Post on 17-Jan-2016
HEALTH SYSTEMS ORGANIZATION
18 February 2008
HEALTHCARE ORGANIZATIONS
• In-patient
• Out-patient
• Home services
• Day care
• Equipment/Supplies
• Spa
INTERORGANIZATIONAL RELATIONSHIPS
• MARKET TRANSACTIONS– INPUT - SUPPLIERS– OUTPUT - INSURANCE COMPANIES,
EMPLOYERS, PATIENTS
• INVOLUNTARY RELATIONSHIPS– GOVERNMENTAL- REGULATORY – PRIVATE - FINANCIAL
• STRATEGIC ALLIANCES
INTEGRATED ORGANIZATIONS
• HOSPITALS, PHYSICIANS, INSURERS, AND PURCHASERS FORM VERTICALLY AND HORIZONTALLY INTEGRATED ORGANIZATIONS
• IN OTHER CONTEXTS THESE ARE CALLED MONOPOLIES
HORIZONTAL INTEGRATION
• LINKING ORGANIZATIONS OF THE SAME TYPE TO INCREASE MARKET SHARE
• MEDICAL EXAMPLE– BUYING ALL THE NURSING HOMES
• MONOPOLY EXAMPLE– AT&T, Cox Cable
VERTICAL INTEGRATION
• 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
STRATEGIC ALLIANCE
• ANY FORMAL ARRANGEMENTS BETWEEN TWO OR MORE ORGANIZATIONS FOR PURPOSES OF MUTUAL GAIN
• THREE TYPES OF ALLIANCE– POOLED RESOURCES– SHARED PURPOSE– CONTRACTUAL/OWNERSHIP
INDEPENDENT PRACTICE ASSOCIATIONS
• LEGAL ENTITY COMPOSED OF PHYSICIANS WHO HAVE ORGANIZED FOR THE PURPOSE OF NEGOTIATING CONTRACTS TO PROVIDE SERVICES
• GROUP PRACTICE
SELF-REFERRAL
• ILLEGAL !
• DO YOU WORK FOR THEM OR ARE YOU BEING BRIBED ?
• STRATEGIC ALLIANCES (page 234)
PAYORS
• FEDERAL GOVERNMENT
• STATE GOVERNMENT
• EMPLOYERS
• CHARITIES
• INDIVIDUALS
INSURANCE
• ARE THEY PAYORS?
• SINGLE PARTY PAYOR
• NATIONAL HEALTH
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
SELF INSURANCE
• GENERALLY INVOLVES THIRD PARTY ADMINISTRATORS
• LOOKS JUST LIKE INSURANCE
• USUALLY INCLUDES SOME TYPE OF CATASTROPHIC REINSURANCE
DIRECT CONTRACTING
• TAKES OUT THE INSURANCE COMPANY
• SAVES MONEY
• CREATES ISSUES FOR FOLLOW-UP
MANAGED CARE ORGANIZATIONS
• INTEGRATION OF FINANCING AND SERVICE DELIVERY
• INSURANCE COMPANIES WITH CAPTIVE PROVIDERS
• USE SOME SYSTEM OF GATEKEEPING
TYPES OF MCO
• HMO - HEALTH MAINTENANCE ORGANIZATIONS
• PPO - PREFERRED PROVIDER ORGANIZATIONS
• POS - 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 CAN CONSENT
• KNOW WHO HAS THE AUTHORITY AND TALK ONLY TO THEM
• PARENTS HAVE LIMITED AUTHORITY OVER 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
• THIS IS ABOUT NOT LOOSING A LAW SUIT
EXCEPTIONS TO CONSENT
• EMERGENCY EXCEPTION – PRESERVATION OF LIFE AND LIMB– THE PATIENT IS MEDICALLY OR
LEGALLY INCOMPETENT
• STATUTORY EXCEPTIONS– PUBLIC HEALTH LAW– MENTAL HEALTH LAW
• COURT ORDERED CARE