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Researchers recommend a reorganization of the medical profession into larger groups with a multispecialty mix. We analyze whether there is evidence for the superiority of these models and if this organizational transformation is underway.

We summarize the evidence on scale and scope economies in physician group practice, and then review the trends in physician group size and specialty mix to conduct survivorship tests of the most efficient models.

The distribution of physician groups exhibits two interesting tails. In the lower tail, a large percentage of physicians continue to practice in small, physician-owned practices. In the upper tail, there is a small but rapidly growing percentage of large groups that have been organized primarily by non-physician owners.

While our analysis includes no original data, it does collate all known surveys of physician practice characteristics and group practice formation to provide a consistent picture of physician organization.

Our review suggests that scale and scope economies in physician practice are limited. This may explain why most physicians have retained their small practices.

Larger, multispecialty groups have been primarily organized by non-physician owners in vertically integrated arrangements. There is little evidence supporting the efficiencies of such models and some concern they may pose anticompetitive threats.

This is the first comprehensive review of the scale and scope economies of physician practice in nearly two decades. The research results do not appear to have changed much; nor has much changed in physician practice organization.

As all countries in the world, Polish health care system has to challenge four fundamental transformations: demographic, technological, epidemiological and cultural. Each of them generates serious threats for the sustainability of the system. The Polish society is ageing even faster than other in the European Union. For the sustainability of the system, the ageing of the population is a double challenge: on the expenditure side and on the financing side.

The Polish health care system is characterised by three negative features: under-financing of health care, misguided organisation of the health sector and health care entities and a dramatic shortage of health care professionals. The share of GDP devoted to health has remained constant over the last years at the level of 6.3%–6.7%. Poland has one of the lowest rates of practicing doctors and nurses in the EU countries. Lack of attractiveness of the medical professions caused by consistently low wages has created a huge generation gap.

Looking from the perspective of cost-effectiveness, we must to state, that the system, with its small financial outlays, provides a relatively high level of health for the population. However, it does not mean that better results could not be achieved. The majority of the public hospitals run in the form of independent public health care units that are highly inefficient and indebted. All attempts to restructure the sector and to solve the problem of arrears of the public hospitals failed so far.

To face the challenges, Poland must change its health policy. An increase in the sector's financing is needed, bearing in mind that increasing outlays alone is certainly not enough to solve all problems and secure sustainability. Deep structural and organisational changes are necessary. Unfortunately, politicians avoid making difficult but necessary decisions, e.g., drastic restructuring of the hospital sector, preferring above all to increase public spending on health.

Health-care systems currently face great challenges, including an increasing elderly population. To respond to this problem, a hospital emergency department, three municipalities, and self-employed general practitioners in Denmark decided to collaborate with the aim of reorganizing treatment of elderly acute ill patients. By establishing a small-scale collaborative community and through an action research process, we show, how to jointly explore and develop a new organization design for in-home hospital treatment that enables the health professionals to collaborate in new ways, and at the same time to investigate and improve this cocreation process and codesign of knowledge among multiple different stakeholders.

Healthcare provision in Denmark reflects some of the key principles of the welfare state. By securing relatively easy and equal access for all Danish residents regardless of income via general tax financing, the Danish healthcare system has strong ethical merits. All residents are entitled to comprehensive healthcare services. The Danish healthcare system is also relatively efficient. Total healthcare expenditures – including public and private – amount to 10% of GDP, above the OECD 8.8% average but well below the costs in the other Nordic countries, Germany, Switzerland and the United Stated. Notwithstanding its merits, healthcare in Denmark shares key predicaments with other OECD countries, primarily how to improve health outcomes while containing care expenditures. All of the OECD countries aim to improve population life expectancy and health quality. Yet their ageing and increasingly obese populations are exacerbating the demands on their respective healthcare systems. This chapter examines changes in how Denmark has managed these challenges. The main argument is that the healthcare system performance on managing health outcomes and costs improved remarkably from the 1990s to the early 2020s, although outcome inequalities remain. Notable changes in the system were targeted innovations in treatment procedures and expansion of municipal rehabilitation and preventive efforts, along with strict budget controls.

The hospital–physician relationship (HPR) has been the focus of many scholars given the potential impact of this relationship on hospitals’ ability to achieve socially and organizationally desirable health care outcomes. Hospitals are dominated by professionals and share many commonalities with professional service firms (PSFs). In this chapter, we explore an alternative HPR based on the governance models prevalent in PSFs.

