International health services management education: an overview of major efforts and lessons learned during the 1990s.

In this paper, the authors examine select major pedagogical and methodological issues concerning health care management executive training and academic program development in the former Soviet sphere of influence during the 1990s. Experience from programs offered during the 1990s has direct implications for the continued development of health care management programs and faculty in the United States. In essence, each of the nations that were involved represented an experimental setting for the introduction and improvement of management skills in the health care sector and the development of professional health care managers. Evaluative findings should help to inform future efforts to construct and deliver effective international and domestic management educational programs.

The pillars of health management education: lessons from the CEE experience.

AUPHA faculty members have had the opportunity to provide health care executive training and to work in partnership with academic institutions in Central and Eastern Europe and in the New Independent States of the former Soviet Union. This article presents some observations on health management education that demonstrate the similarity in issues faced by programs in the U.S. and in CEE. The health management educational partnership program was designed to provide technical assistance to emerging health management programs in the CEE. The partnership program has been mutually beneficial for several reasons. The role of physicians in leadership and the management educational needs that result provide one example of an issue that health management educational programs must address. The emergence of the roles of other health professions and growing contribution that they will make has its parallel in the American ascendance of the role of interdisciplinary team in clinical decision making. The partnership and executive training experiences have caused U.S. partners to focus consciously on pedagogical methods. The nature of the issues faced by emerging CEE health management programs suggests that mutual support among programs in the region after the partnership program is necessary in order to provide a forum for debate. The focus of the debate should continue to be on the role of management in health reform, content of curriculum, research focus and pedagogical methods appropriate for health care management undergraduate and graduate programs. The result will be a strengthening of the health management academic discipline in the region. The future of the AUPHA should predicated on the same principles, the roots from which it has grown.

Accreditation processes in the Slovak Republic.

This article provides a conceptual framework for understanding changes occurring in the accreditation process for institutions of higher learning in the Slovak Republic. Health sector transformation is occurring rapidly throughout the Central and Eastern European region as former socialist states are experimenting with market-oriented approaches. Educators and universities are playing an important role in the development of knowledge, skills and abilities of current and future health practitioners. Accreditation is viewed as an important process in the continuing development of quality health service management curricula and preparing competent practitioners for the health care field. Historical considerations are examined as well as future directions for accreditation in the Slovak Republic.

The medical practice as business organization.

Medical practices historically have not been examined in terms of their organizational structures and of the appropriateness of their structures for survival as business entities. In this paper, we propose a model for the typical medical practice and discuss its fit with current organizational theory. It is apparent that the medical practice organization does not fit with the demands of a rapidly changing and complex environment. To survive and grow, the medical practice organization must align itself with others that have an interest and stake in the health care system, develop teamwork among physicians, bridge the gap between physicians and others in the organization, and recognize that the work done in the organization depends on other components of the organization.

The effects of ownership, operating environment, and strategic choices on nursing home efficiency.

This article reports on a study of the labor efficiency of 461 nursing homes located in Pennsylvania. Data envelopment analysis was used to estimate efficiency scores. Tobit equations were estimated for the entire sample and for subsamples consisting of for-profit (FP) and not-for-profit (NFP) nursing homes. The authors found that the major factors explaining efficiency were managerial and environmental characteristics such as ownership, occupancy rate, size, payment source, wage rate, and per capita income, rather than quality characteristics of nursing homes. Analysis of the FP and NFP subsamples suggests that many NFP homes may respond to environmental pressures by increasing their efficiency, whereas FP homes tend to operate at a high level of efficiency irrespective of environmental and regulatory pressures.

Subacute care, Medicare benefits, and nursing home behavior.

Two policy changes in 1988, one administrative and one legislative, allowed greater Medicare coverage of subacute care in skilled nursing facilities (SNFs). The Medicare Catastrophic Coverage Act (MCCA) of 1988, in conjunction with an administrative directive, or transmittal, from the Health Care Financing Administration (HCFA), changed the Medicare SNF benefit structure substantially. In this study, we specified a simultaneous equation system to explain the effects of the benefit changes on Medicare use. The results suggest that the two policy changes increased Medicare use in Pennsylvania SNFs substantially; however, the increase was associated with facility and case mix characteristics, which suggest that the increase was largely attributable to reclassification of current patients from other payer categories, Medicaid and self-pay, rather than new admissions. The effects of the MCCA and the HCFA transmittal on increased Medicare use were unanticipated and have important implications for the way in which subacute care is defined and financed in future benefit discussions.

Structure, environment and strategic outcome: a study of Pennsylvania nursing homes.

This study applies Porter's model of competitive advantage to the nursing home industry. Discriminant analysis is used to identify organizational and environmental characteristics associated with nursing homes which have demonstrated valued strategic outcomes, and to distinguish the more successful nursing homes from their rivals. The results of the discriminant analysis suggest that nursing homes with superior payer mix outcomes are distinguishable from their less successful rivals in areas associated with a focused generic strategy. The study suggests that nursing homes which are better staffed, of smaller size and lower price are more likely to achieve high levels of self-pay utilization. Independent living units, continuing care retirement communities in particular, are likely to act synergistically with nursing home organizational characteristics to enhance competitive advantage by linking the value chain of the nursing home to that of retirement housing. Nursing homes with higher proportions of Medicare were found to provide a unique product when compared to their rivals. Profit status does not discriminate better self-pay strategic utilization, but for-profit facilities are more likely to pursue a Medicare strategy. Concern was raised that, as nursing homes become more strategically oriented, Medicaid access may become more problematic.

