Hospital progress最新文献

The master indenture enables members of multiinstitutional health care systems to finance capital programs and expansions by borrowing on the basis of systemwide revenues and assets. Participation in a master indenture financing may be structured in two ways. In a restricted group, only the parent organization issues notes, and only the parent is directly liable for the debt. To ensure that each member's revenues flow to the parent, the latter must have sole member status and be permitted to approve subsidiaries' debts, budgets, amendments to articles and bylaws of incorporation, and selection of trustees. Each entity's articles and bylaws must permit it to support the system members' common charitable purpose. In contrast, members of an obligated group have direct joint and several liability for master indenture notes. If one subsidiary misses a payment, the parent can call for payment from other obligated group members. Limitations on a member's obligation to support system debt in case of insolvency or bankruptcy may be included in the master indenture provisions. Whichever structure is selected, the amount of debt that can be incurred is based on the institutions' combined financial statements. The master indenture thus allows financially weak institutions to benefit from the credit strengths of stranger system members and permits the parent organization to control members' access to capital markets.

Because of the development of multihospital systems and the establishment of diagnosis related groups, hospitals increasingly will establish matrix organizations for their corporate structures. St. Luke's Hospital adopted the matrix concept in the mid-1970s, utilizing program administrators for each specialty service or "clinical center of excellence." Such centers have been developed in digestive diseases, cardiovascular and pulmonary medicine, orthopedics and rheumatology, ophthalmology, and behavioral health. The program administrator's functions are diverse: To serve as primary liaison between physicians and the hospital; To project levels of program utilization and patient and physician satisfaction, to identify areas requiring administrative and marketing emphasis, and to develop the program's marketing plan; To develop, implement, and evaluate the program's strategic, operational, and financial plans; To recruit physicians to practice at St. Luke's and to cultivate referrals from outside physicians; To participate in selecting members of all board and medical staff committees relating to the particular specialty area; and To determine the need for new programs within the specialty area and to develop services. As indicated by a medical staff survey, most physicians at St. Luke's believe that the program administrator system has improved communication with the hospital administration, that the program administrator is able to respond effectively to physician requests and problems, and that the quality of patient care has been enhanced. A great majority said they would recommend the system to other hospitals.

The U.S. bishops' statements on racism over the last 40 years have addressed the structural as well as the personal aspects of racial discrimination. They have noted its persistence, described it as a moral and religious problem, and called for aggressive action among Catholics to combat it. "Meaningful equality" for blacks, however, remains a distant dream, the U.S. Supreme Court noted in a recent case involving institutional discrimination, because of the basically disadvantaged position into which blacks are born. As statistics on health, education, work, and standard of living illustrate, the socioeconomic opportunities available to blacks are markedly lower than those available to white Americans. Despite these odds, efforts to improve blacks' chances of contributing to society--through affirmative action programs--have achieved striking results in industry. Hospitals, as major workplaces, likewise should focus greater attention on developing and extending minority employment and advancement programs. Catholic health care facilities especially should evaluate their commitments to affirmative action. Increased efforts to eliminate discrimination in all aspects of a hospital's relationships with the business community as well as with its own employees will cause them to be recognized as symbols of justice not only in the workplace but also in society.

Preferred provider organizations (PPOs) have caused concern because they raise the question whether providers can establish mechanisms to control the price of medical care without violating antitrust laws. The U.S. Supreme Court recently decided in Arizona v. Maricopa County Medical Society that the practices of a physicians' organization which set fee schedules by majority vote constituted price fixing because "independent competing entrepreneurs" made the agreements. The decision implies that PPOs must carefully structure collective efforts to set prices in order to avoid unlawful agreement among competitors. To avoid antitrust exposure, hospitals may independently determine prices and contract individually with providers, or they may act as brokers for individual physicians, establishing fees and claims-processing procedures and then contracting with physicians who agree to these requirements. Setting fees independently may be difficult, however, since hospitals need to know what payment physicians will accept. Thus some physician involvement is probably inevitable. No antitrust liability results, however, if individual physicians are sampled in an information-gathering process but do not collectively set fees. In addition, a PPO that is structured as a partnership or other joint arrangement involving true risk sharing should withstand antitrust challenge. In recent business review letters, the Department of Justice approved two different PPO structures: A Hospital Corporation of America subsidiary would contract (nonexclusively) with providers, hospitals, and third party payers to treat the third party payers' beneficiaries at discounted rates. The charges would be negotiated individually with each physician and hospital. A management consultant firm would act as an intermediary between providers and third party payers, negotiating patient discounts but not participating in fee setting. A PPO need not be structured in every respect like these programs. Individual situations vary, and with sound antitrust advice, PPOs can avoid legal pitfalls.