We summarize the issues presented by current HPRs and discuss the governance models dominant in PSFs.

We identify the non-equity partnership model as a governance archetype for hospitals; this model accounts for both the professional dominance in health care decisions and the increasing demand for higher accountability and efficiency.

There should be careful consideration of existing regulations such as the Stark law and the antikickback statue before the proposed governance model and the compensation structure for physician partners is adopted.

While our governance archetype is based on a review of the literature on HPRs and PSFs, further research is needed to test our model.

Given the dominance of not-for-profit (NFP) ownership in the hospital industry, we believe the non-equity partnership model can help align physician incentives with those of the hospital, and strengthen HPRs to meet the demands of the changing health care environment.

This is the first chapter to explore an alternative hospital–physician integration strategy by examining the governance models in PSFs, which similar to hospitals have a high reliance on a predominantly professional staff.

The COVID-19 pandemic stressed the health care sector's longstanding pain points, including the poor quality of frontline work and the staffing challenges that result from it. This has renewed interest in technology-centered approaches to achieving not only the “Triple Aim” of reducing costs while raising access and quality but also the “Quadruple Aim” of doing so without further squeezing wages and abrading job quality for frontline workers.

How can we leverage technology toward the achievement of the Quadruple Aim? I view this as a “grand challenge” for health care managers and policymakers. Those looking for guidance will find that most analyses of the workforce impact of technological change consider broad classes of technology such as computers or robots outside of any particular industry context. Further, they typically predict changes in work or labor market outcomes will come about at some ill-defined point in the medium to long run. This decontextualization and detemporization proves markedly problematic in the health care sector: the nonmarket, institutional factors driving technology adoption and implementation loom especially large in frontline care delivery, and managers and policymakers understandably must consider a well-defined, near-term, i.e., 5–10-year, time horizon.

This study is predicated on interviews with hospital and home health agency administrators, union representatives, health care information technology (IT) experts and consultants, and technology developers. I detail the near-term drivers and anticipated workforce impact of technological changes in frontline care delivery. With my emergent prescriptions for managers and policymakers, I hope to guide sectoral actors in using technology to address the “grand challenge” inherent to achieving the Quadruple Aim.

The paper sets forth and examines the assumptions underlying two global ideas – world class and best practices – and their application to (higher) education and health organizations. Our basic (ex-ante) assumption is that both sectors are influenced by organizational fields that embody these ideas. However, we also assume that these sectors differ, and thus, that one should find between sector variations in the influence of such ideas. The findings suggest that both sectors have been affected by hegemonic ideas, yet in rather different ways, and that these ideas, particularly the metrics being used, pose different challenges in the two sectors.

In this chapter, we focus on the major reforms intended to ensure the sustainability of health care in Denmark between 2000 and 2020 and the evidence for the effectiveness of these reforms. We take a broad definition of sustainability and include reforms that aimed to improve the productivity of the health care sector both in terms of increasing activity for the same set of inputs and in terms of improving the quality of care. A characterisation of the Danish health care system as having gone through evolution rather than revolution (Pedersen, Christiansen, & Bech, 2005) is, with one exception, still true today, and reforms have been relatively few. As we demonstrate there is a relative lack of formal evaluations of these reforms.

In the first decade of the period, the majority of new policy measures aimed to increase the quantity of care provided by the health care sector. With the introduction of diagnosis-related groups (DRGs) to measure hospital activity, a wave of reforms created a stronger link between activity and hospital reimbursement, and introduced additional incentives for increasing activity, alongside requirements for increased technical efficiency. A centralisation reform in 2007 reduced the number of administrative units and saw the beginning of a development that would also lead to fewer hospital units. Procurements of medicines were professionalised, and a national council was established to consider the use of expensive hospital medicine.

In the second-half of the period, policy makers began questioning whether increased activity was always for the better, and slowly began experimenting with initiatives that would shift the focus to the quality and appropriateness of care. As in many other countries, this move occurred in the light of a realisation of a shift in the demographic structure of the country and the change this was expected to create for the future demand for health care.

Although some empirical evidence exists, it is striking that few of the changes to the health care sector has been subject to formal academic evaluation – especially when considering the availability of high quality nationwide micro data. We point to a number of important lessons that could be drawn from the Danish experiences.

However, the greatest potential for research into the sustainability of health care in the Danish setting is probably still to be realised by taking advantage of the possibilities of linking micro data on individuals' health care utilisation, schooling outcomes and labour supply, with the possibility of following individuals across decades. For example, Danish micro data make it possible to follow newborns in 1990 until they reach adulthood and simultaneously follow their parents from adulthood until they reach 60 years of age where the prevalence of chronic diseases begins to show.

