The future of medical practice

Financial Profit in Medicine: A Position Paper From the American College of Physicians

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

Academic Medicine and Medical Professionalism: A Legacy and a Portal Into an Evolving Field of Educational Scholarship

In this Invited Commentary, the author examines two curated Academic Medicine volumes showcasing foundational research and key writings on professionalism in medicine and medical education, collectively spanning from 1994 to 2016. The author reviews the beginnings of the medical professionalism movement and examines how the trends and themes reflected in the first volume-specifically the work to define, assess, and institutionalize professionalism-capture key elements in this movement. He then examines how the trends and themes in the second volume align with and build on those from the first, noting two themes that extend across a number of second volume articles: a unit-of-analysis issue and the challenge of context. The author identifies several topics that have yet to be adequately mined and calls attention to two bridge-spanning articles in the second volume that, respectively, take us into the future (around the topic of identify formation) and back to the past (on the hidden curriculum). Finally, the author reflects on "directions home" in medicine's noble search for its moral core and collective identity.

New Technology, Bureaucracy, and the Social Construction of Medical Prices

This article presents an analysis of the social roots of medical service price inflation. The author argues that a struggle between hospital managers and physicians to control medical services has inflationary consequences. The author also contends that new technology acts as a strategic resource for managers in this struggle. Because the technology is new, few data exist for evaluating the demand for it and its medical and financial effects. Managers thus play a "hypothetical game" and set prices through bureaucratic means that reflect their preferences for technology and help pay for the equipment. An empirical case study involving the purchase of nuclear magnetic resonance equipment in Omaha, Nebraska, supports and illustrates the argument.

The effects of the fraud and abuse enforcement program under the National Health Insurance program in Korea

OBJECTIVE

To examine the general deterrence effect of the Korean government's fraud and abuse enforcement program on medical clinics in the country. The effects were evaluated by analyzing the association between the fear of penalty from a potential onsite investigation and the costliness index (CI).

METHOD

Using a stratified proportional systematic sampling method, 800 out of the 15,443 clinics in Korea that had not had an onsite investigation before June 2007 were selected. Perceived deterrence was measured via face-to-face interviews with the chief doctor of each clinic; these were conducted in July and August 2007. CI was calculated by dividing observed costs by expected costs based on National Health Insurance Claims from January to October 2007.

RESULTS

Clinics with a high fear of penalty had a significantly lower CI than did other clinics after adjusting for factors related to the provider's perception of onsite investigation, the provider's service experiences, and general characteristics such as provider's sex and age.

CONCLUSION

Designing effective fraud and abuse control programs can improve the efficiency of providing services to patients.

2006 ACR presidential oration. The ring in the radiograph: profession and principle

A profession demands unconditional acceptance of the inalienable responsibilities to those it serves. Such obligations to patients, colleagues, and society infuse the specialty of radiology with meaning that elevates it to a profession and distinguishes radiologists' efforts from a simple occupation. The recognition and fulfillment of these duties are also how the ACR differentiates itself from an ordinary trade association. Professional insight provides a platform for analysis of and response to the issues confronting our specialty from the perspective of our founding principles and ethics. Judged by its history and recent leadership, the ACR has served and continues to serve this critical function by providing commitment, direction, and voice for our profession's core values.

The role of doctors as health care managers: an international perspective

The participation of physicians in health care management has followed different paths in developed and developing countries. However, we can say that in most of the countries the physicians have had cyclical patterns of participation and withdrawal from health care management. It is readily apparent that these patterns are different in each country. We propose to take into account three different levels of analysis in which different factors interact to define the country specific pattern of physician involvement in health care management, as well as to assess the international convergence and divergence paths on physician participation. We present here a conceptual framework that could facilitate the analysis of this theme under a comparative perspective. We start by discussing a conceptual framework of the determinants of physician participation in health care management. Then, we assess the current trends and perspectives in both developed and Latin American countries of physician participation in health care management.

The constitution of physicians' power: a theoretical framework for comparative analysis

Drawing on literatures documenting the experience of physicians in both European and American societies, a new theoretical framework for explaining variations in the professional power of physicians is provided. Most studies of professions have used professional organization as the principal explanatory variable, with state policy and the organization of civil society as secondary mediating factors. Our approach instead treats strategies of state power and forms of civil society as central features shaping the ability of the profession to exert power. Such a three-dimensional approach not only allows us to make more powerful classifications explaining contemporary differences, but also allows us to trace historical shifts and anticipate alternative futures in professional power. For example, in those societies where the state's intervention is limited and civil society is pluralistic, professional power is potentially greatest. But increasing state power does not necessarily reduce professional power. Where the state is most powerful and organizes all groups in civil society, professionals and society can be united in common struggle against the state. In response to that, it is likely that such centralized states will opt for corporatist solutions to maximize the internal differentiation of society and pit those once allied against one another, and preclude the organization of powerful autonomous interest groups.

