Organization of Care
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Transcript of Organization of Care
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Organization of Care
M6920October 16, 2001
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Columbia University School of Nursing M6920, Fall, 2001
Comparing Health Systems*
Basic Policy (scope & goal)
Organizational Structure
Economic Support Staffing
Facilities Supplies Delivery Patterns Preventive
Services Regulations
* Adapted from Roemer, Comparative Health Systems
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Columbia University School of Nursing M6920, Fall, 2001
Basic Policy (scope & goal)
Who will be served? Intended to
• cure the ill?• prevent disease?• meet economic goals of
participants?
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Columbia University School of Nursing M6920, Fall, 2001
Organizational Structure
Ministry of health Competition among components National or regional
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Columbia University School of Nursing M6920, Fall, 2001
Economic Support
Personal finances Taxation Pooled funding (insurance) Voluntary (charity)
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Columbia University School of Nursing M6920, Fall, 2001
Staffing
Highly professionalized• trained in-country• imported
Many paraprofessionals Volunteers
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Columbia University School of Nursing M6920, Fall, 2001
Facilities
Hospitals• community• referral• tertiary
Clinics Solo practitioner offices Health posts/outreach centers
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Columbia University School of Nursing M6920, Fall, 2001
Supplies
Centrally managed? Locally produced or imported? Global budget?
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Columbia University School of Nursing M6920, Fall, 2001
Delivery Patterns
Entry point for care Continuity of care Gatekeepers Decision-makers
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Columbia University School of Nursing M6920, Fall, 2001
Preventive Services
Priority Inclusion in personal care Funding
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Columbia University School of Nursing M6920, Fall, 2001
Regulations
National or regional Scope Support for enforcement
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Columbia University School of Nursing M6920, Fall, 2001
The US non-system
No overarching policy
Decentralized structure
Mixed economic support
Physician-led hierarchy
Hospital based ?
Supplies from private sector
Mixed delivery pattern
Increasing preventive services
State-based regulation
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Columbia University School of Nursing M6920, Fall, 2001
Organizational questions:
How are the various portions of the system of care-giving connected to one another?
Who connects the system and facilitates or controls access?
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Columbia University School of Nursing M6920, Fall, 2001
Special concerns
Vulnerable groups• Physical, social, economic,
psychological reason Feared bad outcome
• a condition, a treatment failure, some other problem?
Size of a population group
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Columbia University School of Nursing M6920, Fall, 2001
Perspectives on an ideal system
Healthy family? Family with chronic
condition? Primary care
provider?
Specialist? Hospital? Insurer? Employer/
purchaser?
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Columbia University School of Nursing M6920, Fall, 2001
Major axes of comparison
entry point• practitioner• clinic• E.R.
time of entry• routine/maintenance• specific symptom• traumatic event
payment source• self• indemnity insurance• capitated plan
structure of system• independent units• vertically integrated
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Columbia University School of Nursing M6920, Fall, 2001
Hospitals
originally charity or public entities• 6500 community hospitals in US
• 1400 are city, state, county proprietary multi-hospital systems (horizontal
integration) vertically integrated systems
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Columbia University School of Nursing M6920, Fall, 2001
Practitioners
individual entrepreneur
contract• railroads • mining companies• unions
multi-specialty groups• salaried fee for
service• capitated
institutionally based
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Columbia University School of Nursing M6920, Fall, 2001
Special populations
Frontier Nursing Service community mental health centers public health department clinics family planning clinics--4000 clinics Ryan White programs Health care for homeless
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Columbia University School of Nursing M6920, Fall, 2001
Migrant/community health centers
• 600 at 2500 sites• 14% of eligible
migrants served
CHC payments
40%
38%
10%
12%
Medicaid UninsuredMedicare Commercial
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Columbia University School of Nursing M6920, Fall, 2001
We reorganize when
A new technology is discovered A new type of worker enters
the process Another method is more
financially viable or more profitable
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Columbia University School of Nursing M6920, Fall, 2001
New York City Hospitals Operating Margins, 1999
-5.00%
-4.00%
-3.00%
-2.00%
-1.00%
0.00%
1.00%
Small Medium Large
AffiliatedUnaffiliated
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Columbia University School of Nursing M6920, Fall, 2001
New York City Hospitals Payer Mix and Use, 1999HospitalSize
%Medicaid& selfpay
% in groupwith >35%Medicaid
Occu-pancyRate
% changeindischarges
Small 45% 58% 76% -0.1%
Medium 51 75 81 -0.1
Large 31 17 82 3.9
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Columbia University School of Nursing M6920, Fall, 2001
Reimbursement
Fee for service--payment per procedure• can be provider or hospital
Fee for service--payment per episode Payment per day
• hospitals• private duty RN
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Columbia University School of Nursing M6920, Fall, 2001
Reimbursement, cont.
Salary--payment per hour/week/month• staff model HMO• typical nurse payment
Capitation• could go to hospital via HMO contract• with and without risk
Global budget--for hospital
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Columbia University School of Nursing M6920, Fall, 2001
Setting level of payment
payment for procedures • limits via fee setting haven't worked
payment for intellectual activity• RBRVS
what the market will bear• Bargained collectively--union model• Open competition• Professional agreement
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Columbia University School of Nursing M6920, Fall, 2001
Managed care can be socially responsible if it enrolls a representative segment of the
population identifies and acts on opportunities to
improve community health participates in community-wide data
sharing includes community in governance
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Columbia University School of Nursing M6920, Fall, 2001
and it. . .
participates in health professions education
collaborates with public health infrastructure
advocates publicly for health promotion/disease prevention policies