Evolution and Transformation of the Health System

Models and Systems of Health Services Organization

Evolution and Transformation of the Health SystemPA 574: Health Systems OrganizationSession 2 January 13, 2011What is a Health System?Includes all the activities whose primary purpose is to promote, restore or maintain healthFormal health services, traditional services, public health, alternativesHealth systems:Improve health of populationsRespond to peoples expectationsProvide financial protection against costs of ill healthFunctional ComponentsFinancingTo obtain health servicesInsuranceProtection against risksDeliveryProviders of servicesPaymentReimbursement

Shi & Singh, Figure 1-1, p. 6External Forces Affecting Health ServicesSocial values and culturesPopulation characteristicsPolitical climateEconomic conditionsPhysical environmentTechnology developmentGlobal influencesShi & Singh, Figure 1-2, p. 10Institute of Medicine Six Aims/Ten RulesSix AimsSafeEffectivePatient-centeredTimelyEfficientEquitableTen Rules for System Redesign

Institute of Medicine Ten Rules for System RedesignCare is based on continuous healing relationships;Care is customized according to patient needs/values;The patient is the source of control;Knowledge is shared and information flows freely;Decision making is evidence-based;Safety is a system property;Transparency is necessary;Needs are anticipated;Waste is continuously decreased; and,Cooperation among clinicians is a priority.

Levels of the Health Care System (Berwick, 2002)Level 1: Patient and CommunityExperience of patientsLevel 2: MicrosystemFunctioning of small units of care deliveryLevel 3: OrganizationFunctioning of organizations that house microsystemsLevel 4: EnvironmentPolicy, payment, regulation, accreditationShapes behavior, interests and opportunities of Level 3 organizationsHistorical Forces of Transformation Brainstorm:

What has transformed health services delivery over past few decades?

*07/16/96*##TransformationProfessional sovereigntyUrbanizationScience and technologyGrowth of institutionsDependencyCohesion among medical professionalsLicensing and regulationHealth professions education*07/16/96*##TransformationGrowth in public healthConsumer advocacyIncrease in chronic conditions and longevityServices to special interest groups (veterans, disease, racial/ethnic)New forms of coverage

Evolution and Transformation of the Health Care Delivery SystemScience & Technology

Mid 18th to late 19th Late 19th to late 20th Late 20th to 21st

Consumer Professional CorporateSovereignty Dominance Dominance

Beliefs and Values

Social, Economic & Political ConstraintsShi & Singh: Figure 3.1; p. 11311BreakPlease be back in 10 minutesBeliefs, Values and Health

Market Commodity or Public Good?13Beliefs, Values and Health Care: Market Commodity or Public Good?Market justice and social justice (Table 2-4; p. 59)Belief in advancement of scienceCapitalist orientation leads to health care viewed as a market commodity, not as public resourceCulture of capitalism consistent with entrepreneurial spirit, self-determination and personal responsibilitySome concern for underprivileged based on underlying values of equity and fairnessPrinciples of free enterprise dominate*07/16/96*##Market Commodity or Public Good?Consideration of critical human concernsProtection of societyApplication to health care deliveryHealth insuranceHealth services organizationEquality/inequalityDistributional (in)efficiency

*07/16/96*##Integration of Individual and Community HealthAttempt 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 systemsIncrease quality and years of healthy lifeEliminate health disparities28 focus areas (Ex. 2-1, p. 67)*07/16/96*##Shift in Health System Reform PreferencesThe process uncovered more than just the publics preference for a public, comprehensive system financed through a combination of taxes. (Scenario #2) AZ was not unique in fact, this type of result is very common - public financing, within the current, largely private delivery system.

Initially, people were more focused on what was covered rated comprehensive coverage (scenarios 1 and 2) higher than limited coverage. By afternoon, discussion and ratings were higher for a centrally/publicly financed system (scenarios 2 and 4) and both comp. and ltd private coverage had fallen to average ratings of 4.0. (scenarios 1 and 3)

Note this research focused specifically on insurance and not care because previous research indicated strong support for single-payer (i.e. government or quasi-government) insurance and little support for government provision of care.

Also, one of the primary questions that hadnt been answered in such research was definition of basic benefits strong support for access to basic care little discussion about what that means front end primary/preventive or back-end catastrophic both could fit definition. The result here indicate that while in the final judgment there was fairly strong support for limited benefits, support for more comprehensive coverage was stronger.

And the how do you want to pay for it? question in a nutshell, taxes. The answer was consistently unsurprising a combination of personal and business income taxes personal based on sliding scale (progressive people who make more contribute more within floor/ceiling limits) and business (either profit or payroll based didnt get into details since discussion was based on values that said ERs have a stake in health/productivity, etc of workforce and the fact that they didnt trust ERs to increase wages as equal offset to premium contributions). In addition, they wanted sales and sin taxes sin taxes for the obvious reasons, and sales (regressive) because everyone should pay something informal workforce, winter visitors, etc.

It was clear from the discussion, people clearly understood the trade-offs of benefits in lieu of wages, and of premiums in lieu of taxes. All in all people are remarkably pragmatic and reasoned.

17Fixing Health Care: Wyden & BennettNew developments in health care reform -- political forces, alliances, federal/state rolesEmphasis on accessibilityProposed Healthy Americans ActGuarantees market-driven choicesAdministrative savingsFeasibility?*07/16/96*##Performance of US Health Care System (2006/2008)Scorecard using national and international data to identify performance benchmarksRatio scores of US average to benchmark Healthy lives score: 75/72 / 100Quality score: 72/71 /100Access score: 67/58 /100Equity score: 70/71 /100Efficiency score: 52/53 /100Overall score: 67/65 /100Importance of policies to take coherent, whole-system approach to change and address interaction of access, quality, and cost*07/16/96*##Recommendations for a High-Performance U.S. Health SystemAffordable coverage for allAlign incentives with value and effective cost controlAccountable, accessible, patient-centered and coordinated careAim high to improve quality, health outcomes, and efficiencyAccountable leadership and collaboration to set and achieve national goals*07/16/96*##Measures of UtilizationExtent to which health services are consumedCritical assessment necessary to assess capacityTypes of Measures:Access to primary careUtilization of primary careUtilization of targeted services Average daily censusOccupancy rateAverage length of stay

*07/16/96*##Health Status MeasuresSelf-perception of health and well-beingLife expectancy - longevityMorbidity diseaseDisability dysfunctionMortality - death ratesDemographic populationOther kinds of health status*07/16/96*##Making Sense of It All How do you untangle this mess of ideas and proposals?

Implications for first paper vis a vis how to improve the system*07/16/96*##Next WeekHealth system resourcesRedesign of primary care to enhance health services deliveryGroup presentation #1: Lewis, Ch.1

Shi & Singh, Ch. 5World Health Report 2008, Ch. 4Review Oregon Health Information websiteFriedberg et al. (2010): Primary CareKilo and Wasson (2010): Practice RedesignMargolius and Bodenheimer (2010): Transforming Primary CareBodenheimer and Pham (2010): Primary Care: Current Problems Grundy et al. (2010): Multi-Stakeholder Movement for Primary Care RenewalLewis, Chapter 124