Medicine as business and profession

This paper analyzes one dimension of the frequently alleged contradiction between treating medicine as a business and as a profession, namely the incompatibility between viewing the physician patient relationship in economic and moral terms. The paper explores the utilitarian foundations of economics and the deontological foundations of professional medical ethics as one source for the business/medicine conflict that influences beliefs about the proper understanding of the therapeutic relationship. It then, focuses on the contrast and distinction between medicine as business and profession by critically analyzing the classic economic view of the moral status of medicine articulated by Kenneth Arrow. The paper concludes with a discussion of some advantages associated with regarding medicine as a business.

Pediatric surgery--whither goest thou?

What I have attempted to do in this analysis is to give you my views of pediatric surgery as it stands today in terms of its original goals. I have also attempted to look ahead and to analyze the straws in the wind, hopefully offering some potential solutions for the issues we are currently facing. If we remember who we really are and what our purpose is, great opportunity lies ahead. To those of us who are not satisfied with the present outlook there is much to be investigated and much to be contributed.

Rationing and professional autonomy

The effort to control inflation of the cost of health care in the United States in recent years has focused on a strategy of introducing competition by encouraging prospective payment systems such as DRGs and HMOs. Changes associated with these new payment systems have engendered a debate that has been conducted partly in terms of medical ethics. Because they tend in various ways to provide physicians with incentives to reduce medical costs, prospective payment systems have been alleged to create ethical conflicts for physicians. The obligation to practice cost-effective medicine is said to conflict with the obligation of physicians under the traditional professional view of medical ethics to provide the best care to patients without regard to cost or other matters. At bottom is the concern that the net effect of these changes will be to force physicians to ration medical services. Not only will patients suffer thereby, but professional authority will be weakened as efficiency protocols and various bonuses or inducements alter the norms of clinical decision-making.

The commodification of American health care

Since 1980, cost containment efforts have radically transformed the delivery of medical services in the United States. The number and diversity of private, for-profit delivery systems have significantly increased and so has the competition among them. Some Marxists have conceptualized these changes as a transition from a non-commodity to a commodity form of medical care. They have labeled this the process of 'commodification' of medical services. However, this paper demonstrates that this process took place over 50 years ago. In light of this historical finding, an alternative Marxian analysis of the current medical conjuncture is briefly presented. Several of the key attractions of this approach are discussed.

Corporatization and the social transformation of doctoring

Corporatization of health care is dramatically transforming the medical workplace and profoundly altering the everyday work of the doctor. In this article, the authors discuss recent changes in U.S. health care and their impact on doctoring, and outline the major theoretical explanations of the social transformation of medical work under advanced capitalism. The adequacy of the prevailing view of professionalism (Freidson's notion of professional dominance) is considered, and an alternative view, informed by recent changes, is offered. While the social transformation of doctoring is discussed with reference to recent U.S. experience, no country or health system can be considered immune. Indeed, U.S. experience may be instructive for doctors and health care researchers in other national settings as to what they may expect.

Corporately managed health care and the new role of physicians

The roles described are not all-inclusive, since a small proportion of physicians, as in times past, will continue to pursue diverse careers outside of an tangential to health care. Neither are the roles mutually exclusive, as physician-managers are also organizational employees, as independently contracting professionals may also be partly fee for service, as physician entrepreneurs may be fee for service practitioners or contracting professionals, and so forth. The point is, that as the delivery of health care becomes a more complex and formalized process, and as large organizations delivering and insuring health care become more predominant, the various roles of physicians are becoming more distinctly obvious. What are the implications of this trend toward greater internal segmentation of the medical profession? At this juncture, they are not entirely clear. It could mean that some groups of physicians will achieve higher status and more rewards than other groups, which might result in greater conflicts within the medical profession. Undoubtedly, the emergence of corporately managed health care and the development of new (and possibly divergent) roles for physicians confronts the medical profession and its members with the gnawing questions of who they really are and what do they really want to be? Ultimately, the greatest challenge may be in finding a common set of commitments and values which transcend our many different roles, and which provide physicians with a clear and continuing sense of ourselves as medical professionals.

HMOs: America today, Britain tomorrow? Exit the white coat, enter the pinstriped suit

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Mortality transition in Korea: its implications for health policy and education

This paper discusses the progress and prospects for mortality reduction in Korea, drawing upon the scanty data available in the literature. Data suggest that recent mortality improvement in Korea is slowing; that male mortality patterns at older ages are deviating from model life tables: that infant and child mortality is relatively high; and that transitional changes in the cause-of-death structure of infants and children are lagging behind their elders. Implications of these trends form a principal basis for concern about health policy issues in Korea. Any continuing progress in mortality would require major effort in several areas: accurate and adequate assessment of disease patterns and health behavior; reexamination of current health care strategies and public health measures; and analyses of social and economic development policies relevant to health conditions.

Current and future directions in reimbursement for psychiatric services

Psychiatric services are currently facing one of the true crises in a historical development that began in the attics, asylums, and streets. The cause for this crisis in reimbursement is commonly attributed to what many believe is a temporary dip in the economy that has led third-party payers to overreact unnecessarily and unreasonably by limiting benefits and payouts. Such persons believe unwarranted anxieties about the economy and reimbursement for services will lessen with consumer demands, reassurances by health-care providers that the care is quality and cost-effective, and the expected stabilization in a destabilized economy. Others see a much more uncertain and lengthy course of events.