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Medicare has adopted a physician fee schedule that places emphasis on measuring physicians' work. We assessed the construct validity of self-reported work scores for 11 selected medical services performed by 44 internists in two large group practices. These physicians' work scores correlated highly with their ratings of time, physical and mental effort, and stress required to produce the services. Eighty-five percent of the variance in total work scores could be explained by the dimensions of work. Time was the most important input, but mental effort also was important for internists. We also found that physicians may reduce the total work required to produce two services for a patient if they provided those services in one visit, rather than in separate visits. Savings occurred for service pairs in which the physician could reduce his or her own time. Our findings imply that the Medicare fee schedule pays internists mainly for the time and mental effort required to produce medical services. They also underscore the importance to physicians of saving time by providing two services during the same patient visit.

This study was designed to identify the relevant components of the organizational culture of medical group practices and to develop an instrument to measure those cultures. Building on the work of industrial psychologists and organizational sociologists, a 35-item instrument was developed through an iterative process with more than 100 medical groups. The final instrument was tested using responses from physicians practicing in two very different medical groups: one a prepaid group practice with salaried physicians and the other, until recently, a fee-for-service practice. Using stepwise discriminant analysis of the responses to this instrument, more than 90% of the physicians were able to be placed in the appropriate practice setting.

Physician payment reform will base payment largely upon physician work. Current reforms assume that services are provided independently, yet physicians may often perform two or more services at one time. There is evidence from other industries that services provided jointly may not require the same total resources as identical services provided independently. This study evaluated whether physician-reported work and time were the same for some common services when provided jointly and when provided separately. Six case vignettes were constructed consisting of two services each. Forty-four general internists rated the total work and time required for each vignette performed as a whole, and for the two services performed separately. Total work was estimated using a magnitude estimation technique similar to that used in developing the resource-based relative value scale. For five of the six vignettes, the work rating for performing the services together was significantly less than the sum of the ratings for the separate services. The work savings associated with providing services together ranged from 4 to 30 of the total work of the separate services. A similar reduction was observed for the estimated time to perform services jointly in four of the six vignettes. In no case was work or time lower when services were provided separately. Physicians report lower work and time for at least some pairs of services, compared with providing the same services separately. Reimbursement mechanisms that fail to account for these reductions may provide incentives to combine or add services.

This article explores quality assurance issues that are likely to arise related to limited-service rural hospitals, an institutional alternative to existing ru ral hospitals. In exploring these issues, we use as an example, the Montana Medical Assistance Facility, a limited-service rural hospital model about to be im plemented by the Health Care Financing Administra tion as a demonstration. While such medical assist ance facilities will need to meet licensure and certi fication requirements, it is not reasonable to expect them to meet regulations that are designed for large hospitals. Also, because of their limited resources, medical assistance facilities will likely need outside help from a larger institution to perform quality as surance activities, particularly peer review activi ties. A key challenge for the medical assistance facil ity will be to define the nature of this relationship, while retaining ultimate responsibility for quality of patient care. Assuring quality of care is a particularly important issue for medical assistance facilities since community acceptance and financial viability will depend critically on establishing a record for quality of care that is at least comparable to existing small, rural hospitals.

Patients on chronic carbidopa-levodopa (Sinemet®) therapy underwent thyroid function testing that included measurement of serum thyroxine (T4), triiodothyronine (T3), thyrotropin (TSH), T3uptake (T3U), free T4index (FT4I), and free T3index (FT3I). The subjects were studied both in a random sampling and in a controlled manner, fasting and 2 hours after receiving the drug. All subjects were euthyroid by testing, and there was no significant difference in thyroid hormone levels of patients and controls or in fasting values and values 2 hours after the drug. However, there was a small but significant reduction in serum TSH levels after Sinemet®. Therapeutic doses of Sinemet® have no significant effect on thyroid function in euthyroid patients with Parkinson disease.

To the Editor.—Hypophosphatemia is a serious consequence of many common clinical entities. Despite the recent emphasis on the consequences and treatment of hypophosphatemia,1 few clinicians recognize the potential toxicity of oral phosphate therapy. The following reports a case of hypocalcemia from hyperphosphatemia induced by oral phosphate replacement therapy.Report of a Case.—A 98-year-old man was hospitalized for a left lower lobe pneumonia. His family had noted progressive deterioration of his mental status, increasing shortness of breath, and poor dietary intake during the week before. There was no history of renal impairment. The temperature was 38.3 °C; pulse rate, 90 per minute; blood pressure, 120/70 mm Hg; and respiratory rate, 28 per minute. Examination showed a lethargic, disoriented, elderly man with bibasilar rales. Admission laboratory findings disclosed the following values: normal electrolytes, creatine, 0.9 mg/dL; BUN, 7 mg/dL; serum calcium, 9.0 mg/dL; phosphate, 1.9 mg/dL; and albumin, 2.8 mg/dL.