Leaders as combat fighter pilots. Research project targets leaders who support money-losing business strategies.

When strategic plans go awry and begin losing money, the smart thing to do is change course. But some leaders get so involved with the plan, they fail to navigate properly and fly right into the target. The organization can lose millions. Examine why this happens and what you can do to prevent it from happening in your organization.

Competencies for health management practice: a practitioner's perspective.

The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed.

Health care trends lead to specialization of the MBA.

Four authors associated with St. Thomas University, John G. Reiling, M.B.A., John W. LaBree, M.D., Frederick J. "Fritz" Wenzel, FACMPE, and Carl Platou, M.B.A., write about how the changing nature of health care has fostered the need for a specialized Master of Business Administration in Medical Group Management degree program.

Managing managed care. Grouping together is the answer.

Working through an organization is the only way to manage in a managed care system. To be successful we need sophisticated management information systems, outstanding leadership and management, and a discretionary income distribution system. We must be willing to accept venture risk even though we will not win all the time. We must be aggressive in developing these systems. In order to survive, the successful organization will have to manage first, itself; second, the buyer of care; and third, its own image. It must also learn how to deal with the competition.

Medicare risk contracting. Lessons from an unsuccessful demonstration.

The Tax Equity and Fiscal Responsibility Act of 1982 provided a full-risk Medicare capitation financing option for health maintenance organizations and competitive medical plans. Two rounds of demonstrations were conducted, followed by the publication of final regulations in January 1985. The first-round demonstration at Marshfield, Wis, was operational for 28 months. Thirty-seven percent of all resident beneficiaries enrolled. Aggregate losses exceeded $3 million (11.6% of revenue). Management implemented increasingly more stringent utilization review. Overall hospital utilization declined 261.7 days per 1000 from fiscal year 1981 to 1982; nonetheless, federal reimbursement was insufficient to meet program costs and the demonstration was terminated. The central reimbursement method used in Medicare risk contracting (adjusted average per capita cost) does not adequately control for enrollment selection, unmet medical need, or recent regional cost variations. Reimbursement set at 95% of estimated fee-for-service costs does not recognize, and in the long run will not support, an efficiently operating delivery system.

Medicare risk contracts--success or failure?

Recent legislation has led to a new popularity in risk contracting. In 1980 a demonstration was begun by the Health Care Financing Administration that provided input for the current capitation program. Administrators from two groups involved in the demonstration program--the Marshfield Clinic and MedCenters Health Plan--offer the unique perspectives of a medical group practice and a health maintenance organization. Significant issues for any group considering entering a Medicare risk based contract are discussed.

Conflict: an imperative for success.

Conflict in organizations of any type is inevitable. Medical institutions, particularly multispecialty clinics, are no exception. This paper presents an examination of the anatomy of conflict in group practice settings. Several case studies, including the "Hunterdon Experiment," are presented to illustrate the outcome of conflict situations where management was unable to direct its energy to productive ends. Recommendations are made for identifying, considering, and resolving conflicts in a proactive fashion. The conflict management role of the top management of the organization is described, with particular emphasis on the pivotal position of the Medical Director.

A Ten-Year Survey of Snowmobile Accidents, Injuries, and Fatalities in Wisconsin.

In brief: Snowmobile accidents and resulting casualties in Wisconsin were surveyed from 1973 to 1982. The number and rate of accidents peaked in 1974-75 and then declined through 1982, apparently because of state legislation providing for safety programs and trail development. Drivers aged 12 to 30 and with more than 100 hours' experience accounted for most accidents. Faulty judgment by drivers caused 57% of all accidents, and alcohol was involved in 61% of the fatal accidents. During the study period the most common injury site shifted from the head to the extremities. Recommendations to further reduce accidents are offered.

Combined gynecologic surgical procedures and cholecystectomy.

This report presents our experiences with combined gynecologic surgical procedures and cholecystectomy from 1976 to 1983. The review evaluated risks, cost, and hospital stay in combined surgical procedures. Hospital charts were reviewed in 46 cases. The patients were compared with 178 patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1981. Of the 46 patients reviewed, 22 (47.8%) had preoperative diagnosis of cholelithiasis. We believe it appropriate to combine gynecologic surgical procedures with cholecystectomy when indicated. This eliminates a significant postoperative complication, cholecystitis, a second general anesthetic, and future hospitalization with additional time off work and patient recovery time.

