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Organization of Care M6920 October 16, 2001
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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
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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?
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Columbia University School of NursingM6920, Fall, 2001 Organizational Structure l Ministry of health l Competition among components l National or regional
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Columbia University School of NursingM6920, Fall, 2001 Economic Support l Personal finances l Taxation l Pooled funding (insurance) l Voluntary (charity)
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Columbia University School of NursingM6920, Fall, 2001 Staffing l Highly professionalized trained in-country imported l Many paraprofessionals l Volunteers
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Columbia University School of NursingM6920, Fall, 2001 Facilities l Hospitals community referral tertiary l Clinics l Solo practitioner offices l Health posts/outreach centers
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Columbia University School of NursingM6920, Fall, 2001 Supplies l Centrally managed? l Locally produced or imported? l Global budget?
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Columbia University School of NursingM6920, Fall, 2001 Delivery Patterns l Entry point for care l Continuity of care l Gatekeepers l Decision-makers
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Columbia University School of NursingM6920, Fall, 2001 Preventive Services l Priority l Inclusion in personal care l Funding
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Columbia University School of NursingM6920, Fall, 2001 Regulations l National or regional l Scope l Support for enforcement
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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
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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?
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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
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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?
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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
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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
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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
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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
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Columbia University School of NursingM6920, Fall, 2001 Migrant/community health centers 600 at 2500 sites 14% of eligible migrants served
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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
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Columbia University School of NursingM6920, Fall, 2001 New York City Hospitals Operating Margins, 1999
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Columbia University School of NursingM6920, Fall, 2001 New York City Hospitals Payer Mix and Use, 1999
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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
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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
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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
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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
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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
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