Hospitals worldwide are facing the same opportunities and threats: the demographics of an aging population; steady increases in chronic diseases and severe illnesses; and a steadily increasing demand for medical services with more intensive treatment for multi-morbid patients. Additionally, patients are becoming more demanding. They expect high quality medicine within a dignity-driven and painless healing environment.

The severe financial pressures that these developments entail oblige care providers to more and more cost-containment and to apply process reengineering, as well as continuous performance improvement measures, so as to achieve future financial sustainability. At the same time, regulators are calling for improved patient outcomes. Benchmarking and best practice management are successfully proven performance improvement tools for enabling hospitals to achieve a higher level of clinical output quality, enhanced patient satisfaction, and care delivery capability, while simultaneously containing and reducing costs.

This chapter aims to clarify what benchmarking is and what it is not. Furthermore, it is stated that benchmarking is a powerful managerial tool for improving decision-making processes that can contribute to the above-mentioned improvement measures in health care delivery. The benchmarking approach described in this chapter is oriented toward the philosophy of an input–output model and is explained based on practical international examples from different industries in various countries.

Benchmarking is not a project with a defined start and end point, but a continuous initiative of comparing key performance indicators, process structures, and best practices from best-in-class companies inside and outside industry.

Benchmarking is an ongoing process of measuring and searching for best-in-class performance:

• Measure yourself with yourself over time against key performance indicators

• Measure yourself against others

• Identify best practices

• Equal or exceed this best practice in your institution

• Focus on simple and effective ways to implement solutions

Measure yourself with yourself over time against key performance indicators

Measure yourself against others

Identify best practices

Equal or exceed this best practice in your institution

Focus on simple and effective ways to implement solutions

Comparing only figures, such as average length of stay, costs of procedures, infection rates, or out-of-stock rates, can lead easily to wrong conclusions and decision making with often-disastrous consequences. Just looking at figures and ratios is not the basis for detecting potential excellence. It is necessary to look beyond the numbers to understand how processes work and contribute to best-in-class results. Best practices from even quite different industries can enable hospitals to leapfrog results in patient orientation, clinical excellence, and cost-effectiveness.

Despite common benchmarking approaches, it is pointed out that a comparison without “looking behind the figures” (what it means to be familiar with the process structure, process dynamic and drivers, process institutions/rules and process-related incentive components) will be extremely limited referring to reliability and quality of findings.

In order to demonstrate transferability of benchmarking results between different industries practical examples from health care, automotive, and hotel service have been selected.

Additionally, it is depicted that international comparisons between hospitals providing medical services in different health care systems do have a great potential for achieving leapfrog results in medical quality, organization of service provision, effective work structures, purchasing and logistics processes, or management, etc.

The long-term financial stability of hospital systems represents a “grand challenge” in health care. New ownership forms, such as private equity (PE), promise to achieve better financial performance than nonprofit or for-profit systems. In this study, we compare two systems with many similarities, but radically different ownership structures, missions, governance, and merger and acquisition (M&A) strategies. Both were nonprofit, religious systems serving low-income communities – Montefiore Health System and Caritas Christi Health Care.

Montefiore's M&A strategy was to invest in local hospitals and create an integrated regional system, increasing revenues by adding primary doctors and community hospitals as feeders into the system and achieving efficiencies through effective resource allocation across specialized units. Slow and steady timing of acquisitions allowed for organizational learning and balancing of debt and equity. By 2019, it owned 11 hospitals with 40,000 employees and had strong positive financials and low reliance on debt.

By contrast, in 2010, PE firm Cerberus Capital bought out Caritas (renamed Steward Health Care System) and took control of the Board of Directors, who set the system's strategic direction. Cerberus used Steward as a platform for a massive debt-driven acquisition strategy. In 2016, it sold off most of its hospitals’ property for $1.25 billion, leaving hospitals saddled with long-term inflated leases; paid itself almost $500 million in dividends; and used the rest for leveraged buyouts of 27 hospitals in 9 states in 3 years. The rapid, scattershot M&A strategy was designed to create a large corporation that could be sold off in five years for financial gain – not for health care integration. Its debt load exploded, and by 2019, its financials were deeply in the red. Its Massachusetts hospitals were the worst financial performers of any system in the state. Cerberus exited Steward in 2020 in a deal that left its physicians, the new owners, holding the debt.