This new system complements and supplements the existing PHE syndromic surveillance systems and is now integrated into the routine daily processes that form this national syndromic surveillance service.
Several HMOs are using physician-nurse practitioner teams to provide primary care to nursing home residents. The potential to improve the delivery of these services in nursing homes, particularly to long-stay residents, is apparent. However, obstacles arise in developing this practice model in HMOs, including difficulty recruiting both nurse practitioners and physicians and the lack of HMO-based research on the effects of such a model.
Academic medical centers (AMCs)-the medical school, the teaching hospital, and the faculty practice plan-depend heavily on patient revenues. Growth in managed care is changing AMCs' revenue streams and creating stresses that are already apparent in areas with a high penetration of health maintenance organizations (HMOs). The prevalence of managed care requires that AMCs adapt to survive and also raises public policy issues related to the financing of medical education. This Commentary discusses the problems facing AMCs that stem from the advent of managed care.Definitions of managed care differ; for our purposes here, it encompasses any measure that, from the perspective of the purchaser of health care, favorably affects the price of services, the site at which the services are received, or their rate of use. Managed care assumes many forms and is becoming the predominant force in the health care marketplace. For example, enrollment in HMOs reached 38.8 million in June 1992, compared with 10.2 million ten years earlier.1 Although enrollment estimates for preferred provider organizations (PPOs) vary widely, by all accounts the number of persons under PPO arrangements has surpassed HMO enrollment; PPOs were only a nascent force ten years ago. Inpatient precertification and concurrent review-bold measures a decade ago-have become the norm in indemnity plans. Specialized programs have evolved to control costs of services such as mental health care and prescription drugs. Managed care also is becoming an integral part of Medicare and Medicaidcritical revenue sources for AMCs. Finally, most reform proposals embrace competitive health plans or other vehicles to promote managed care.Teaching hospitals and faculty practice plans can relate to managed care entities in multiple ways: ( 1 ) AMCs can contract for an individual specialty service, which might be reimbursed on either a discounted fee-for-service basis or a capitation basis; (2) AMC hospitals and physicians can be paid a
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