There are lots of ways that an administrator / manager's policy impacts the overall health status of a target population.
Probably the simplest example - Each year comes the budget time. Do we have the money to continue to offer ______ service at the level we did.
I have worked for 20 years in a community that was served by 2 hospitals. Recently the two hospitals merged, despite objection from many of the physicians at the smaller (profitable hospital) with the larger (money losing hospital) - Now the unified hospital is losing money, has lost physicians, waiting times in the emergency department have increased, employee moral is down (which has a negative effect on patient care), physicians employed by the smaller hospital were left go - and not offered jobs by the new entity - eliminating ANY choice of physician groups in some specialties.
The now monopoly hospital is negotiating with insurance companies for higher payments for services (which will then increase insurance costs for employers - causing more employers to drop insurance or charge employees a higher copayment)
Administrators often are "bean counters" - MBA/MHA with less direct involvement in patient care that administrators 50 years ago. Decisions are made as "business decisions" with little thought to the lowly patient (OH...is that why we do this?? If a service is not directly profitable - the service is often victim to service cuts in the name of "cost containment". The end effect may be to increase total costs to the community (which then indirectly causes the costs of providing service to increase to the hospital)
I often use this article when I give lectures to my wife's classes about formularies and their potential risks. The study found that HMO plans that had more restrictions actually INCREASED total health care costs. The RX costs may have gone down, but total costs went up.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed
In most HMOs there is one person responsible for (and often bonused on) prescription costs, someone else is held respsonsible for reducing inpatient hospital costs (and so is his bonus tied to this), yet another person is responsible for control of imaging costs (MRI, CT, Ultrasounds)... You get the idea.
If you are responsible for the budget of a HMO drug plan - and a new drug if approve for your fomulary is likely to be used very frequently - by your estimates it might actually increase total RX costs in your plan by 5% (just for this one new drug) - and your budget only is for a total 3% raise - you are probably going to turn it down to save your job (Annual review is comming up you know...)
The same drug has been show in studies to reduce the average length of stay for inpatients with a common medical condition by 2 days. The manager of the inpatient utilization department wants every doctor to use the new drug - it might reduce his inpatient costs by 2%.
The problem - each is serving their own best interst (and their perception of the best interst of the HMO) - The poor doctor (God help him - he might just want to do what is best for the patient) spends 30 minutes on the phone fighting with the pharmacy director, HMO medical director, maybe even calling the CEO's office to get the patient the medication which would get him home sooner and reduce total costs - ...you get the idea.
Edited by FamilyPhysician on July 19 2006 at 11:36pm__________________
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