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