Question

Evaluate how physician-hospital partnerships can affect the quality of care and efficient and effective decision-making.

Answer 1

Ans) Two major models of physician/hospital relationships—the dual authority model and the shared authority model.

- The implications of each of these along with the forces influencing their continued development were examined. Evidence regarding the association of more shared decision-making models and the cost and quality of care.

- A number of issues pertaining to the changing context of clinical and institutional decision making were presented, suggesting that some fundamental changes may take place in the structure of hospital medical staffs.

- These points have a number of possible implications for for-profit hospitals.

- First, they are likely to continue to be somewhat more selective than voluntary hospitals in their choice of services to offer the community. Specifically, they will tend to offer services that enhance the return on the overall portfolio or mix of services provided. Because of the greater involvement of physicians in hospital governance, for-profit hospitals may be more reluctant to compete directly with their medical staffs and more likely to offer services that are complementary to rather than substitutable for physician services in the community.

- Second, for-profit hospitals, particularly those owned by investor-owned chains, may be better able than voluntary hospitals to deal with "compromise" or "judgmental" decisions. This is because they have a more clearly defined and homogenous group of constituents (stockholders) and generally more overall centralized direction from the corporate headquarters office. As a result, preferences regarding desired outcomes may be more clear. Investor-owned hospitals may, therefore, be more able to make rapid adjustment to external changes (e.g., changes in third-party reimbursement or changes in competition) than most voluntary hospitals can.

- Third, because the interests of physicians and the hospital may be more closely aligned in for-profit hospitals, the dual authority model of decision making is less problematic. Perhaps the lesser degree of physician involvement in daily committee work that characterizes for-profit hospitals reflects a higher degree of agreement on a more homogenous and targeted set of goals and greater physician involvement in the governance process. In contrast, voluntary hospitals deal with the issues created by the dual authority model through a rather elaborate system of committees attempting to achieve increased physician participation and involvement. Although both types of hospitals may be shifting toward a more shared authority model, investor-owned hospitals may be able to make the adjustment more quickly and easily because of the greater degree of agreement on overall goals and the history of physician involvement in decision making at the governance level of the organization.

- But it is also important to note that the above differences and their implications may be attenuated by some growing similarities between for-profit and voluntary hospitals in their economic orientations. Under pressures for cost containment, plus increased competition, voluntary hospitals have had to give more concerted thought both-to their short-run operational needs and to longer-run capital formation requirements. A number of voluntary hospitals have corporately reorganized, in many instances creating for-profit subsidiaries to expand the hospital's sources of revenue. Some of the above differences may also be attenuated by the continued growth of multi-unit systems among not-for-profit hospitals.

- Through their corporate office expertise and structure, such systems may be able to offer the same kinds of advantages as the investor-owned systems. In brief, although important differences still exist between the mission, philosophy, structure, and decision making of for-profit and not-for-profit hospitals, forces are currently in motion that over time may diminish some of these differences.