. However, in order to be fully effective,
eventually all practices will have to be part of the system.
• Performance measures are the building blocks of the
quality of care effort and medical societies will continue
to be the leaders in developing and maintaining them.
In order to be sufficiently usable, performance measures
will need to be specialty-specific and thus specialty
societies will be leaders in this effort.
• The implementation of quality standards will be
incremental in nature and will involve some false starts.
An organized and coordinated effort is needed to learn
from the mistakes that are made along the way.
• The implementation of quality of care standards and
systems will increasingly be linked to payment systems.
In many cases, the payment dimension will distort the
real intent and effect of the quality measures and be
transformed into cost reduction too ls. It will be up to
the profession of medicine and their organizations to
ensure that real quality of care is not hijacked by purely
economic objectives.
15
Patient Safety
The Institute of Medicine in its 2001 report, To Err is Human, shed light on the inadequacies of our health care system
from a safety perspective. Although estimates of the injury, illness and death caused by healthcare itself vary greatly, it
is generally accepted that safety is an area of great potential improvement in health care. Concurrent with this national
focus on patient safety has been the realization that quality and safety deficiencies are mainly a systems problem which
requires a systems approach to resolve. Patient safety is an important part of the overall quality movement because it is
one of the easier dimensions of quality to measure and address. However it does involve a paradigm shift from personal
competence and culpability towards team based care and a systems approach to care delivery.
It is generally accepted that a team approach is needed to achieve real progress in the quality and patient safety arena.
However, before this effort can really mature in a system-wide fashion, some enabling steps are necessary. There must
be a critical mass of generally agreed upon performance measures and information technology tools must be developed
to support interoperable electronic medical records and usable quality of care data bases. This movement is happening
incrementally and will be linked more and more with payment systems so that “value” becomes the operable concept that
is discussed in healthcare policy development.
Trends:
• The medical profession has heretofore focused on
personal competence and accountability in which the
physician is always responsible for the patient’s safety.
This paradigm is evolving towards a systems approach
in which healthcare teams are responsible for care, and
they are supported by systems that reinforce delivery of
proper care.
• A systems approach to safety is being introduced to
health care and success in the fields of aviation; nuclear
energy and anesthesia are being applied more broadly to
healthcare delivery.
16
• Failure Modes and Effect Analysis, an engineering
approach to examining possible failure modes
and mitigating their impact is now being applied
comprehensively in hospitals (a Joint Commission
requirement).
• There is an increasing focus on human fatigue and the
role that plays in jeopardizing patient safety. Increasingly
stringent guidance for the hours healthcare professionals
may work, particularly for interns and fellows, is being
published and implemented.
• Standardization of care is seen as a key to enhancing
patient safety and this is pervading all aspects of care
design including standardization of the hospital room
where each room is an exact duplicate designed with the
care processes in mind.
• The medical profession must take the lead in the continuing development of quality of care measures and
implementation systems. Ensuring the quality of care is one of the most fundamental elements of professionalism
and, in order to maintain the profession, it is essential that physicians maintain control of this critical work.
• While most physicians are aware of the quality of care movement, many see it mainly through the linkages with
payment systems such as pay-for-performance. Medical societies must keep their members informed regarding what
is happening in this field and provide advice and assistance in adapting to the new quality of care requirements that
are certain to become integral to the practice of medicine.
• Physicians will look to their medical societies for guidance and support related to the development and use of
performance measures as well as the investment in the appropriate HIT tools for using them. Medical societies must
be positioned to provide such support.
• The medical profession, through its medical societies, must be the guardians of professionalism and ensure that
economic factors do not distort the real nature and value of quality measures and programs. Strong advocacy will be
needed in this regard.
• Medical societies are beginning to identify evidenced based strategies for improvement and implement these in both
regional and national improvement efforts. For example the D2B Alliance for Quality, led by the American College
of Cardiology with 38 partnering organizations was able to engage over 1000 hospitals nationwide in lowering their
door to balloon times.