Do for-profit and not-for-profit nursing homes behave differently?

The purpose of this study was to examine behavioral differences between for-profit (FP) and not-for-profit (NFP) nursing homes. Previous studies have failed to establish consistent behavioral differences. This study uses a simultaneous equation model to control for potential endogeneity among system variables, with model parameters estimated using 3SLS. The study provides evidence that NFPs provide significantly higher quality of care to Medicaid beneficiaries and to self-pay residents than do FPs, as evidenced by better staffing and better outcomes among nursing homes with residents at higher risk for adverse outcomes.

Strategic groups, performance, and strategic response in the nursing home industry.

OBJECTIVE: This study examines the effect of strategic group membership on nursing home performance and strategic behavior. DATA SOURCES AND STUDY SETTING: Data from the 1987 Medicare and Medicaid Automated Certification Survey were combined with data from the 1987 and 1989 Pennsylvania Long Term Care Facility Questionnaire. The sample consisted of 383 Pennsylvania nursing homes. STUDY DESIGN: Cluster analysis was used to place the 383 nursing homes into strategic groups on the basis of variables measuring scope and resource deployment. Performance was measured by indicators of the quality of nursing home care (rates of pressure ulcers, catheterization, and restraint usage) and efficiency in services provision. Changes in Medicare participation after passage of the 1988 Medicare Catastrophic Coverage Act (MCCA) measured strategic behavior. MANOVA and Turkey HSD post hoc means tests determined if significant differences were associated with strategic group membership. FINDINGS: Cluster analysis produced an optimal seven-group solution. Differences in group means were significant for the clustering, performance, and conduct variables (p < .0001). Strategic groups characterized by facilities providing a continuum of care services had the best patient care outcomes. The most efficient groups were characterized by facilities with high Medicare census. While all strategic groups increased Medicare census following passage of the MCCA, those dominated by for-profits had the greatest increases. CONCLUSIONS: Our analysis demonstrates that strategic orientation influences nursing home response to regulatory initiatives, a factor that should be recognized in policy formation directed at nursing home reform.

The success and repeal of the Medicare Catastrophic Coverage Act: a paradoxical lesson for health care reform.

Congress intended the Medicare Catastrophic Coverage Act (MCCA) of 1988 to reduce the risk for illness-related catastrophic financial losses in the elderly. The act was short-lived, facing repeal just one year after passage. Many elderly persons were convinced that the costs of the program outweighed the benefits. However nursing home payment provisions of the MCCA may have affected out-of-pocket expenses paid by the elderly for long-term care more than consumers realized at the time of repeal. A transmittal memorandum, issued by the Health Care Financing Administration independent of Congressional action, enhanced consumers' ability to qualify for Medicare nursing home benefits. We investigated the effects of the Medicare policy change on nursing home payer mix and out-of-pocket expenses in 489 Pennsylvania nursing homes. We found that substantial shifts in payer mix from self-pay to Medicare payment sources occurred, reducing out-of-pocket expenses. Unfortunately the debate over the MCCA's repeal did not include discussion of the improved nursing home benefit structure. These findings, and the fate of the MCCA legislation, reinforce the importance of comprehensive information and clear communication in promoting health care reform.

Variations in the outcomes of care provided in Pennsylvania nursing homes. Facility and environmental correlates.

This research study utilizes indicators from federal and state surveys to evaluate variation in outcomes in 438 Medicare certified skilled nursing care facilities in Pennsylvania. First, a standardization function adjusting for patient characteristics known to influence outcomes was developed and estimated. The relationships between organizational and environmental characteristics and the chosen outcome indicators (i.e., differences between the actual and expected rate of mortality, pressure ulcers, urethral catheterization and physical restraints) were then analyzed by weighted least squares regression. Results suggest considerable interfacility variation in rates for these outcome indicators. A portion of this variation is significantly attributable to resident characteristics (P < or = 0.05). However, variation in outcomes in Pennsylvania facilities is also associated with facility characteristics (e.g., size and for-profit status), and environmental characteristics (e.g., per capita income and bed supply). Implications for nursing home management and policy are considered.

The use of standardized indicators as quality improvement tools: an application in Pennsylvania nursing homes.

The Institute of Medicine recommends the use of key quality indicators (resident outcomes that suggest the presence of good or bad care) as tools for interfacility comparison of the quality of care provided in nursing homes. In the spirit of this recommendation, the Health Care Financing Administration released selected results from its Medicare and Medicaid Annual Certification Survey to guide consumers in purchasing nursing home services. However, because this information is published without adjustment for resident characteristics that can influence the outcomes of nursing home care, its utility for policy-makers or consumers interested in variation in nursing home quality is limited. This research study utilizes federal and state survey data to evaluate variations in mortality, pressure ulcers, urethral catheterization, and physical restraint use in 438 Medicare-certified skilled nursing care facilities in Pennsylvania. A standardization function adjusting for resident characteristics known to influence outcomes is developed and estimated by ordinary least squares regression. Results suggest considerable variation in rates for these indicators across Pennsylvania nursing home facilities. Alternative uses for risk-adjusted key quality indicators as tools for improving nursing home quality and assisting potential consumers of nursing home care in making better informed choices are considered.