A view from under the microscope. Medicare prospective risk contracting.

The authors provide an overview of the Marshfield Clinic's four-year demonstration contract with HCFA that resulted in the enrollment under a prospective risk contract of over 8,900 Medicare beneficiaries. Public policy implications are discussed along with recommendations for group practices contemplating Medicare prospective contracts. Recommendations include the attention which must be paid to potential adverse selection, hospital utilization control, and potential technical and methodological problems with the prospective reimbursement system. Data from the demonstration will be of significant value to other groups interested in prospective contracting with HCFA. The concept of prepaid Medicare, if appropriately refined, can serve the best interests of Medicare beneficiaries, providers, and

A model of rural health care. Consumer response among users of the Marshfield Clinic.

Comparisons of prepaid, Medicaid and fee-for-service patients using the Marshfield Clinic and affiliated non-Clinic physicians indicate that a well-organized multispecialty group can successfully provide accessible and responsive care to rural populations and integrate varying types of payment systems. Most patients were highly satisfied, but differences in satisfaction among varying subgroups were substantially attributable to access barriers. Patients in the Greater Marshfield Community Health Plan (prepaied patients) were most generally satisfied, but patients using non-Clinic affiliates were higher on socioemotional satisfaction, reflecting certain barriers to personal care in complex organizational settings.

The limited utility of fibrinogen I 125 leg scanning.

Using venography as the reference procedure, this study examined the utility of fibrinogen I 125 scanning for the detection or demonstration of deep venous thrombosis. The results demonstrate the inability of leg scanning to detect accurately the presence or absence of thrombi in the deep venous system. Most striking was the lack of sensitivity of this procedure in areas where the propensity for embolization is greatest. Sensitivity is extremely low in the anatomic areas where leg scanning demonstrates reasonable specificity. The results are nearly identical in the extremity not operated upon. The validity of all prior studies relying heavily or exclusively on 125I leg scans to determine the presence or absence of thrombi must be critically reassessed.

Can the frequency of myocardial infarction be reduced during coronary artery operations.

A prospective experiment was carried out in 56 patients undergoing coronary artery revascularization to determine whether those having a glucose-insulin-potassium (GIK) perfusion during the procedure would have fewer myocardial infarctions (MI) compared with patients given a control perfusion of Normosol-R. Six patients (11%) developed an MI, defined as a 24-hour creatine phosphokinase MB isoenzyme value of 100 IU per liter or greater. Four (13%) had control perfusions and 2(8%) had GIK perfusion. One MI in a double-graft recipient who had GIK perfusion occurred because of a technical surgical error; therefore, the corrected MI rate was 13% in control patients compared with 4% for the GIK group. These data, as well as the more frequent spontaneous defibrillation in patients who had GIK perfusion, suggest that GIK was of benefit.

Composition of the subscribers in a rural prepair group practice plan.

To determine the degree to which enrollees of the Greater Marshfield Community Health Plan were representative of the community the plan was designed to serve, a telephone survey of 1,838 households in the 30-township area was undertaken. The response rate was 93%, and data were obtained from 1,718 households containing 5,260 persons. Of these, 484 households had at least one health plan member. Since the plan accepts only persons under age 65, analysis of the data was limited to those persons aged 64 and younger. Results indicate that enrollees showed good representation of demographic variables such as age, sex, and relationship to the household head when they were compared to the under 65 population of the area. When the enrollee's socioeconomic characteristics (education, income, and occupation) were studied, it was found that, although enrollees showed good representation for most categories they tended to underrepresent the under 65 area population in the lowest income and education classes, as well as in the semiskilled or unskilled occupations. The opposite was true for the upper income and educational classes. Data on location of residence indicated that a strong relationship existed between enrollment and proximity to Marshfield, where the major health care center is located. The use of health services was found to be positively related to membership, with enrollees overrepresented among those with recent hospital or physician contacts. The ability to obtain coverage through employment or by other means was found not to be related to membership. Satisfaction as expressed by participants was much higher in the prepaid program than among those with other forms of coverage.