PA 574: Health Systems Organization Session 2 – January 13, 2011

 Includes all the activities whose primary purpose is to promote, restore or maintain health  Formal health services, traditional services, public health, alternatives  Health systems:  Improve health of populations  Respond to people’s expectations  Provide financial protection against costs of ill health

 Financing  To obtain health services  Insurance  Protection against risks  Delivery  Providers of services  Payment  Reimbursement Shi & Singh, Figure 1-1, p. 6

 Social values and cultures  Population characteristics  Political climate  Economic conditions  Physical environment  Technology development  Global influences Shi & Singh, Figure 1-2, p. 10

 Six Aims  Safe  Effective  Patient-centered  Timely  Efficient  Equitable  Ten Rules for System Redesign…

1. Care is based on continuous healing relationships; 2. Care is customized according to patient needs/values; 3. The patient is the source of control; 4. Knowledge is shared and information flows freely; 5. Decision making is evidence-based; 6. Safety is a system property; 7. Transparency is necessary; 8. Needs are anticipated; 9. Waste is continuously decreased; and, 10. Cooperation among clinicians is a priority.

 Level 1: Patient and Community Experience of patients  Level 2: Microsystem Functioning of small units of care delivery  Level 3: Organization Functioning of organizations that house microsystems  Level 4: Environment Policy, payment, regulation, accreditation Shapes behavior, interests and opportunities of Level 3 organizations

Brainstorm: What has transformed health services delivery over past few decades?

 Professional sovereignty  Urbanization  Science and technology  Growth of institutions  Dependency  Cohesion among medical professionals  Licensing and regulation  Health professions education

 Growth in public health  Consumer advocacy  Increase in chronic conditions and longevity  Services to special interest groups (veterans, disease, racial/ethnic)  New forms of coverage

Science & Technology Mid 18 th to late 19 th Late 19 th to late 20 th Late 20 th to 21 st Consumer Professional Corporate Sovereignty Dominance Dominance Beliefs and Values Social, Economic & Political Constraints Shi & Singh: Figure 3.1; p. 113

Please be back in 10 minutes…

Market Commodity or Public Good?

 Market justice and social justice (Table 2-4; p. 59)  Belief in advancement of science  Capitalist orientation leads to health care viewed as a market commodity, not as public resource  Culture of capitalism consistent with entrepreneurial spirit, self-determination and personal responsibility  Some concern for underprivileged based on underlying values of equity and fairness  Principles of free enterprise dominate

 Consideration of critical human concerns  Protection of society  Application to health care delivery  Health insurance  Health services organization  Equality/inequality  Distributional (in)efficiency

 Attempt to integrate medical care, preventive services, health promotion, health education in community (see Fig. 2-5, p. 65)  Healthy People 2010 (see Fig. 2-6, p. 66) Improve systems Increase quality and years of healthy life Eliminate health disparities 28 focus areas (Ex. 2-1, p. 67)

Shift in Health System Reform Preferences

 New developments in health care reform -- political forces, alliances, federal/state roles  Emphasis on accessibility  Proposed Healthy Americans Act Guarantees market-driven choices Administrative savings  Feasibility?

 Scorecard using national and international data to identify performance benchmarks  Ratio scores of US average to benchmark Healthy lives score: 75/72 / 100 Quality score: 72/71 /100 Access score: 67/58 /100 Equity score: 70/71 /100 Efficiency score: 52/53 /100 Overall score: 67/65 /100  Importance of policies to take coherent, whole-system approach to change and address interaction of access, quality, and cost

 Affordable coverage for all  Align incentives with value and effective cost control  Accountable, accessible, patient-centered and coordinated care  Aim high to improve quality, health outcomes, and efficiency  Accountable leadership and collaboration to set and achieve national goals

 Extent to which health services are consumed  Critical assessment necessary to assess capacity  Types of Measures: Access to primary care Utilization of primary care Utilization of targeted services Average daily census Occupancy rate Average length of stay

 Self-perception of health and well-being  Life expectancy - longevity  Morbidity – disease  Disability – dysfunction  Mortality - death rates  Demographic – population  Other kinds of health status

 How do you untangle this mess of ideas and proposals?  Implications for first paper vis a vis how to improve the system

 Health system resources  Redesign of primary care to enhance health services delivery  Group presentation #1: Lewis, Ch.1  Shi & Singh, Ch. 5  World Health Report 2008, Ch. 4  Review Oregon Health Information website  Friedberg et al. (2010): “Primary Care”  Kilo and Wasson (2010): “Practice Redesign”  Margolius and Bodenheimer (2010): “Transforming Primary Care”  Bodenheimer and Pham (2010): “Primary Care: Current Problems …”  Grundy et al. (2010): “Multi-Stakeholder Movement for Primary Care Renewal…”  Lewis, Chapter 1