1. Organization of Care M6920 October 16, 2001

2. Columbia University School of NursingM6920, Fall, 2001 Comparing Health Systems* l Basic Policy (scope & goal) l Organizational Structure l Economic Support l Staffing l Facilities l Supplies l Delivery Patterns l Preventive Services l Regulations * Adapted from Roemer, Comparative Health Systems

3. Columbia University School of NursingM6920, Fall, 2001 Basic Policy (scope & goal) l Who will be served? l Intended to cure the ill? prevent disease? meet economic goals of participants?

4. Columbia University School of NursingM6920, Fall, 2001 Organizational Structure l Ministry of health l Competition among components l National or regional

5. Columbia University School of NursingM6920, Fall, 2001 Economic Support l Personal finances l Taxation l Pooled funding (insurance) l Voluntary (charity)

6. Columbia University School of NursingM6920, Fall, 2001 Staffing l Highly professionalized trained in-country imported l Many paraprofessionals l Volunteers

7. Columbia University School of NursingM6920, Fall, 2001 Facilities l Hospitals community referral tertiary l Clinics l Solo practitioner offices l Health posts/outreach centers

8. Columbia University School of NursingM6920, Fall, 2001 Supplies l Centrally managed? l Locally produced or imported? l Global budget?

9. Columbia University School of NursingM6920, Fall, 2001 Delivery Patterns l Entry point for care l Continuity of care l Gatekeepers l Decision-makers

10. Columbia University School of NursingM6920, Fall, 2001 Preventive Services l Priority l Inclusion in personal care l Funding

11. Columbia University School of NursingM6920, Fall, 2001 Regulations l National or regional l Scope l Support for enforcement

12. Columbia University School of NursingM6920, Fall, 2001 The US non-system l No overarching policy l Decentralized structure l Mixed economic support l Physician-led hierarchy l Hospital based ? l Supplies from private sector l Mixed delivery pattern l Increasing preventive services l State-based regulation

13. Columbia University School of NursingM6920, Fall, 2001 Organizational questions: l How are the various portions of the system of care-giving connected to one another? l Who connects the system and facilitates or controls access?

14. Columbia University School of NursingM6920, Fall, 2001 Special concerns l Vulnerable groups Physical, social, economic, psychological reason l Feared bad outcome a condition, a treatment failure, some other problem? l Size of a population group

15. Columbia University School of NursingM6920, Fall, 2001 Perspectives on an ideal system l Healthy family? l Family with chronic condition? l Primary care provider? l Specialist? l Hospital? l Insurer? l Employer/ purchaser?

16. Columbia University School of NursingM6920, Fall, 2001 Major axes of comparison l entry point practitioner clinic E.R. l time of entry routine/maintenance specific symptom traumatic event l payment source self indemnity insurance capitated plan l structure of system independent units vertically integrated

17. Columbia University School of NursingM6920, Fall, 2001 Hospitals l originally charity or public entities 6500 community hospitals in US 1400 are city, state, county l proprietary l multi-hospital systems (horizontal integration) l vertically integrated systems

18. Columbia University School of NursingM6920, Fall, 2001 Practitioners l individual entrepreneur l contract railroads mining companies unions l multi-specialty groups salaried fee for service capitated l institutionally based

19. Columbia University School of NursingM6920, Fall, 2001 Special populations l Frontier Nursing Service l community mental health centers l public health department clinics l family planning clinics--4000 clinics l Ryan White programs l Health care for homeless

20. Columbia University School of NursingM6920, Fall, 2001 Migrant/community health centers 600 at 2500 sites 14% of eligible migrants served

21. Columbia University School of NursingM6920, Fall, 2001 We reorganize when l A new technology is discovered l A new type of worker enters the process l Another method is more financially viable or more profitable

22. Columbia University School of NursingM6920, Fall, 2001 New York City Hospitals Operating Margins, 1999

23. Columbia University School of NursingM6920, Fall, 2001 New York City Hospitals Payer Mix and Use, 1999

24. Columbia University School of NursingM6920, Fall, 2001 Reimbursement l Fee for service--payment per procedure can be provider or hospital l Fee for service--payment per episode l Payment per day hospitals private duty RN

25. Columbia University School of NursingM6920, Fall, 2001 Reimbursement, cont. l Salary--payment per hour/week/month staff model HMO typical nurse payment l Capitation could go to hospital via HMO contract with and without risk l Global budget--for hospital

26. Columbia University School of NursingM6920, Fall, 2001 Setting level of payment l payment for procedures limits via fee setting haven't worked l payment for intellectual activity RBRVS l what the market will bear Bargained collectively--union model Open competition Professional agreement

27. Columbia University School of NursingM6920, Fall, 2001 Managed care can be socially responsible if it l enrolls a representative segment of the population l identifies and acts on opportunities to improve community health l participates in community-wide data sharing l includes community in governance

28. Columbia University School of NursingM6920, Fall, 2001 and it... l participates in health professions education l collaborates with public health infrastructure l advocates publicly for health promotion/disease prevention policies