1. International Healthcare Systems
Bernardo Ramirez MD, MBA
HSA6112
University of Central Florida
College of Health and Public Affairs
Health Management & Informatics Department

2. THE HEALTH TRIANGLE COST ACCESS EQUITY QUALITY
Adapted from James B. (1979) Quality Management for Health Care Delivery. The Hospital Research and Educational Trust AHA. P15.
And Cost, access, quality Iron Triangle. Harvard Medical International, 2008
Retrieved from the Internet April,

3. HEALTH AS A SYSTEM STRUCTURE PROCESS OUTPUTS OUTCOMES RESOURCES
PRODUCTIVITY
EFFICIENCY
HEALTH SERVICES
HEALTH STATUS
POPULAT ION
UTILIZAT ION
EFFECTIVENESS
Adapted from Donabedian A. (2005) Evaluating the Quality of Medical Care. Milbank Quarterly Vol 83-No4, Reprinted from Vol44No3, And
From Bradbury R. and Ramirez B. (1992) Health Systems Analysis and Hospital Quality Improvement. ISQUA,9th International Conference Mexico.

4. Health Services Elements
Population
Access/utilization (Education, Health Promotion, Options for Care, Legal Aspects, Geographical and Cultural Barriers)
Epidemiology (Transition, Mortality, Morbidity, Population, Life Expectancy)
Life Styles and behaviors (Prevention and chronic health, Patient & Family Centered)

5. Health Services Elements
Resources
Physical Resources, (hospitals, clinics, private-public, Ambulatory services)
Equipment/Technology, Medicines
Human resources (Education, health manpower, Incentives, training, continuing education, Physicians, nurses, technicians and emerging professions)
Financial Resources (Resource allocation, budgets, financial schemes, reimbursement, insurance mechanisms)

6. Health Services Elements
Primary/Secondary health care. Systems.
Management Information Systems
Clinical Standards and Protocols. Safety Issues.
Quality Assurance and Quality Improvement
Legal aspects (malpractice)
Incentives, Performance management.
Cost or services
Efficiency, clinical & Management efficiency
Effectiveness, Health Impact and outcomes

7. Organizing a Hospital as a System
Suppliers
Resources
Design, Redesign
Plan to improve
Community Need
Vision
Customer Knowledge
Customers
Health Status
Processes
Population
Inputs
Throughputs
Outputs/Outcomes
Adapted from Batalden Paul, Nolan Thomas (1992) Organizing Work as a System, Hospital Corporation of America, Quality Resource Group. Nashville USA.

8. Model for Health System Development in Emerging Economies
Medical & Health Related Education
Academic Programs for Healthcare Professionals
Entrepreneurship & Privatization
Healthcare Management Education / Executive Training
Health Insurance Systems
Management of Information
Clinical outcomes
Disease management
Financial management
Pharmaceutical, Information & Medical Tech
Technical Support Systems
Adequate Financing
Access to technology & pharmaceuticals
Investment & development
New Health Delivery Paradigms
Health prevention & promotion
Community based primary care
Improved institutional care
Re-engineered Healthcare System
Improved Population Health
Adapted from William Aaronson notes to AIHA /AUPHA Modules, 1996

9. Public Health Care
Public Health Agencies are Local, state and federal and serve as primary organizations to serve community wide efforts for health promotion, disease prevention, health assessment and provision of medical care to vulnerable population groups

10. Strong Evidence for Vulnerability
Minority populations
Lower socioeconomic status
Substandard Housing
Chronic illness--mental/physical/addicts
Immigrants and Prisoners
Un- or underinsured
Extremes of Age
Socially Isolated
Presented by Margaret Wheeler MD, Disparities in Care of Vulnerable Patients, San Francisco General Hospital_University of California San Francisco. AUPHA Leaders meeting Orlando, FL, 2000

11. Government Programs Medicare (elderly and disabled)
Medicaid (poor, vulnerable)
Federal Employees Health Benefit Program
Military Programs (Tricare, Uniform services & US Family Health Plan)
Veterans Administration
US Public Health Service
Indian Health Service

12. Access to Healthcare in the USA
Managed Care Penetration 2010 (1)
(#’s in millions)
Total U.S. #
Percent U.S.
Managed Care #
Medicare (2)
47.0
15.21%
11.40
Medicaid (3)
46.87
15.17%
33.28
Military (3)
3.8
1.20%
Commercial
161.93
52.40%
86.89
Uninsured (4)
49.4
16.0%
0.0
Total (5)
309.0
100%
135.37
(1) Managed Care Facts Sheets from MCOL (2012)
(2) The Kaiser Family Foundation: Medicare: A Primer. April
(3) Kaiser Commission on Medicaid and the Uninsured. Medicaid and Managed Care: Key Data, Trends and Issues. February ; Kaiser Commission on Medicaid and the Uninsured. Medicaid Enrollment: June 2009 Data Snapshot. US Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2008, Table C-1. September
(4) Cover the Uninsured. Accessed on April 23,
(5) Total U.S. Population data as of April 23, 2010, U.S. Census Bureau.
Note: Persons without health insurance coverage in Florida (2008) 20.5% and in the U.S. 15.5% (Health United States 2011)

13. Causes of Disparities Physician variables Patient variables
Biases, uncertainty
Patient variables
Attitudes, expectations, preferences, biases
System variables
Administrative, financing, accessibility
Presented by Margaret Wheeler MD, Disparities in Care of Vulnerable Patients, San Francisco General Hospital_University of California San Francisco. AUPHA Leaders meeting Orlando, FL, 2000

14. Causes for lack of access
Geographical
Socioeconomic
Cultural
Environment
Vulnerability-Risk (extremes of life)
Discrimination (Minorities-less care even when insured, ethnic, disability)