HEALTH SYSTEMS ORGANIZATION 2 February 2006

INTERORGANIZATIONAL RELATIONSHIPS MARKET TRANSACTIONS –INPUT - SUPPLIERS –OUTPUT - INSURANCE COMPANIES, EMPLOYERS, PATIENTS INVOLUNTARY RELATIONSHIPS –GOVERNMENTAL- REGULATORY –PRIVATE - FINANCIAL STRATEGIC ALLIANCES

STRATEGIC ALLAINCE ANY FORMAL ARRANGEMENTS BETWEEN TWO OR MORE ORGANIZATIONS FOR PURPOSES OF MUTUAL GAIN THREE TYPES OF ALLIANCE –POOLED RESOURCES –SHARED PURPOSE –CONTRACTUAL/OWNERSHIP BONDS

INTEGRATED ORGANIZATIONS HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLY AND HORIZONTALLY INTEGRATED ORGANIZATIONS IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES

HORIZONTAL INTEGRATION THIS IS THE PROCESS OF LINKING ORGANIZATIONS OF THE SAME TYPE TO INCREASE THE SHARE OF A SPECIFIC MARKET MEDICAL EXAMPLE –BUYING ALL THE NURSING HOMES MONOPOLY EXAMPLE –AT&T

VERTICAL INTEGRATION THIS IS THE PROCESS OF LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM MEDICAL EXAMPLE –OCHSNER CLINIC MONOPOLY EXAMPLE –STANDARD OIL

HIGHLY INTEGRATED HEALTH SYSTEM VERTICAL INTEGRATION AND AN INSURANCE CONTRACT BIG MOVE TOWARD THIS IN THE 1980s AND 1990s TREND IS NOW AWAY FROM VERTICAL INTEGRATION

INDEPENDENT PRACTICE ASSOCIATIONS LEGAL ENTITY COMPOSED OF PHYSICIANS WHO HAVE ORGANIZED FOR THE PURPOSE OF NEGOTIATING CONTRACTS TO PROVIDE SERVICES

INSURANCE IS A CONTRACT PARTIES TO THE CONTRACT –THE PATIENT AND THE INSURANCE COMPANY HOW IS THE DOCTOR INVOLVED? HOW IS THE EMPLOYER INVOLVED?

INDEMNIFICATION INSURANCE WHAT MOST OF US THINK OF AS INSURANCE YOU HAVE A LOSS - THE INSURANCE COMPANY FIXES IT OR PAYS FOR IT

DIRECT CONTRACTING TAKES OUT THE INSURANCE COMPANY SAVES MONEY CREATES ISSUES FOR FOLLOW-UP

SELF INSURANCE GENERALLY INVOLVES THIRD PARTY ADMINISTRATORS LOOKS JUST LIKE INSURANCE USUALLY INCLUDES SOME TYPE OF CATASTROPHIC REINSURANCE

MANAGED CARE ORGANIZATIONS INTEGRATION OF FINANCING AND SERVICE DELIVERY INSURANCE COMPANIES WITH CAPTIVE PROVIDERS USE SOME SYSTEM OF GATEKEEPING

TYPES OF MCO HEALTH MAINTENANCE ORGANIZATIONS PREFERRED PROVIDER ORGANIZATIONS POINT OF SERVICE PLANS

THE PURPOSE OF MANAGED CARE IS COST CONTAINMENT HAS IT WORKED? ACCESS TO CARE CONTROL OF PHYSICIANS PREVENTION

CONSENT

Consent to Care you have to have permission from a consenting adult to do anything to them violating this is battery the patient may pick and choose with some exceptions the patient may terminate the relationship by refusing consent

Substitute Consent not everyone is a consenting adult know who has the authority to consent and talk only to them parents have limited authority over the care of their children spouses have no authority over each other

Questions of Ability to Consent you either have someone with the legal ability to consent or you don’t questionable situations have to be addressed by a judge big city hospitals often have the judge’s phone number posted in the ER

Informed Consent more detailed than simple consent many states have statutes on this this is about not loosing a law suit

Exceptions to Consent emergency exception –expectation that anyone would want preservation of life and limb –may apply if the patient is medically or legally incompetent statutory exceptions –public health law –mental health law court ordered care