• Medical societies will continue to play a vital role in codifying state of the art care through the development of clinical
practice guidelines and performance measurements and will facilitate practice compliance with this guidance through
the development of education programs and national quality initiatives based on the principles of quality improvement.
17
Payment Systems and Insurance Reimbursement Reform
Matthew Katz, MS, Fraser Cobbe
Government Involvement
The dramatic downturn in the economy will have significant ramifications for the healthcare industry. While the 2006
AAMSE Trends report indicated “the number of eligible beneficiaries will continue to grow in all government health
programs” the report was issued long before the extent of the economic slowdown materialized. In addition to the ongoing
concerns with the aging population, the economic realities facing the population will rapidly accelerate the dependency
on government programs. Larger unemployment and budget-strapped employers dropping coverage for employees will
drive larger numbers to seek coverage through government programs. Citizens may also struggle to meet their obligations
for co-payments and deductibles even in government programs due to lower earnings. Governments, both State and
Federal, will face tough decisions coping with financing a larger percentage of health care rendered.
Trends:
• The increased number of eligible beneficiaries and the
increased cost of the services provided will strain the
government’s ability to tax and citizens ability to pay for
these services1.
• State and Federal Governments will consider decreasing
reimbursement for all providers or institute utilization
controls as they struggle to finance a larger share of the
care rendered.
• The public-funding sector will most likely retreat to
providing only minimal public health services, leaving
gaping holes in the safety net for the lower-wage
recipients and their families.
• Retirees and other government assistance-eligible
patients will take on a greater burden for their share of
cost with decreasing income and availability of employer
sponsored health benefits and pensions.
Insurance Marketplace
The trend towards great patient responsibility in their insurance coverage will continue to accelerate. As healthcare costs
continue to climb and the nation faces an economic crisis, patients will be asked to take on a greater share of responsibility
for their health care including higher deductibles and co-pays. The trend toward eliminating mandates from insurance
policies and provide patients greater “cafeteria style” insurance coverage will continue to grow. The emergence of these
plans will provide a significant challenge for physicians to understand the coverage limitations of their patients.
Trends:
• Increased patient responsibility thru high-deductibles,
larger co-pays, and health savings accounts.
• Promotion of real time adjudication of claims will lead to
greater focus on prior authorization and time of service
payments.
• Elimination of mandates and increased cafeteria-style
insurance coverage will pose significant challenges
for patients and physicians alike as they attempt to
understand the limitations of coverage2.
• Increased calls for association programs or group
purchasing organizations that can bring together
individuals, associations, and small businesses to
leverage their collective size to receive more favorable
health insurance premiums that are typically reserved for
large employer groups.
• With a declining economic situation, it is expected more
children and others will receive their health care services
through government programs, including Medicaid and
SCHIP.
1. Center on Budget and Policy Priorities, The Effect of Increased Cost-Sharing in Medicaid: A Summary of Research Findings b Leighton Ku and
Victoria Wachino, July, 7 2005
2. Merlis, Mark, Gould, Douglas, and Mahato, Bisundev, Rising Out-of-Pocket Spending for Medical Care: A Growing Strain on Family Budgets,
Feburary 01, 2006
18
Private Public Partnerships (Quasi-Governmental)
The demand for Private Public Partnerships has increased as the governments look to share the burden of increased
financial responsibilities for health care with the private sector. These partnerships often involve a shared responsibility
for the provision of care. The fragmentation of responsibilities can be complex and difficult for patients and physicians to
navigate.
Trends:
• State and Federal Governments will look for additional
opportunities to lower costs by utilizing the private sector
to assist in the administration of government programs.
• Patients and physicians will continue to be burdened with
a myriad of reimbursement and coverage rules for these
partnerships.
• Increased utilization of supplemental plans that assist
patients in covering their share of cost borne through copayments and deductibles.
