Organization of Care
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Transcript of Organization of Care
Organization of Care
M6920October 16, 2001
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
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?
Columbia University School of Nursing M6920, Fall, 2001
Organizational Structure
Ministry of health Competition among components National or regional
Columbia University School of Nursing M6920, Fall, 2001
Economic Support
Personal finances Taxation Pooled funding (insurance) Voluntary (charity)
Columbia University School of Nursing M6920, Fall, 2001
Staffing
Highly professionalized• trained in-country• imported
Many paraprofessionals Volunteers
Columbia University School of Nursing M6920, Fall, 2001
Facilities
Hospitals• community• referral• tertiary
Clinics Solo practitioner offices Health posts/outreach centers
Columbia University School of Nursing M6920, Fall, 2001
Supplies
Centrally managed? Locally produced or imported? Global budget?
Columbia University School of Nursing M6920, Fall, 2001
Delivery Patterns
Entry point for care Continuity of care Gatekeepers Decision-makers
Columbia University School of Nursing M6920, Fall, 2001
Preventive Services
Priority Inclusion in personal care Funding
Columbia University School of Nursing M6920, Fall, 2001
Regulations
National or regional Scope Support for enforcement
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
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?
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
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?
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
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
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
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
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
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
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
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
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
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
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
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
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