The economic, health, or social "profits" of a health care organization, system, or practice largely hinge on having a preponderance of clinical decisions that are mutually beneficial to the patient, the clinician, and the health care organization. Research into how to improve those "profits" of health care organizations historically has focused either on changing the behavior of clinicians via reimbursement mechanisms or on changing patient behavior via insurance-related economic incentives. Both approaches have long and well-respected empirical linages that have contributed incrementally to our understanding of how to increase those profits.
A current effort to influence providers' clinical behavior is the Comprehensive Primary Care Initiative, funded by the Centers for Medicare and Medicaid Services. Participating primary care practices are required to build capacity in specific care delivery approaches and are incentivized through a new fee structure. A midpoint evaluation of the Comprehensive Primary Care Initiative was recently released (Dale et al., 2016). At the end of the second year of the 4-year intervention, their rigorous and clearly conceptualized study analyzed data on a variety of patient outcomes and clinician practices. Very few and small changes were found in either clinician behavior or patient outcomes. A degree of disappointment could be read between the lines.
The failure of financial incentives to make large, sustained, and meaningful changes in clinicians' behaviors that result in improved patient outcomes raises a host of questions. The assumption has been that reimbursement directed at the individual clinician will influence each decision made across multiple patients. The causal pathway from reimbursement to behavior of clinicians or other direct service providers, however, has rarely been articulated or included in studies. This omission contrasts markedly with the considerable health economics research into patient sensitivity to insurance mechanisms. Moving forward, a shift in emphasis is needed toward the managerial and organizational context of the clinician based on a health care management perspective. Conceptual and analytic models in prior research do not control for the degree of influence that management practice plays in the success or failure of financial incentives directed at clinicians. Many possible research topics spring to mind as examples of what could (ought) be the next generation of "profit" research. Here are only three.
1. Health care management scholars need to develop conceptually sound, standardized, and ubiquitously available indicators of managerial actions or influence. This would make possible including management as a control or explanatory variable across research foci.
2. Health care management scholars can develop novel theoretical models of how managers influence the causal flow from reimbursement incentives to clinician and patient decisions. Such models can then be tested against existing theories of clinician behavior.
3. Health care management scholars might generate truly innovative interventions that lead to a greater effect on the "profit" by involving clinic and unit managers as well as department heads and health care executives in the design of management interventions.
We need health care management research that shows that management is the missing "profit" variable. We need health care management experiments.
L. Michele Issel, PhD, RN
Editor-in-Chief
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