Consolidation in the Private Marketplace and Public Administration
The past decade has seen a dramatic consolidation in the private marketplace with large national insurance carriers
absorbing smaller local and regional carriers in an attempt to expand market share. The Federal Government has also
decided to consolidate the administration of the Medicare program by contracting the state fiscal intermediaries into
thirteen regional Medicare Administrative Contractors. Many of the large insurance companies have been awarded the
regional contracts for the administration of the Medicare program. This consolidation greatly enhances the role of a few
large corporations in the provision, administration, and payment of care for large percentages of the population.
Trends:
• Consolidation of Medicare Administrative Contractors will
lead to the development of multi-state reimbursement
policies (Local Coverage Determinations), less local
customer service, and decreased importance of local
medical community input in the administration of the
Medicare program.
• Large corporations and their subsidiaries will dominate
significant patient populations in geographical areas
across the country.
• Health care providers and patients may have a diminished
capacity to interact and negotiate with these large
corporations.
• Continue to stay abreast with the current governmental, both state and federal, health care programs available in
their area. They should be prepared for an increase in the public requesting information on these programs from
their society and should be ready to either provide answers or redirect them to organizations that can better handle
those questions.
• Be prepared and ready to combat any proposed cuts in the reimbursement rates for governmental health care
programs.
• Be ready to assist members in managing new and more complex insurance programs.
• Stay vigilant as larger insurance companies take a larger role in different geographical areas of the country. As
these companies increase in size, there may be a tendency to decrease the importance of the local medical
community.
19
Sources
Medical Society Management, Finance and Communications
Electronic Medical Records and Health Information Technology
1. DesRoches, et al., Catherine M. Electronic Health Records in Ambulatory Care — A National Survey of Physicians.
New England Journal of Medicine. July 3, 2008.359, 50-60.
2. President-Elect Urges Electronic Medical Records in 5 Years. ABC News Medical Unit. January 09, http://
abcnews.go.com/Health/President44/Story?id=6606536&page=1.
Access to Care and Health System Reform
1. Welch, David, Healthcare Reform, Corporate-Style, BusinessWeek, July 29, 2008.
2. US Senate, Senate Finance Committee, Call to Action: Health Reform 2009 Executive Summary, 2009.
3. An Agenda for Change: Improving Quality and Curbing Health Care Spending: Opportunities for the Congress
and the Obama Administration. The Darmouth Institute for Health Policy & Clinical Practice. December 2008.
4. Fall 2008 Policy Proposal: A United States Health Board. The Blue Ridge Academic Health Group. Fall 2008
5. Statement on Health Care Reform. American College of Surgeons. 2008.
6. Brown, David. Shortage of General Surgeons Endangers Rural Americans. Washington Post. January 1, 2009.
Changing Healthcare Workforce
1. Physicians Characteristics and Distribution in the United States. American Medical Association (AMA). 2001.
2. U.S. Bureau of the Census. Current Population Survey. 2001.
3. Plotting the Future of Cytopathology. The Forbes Group. May 2007.
4.
U.S. Bureau of Labor Statistics, TABLE: Unemployed persons by occupation, industry, and duration of
employment, March 2009.
5. The Global Tug-of-War for Health Care Workers. Migration Information Source. December 2004.
6. Physician Workforce Survey Report. Connecticut State Medical Society. September 24, 2008.
Medical Society Membership as a Value Proposition
1. Caraveli , Anna, Ph.D, Building the Future on Member Value: Codevelopment as a Key to Customer Relationships
in the 21st Century, Journal of Association Leadership, Spring 2007.
Public Health Infrastructure and its Relationship to Healthcare Delivery
1. Joint Principles of the Patient-Centered Medical Home. American Academy of Family Physicians, American
Academy of Pediatrics, American College of Physicians, American Osteopathic Association. February 2007.
Available at: > www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.
Par.0001.File.tmp/022107medicalhome.pdf.
2. Beitsch LM, Brooks RG, Glasser JH, Coble YD. The medicine and public health initiative: ten years later. Am J
Prve Med 2005;29:149-53.
3. Benjamin G (Feb 29, 2008). Leading US Health Challenges: The coming decade. Coaltion for Health Funding Hill
Briefing, Washington, DC. Available at: www.aamc.org/advocacy/healthfunding/obesityamerica.htm.
4. Centers for Disease Control and Prevention. CDC policy on climate change and public health. Available at: www.
cdc.gov/nceh/climatechange/pubs/Climate_Change_Policy.pdf.
5. Committee on Climate Change and US Transportation, National Research Council (2008). Potential Impacts of
Climate Change on US Transportation: Special Report 290. Washington, DC: Transportation Research Board;
2008. Available at: www.nap.edu/catalog.php?record_id=12179.
6. Davis R. Marriage. Counseling for Medicine and Public Health: Strengthening the bond between these two health
sectors. Am J Prev Med. 2005;29(2):154–157.
20
7. Frequently asked questions about public health. Trust for America’s Health. Available at: http://healthyamericans.
org/docs/?DocID=201.
8. Guide to Clinical Preventive Services, 2007: Recommendations of the US Preventive Services Task Force. Rockville,
MD: Agency for Healthcare Research and Quality; 2007. AHRQ Publication 07-05100. Available at: www.ahrq.gov/
clinic/pocketgd07.
9. Hung DY, Rundall TG, Tallia AF, Cohen DJ, Halpin HA, Crabtress BF. Rethinking Prevention in Primary Care:
Applying the chronic care model to address health risk behaviors. Milbank Q. 2007;85(1):69–91.
10. Leviton LC, Rhodes SD. Public health: policy, practice, and perceptions. In: Kovner AR, Knickman JR, eds. Jonas
and Kovner’s Health Care Delivery in the United States 8th ed. New York, NY: Springer Publishing Co; 2005.
11. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health
Aff. 2002;21(2):78–93.
12. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207–2212.
13. Ockene JK, Edgerton EA, Teutsch SM, et al. Integrating evidence-based clinical and community strategies to
improve health. Am J Prev Med. 2007;32:244–252.
14. Ready or not?: protecting the public’s health from diseases, disasters, and bioterrorism. Trust for America’s Health.
Available at: http://healthyamericans.org/reports/bioterror07/BioTerrorReport2007.pdf.
15. US Department of Health and Human Services. Understanding and improving health. In: Healthy People 2010. 2nd
ed. Washington, DC: US Dept of Health and Human Services; 2000.
Quality of Care and Patient Safety
1. Wennberg , John E., Fisher , Elliott S., Goodman, David C., and Skinner , Jonathan S. Tracking the Care of Patients
with Severe Chronic Illness. The Dartmouth Atlas of Health Care 2008. The Darmouth Institute for Health Policy &
Clinical Practice. April 2008.
2. Kohn , Linda T., Corrigan , Janet M., and Donaldson , Molla S., Editors. To Err is Human: Building a Safer Health
System. Committee on Quality of Health Care in America, Institute of Medicine. 2000.
Payment Systems and Insurance Reimbursement Reform
1. Ku, Leighton and Wachino , Victoria. The Effect of Increased Cost-Sharing in Medicaid: A Summary of Research
Findings. Center on Budget and Policy Priorities. July, 7 2005.
2. Merlis, Mark, Gould, Douglas, and Mahato, Bisundev. Rising Out-of-Pocket Spending for Medical Care: A Growing
Strain on Family Budgets. February 01, 2006.
AAMSE acknowledges the support of this report by United Health Foundation
21
American Association of Medical Society Executives
555 East Wells Street, Suite 1100
Milwaukee, WI 53202
(414) 221-9275
www.aamse.org

AAMSE Trends Identification Report

Transcription

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