HEALTH SYSTEMS ORGANIZATION

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HEALTH SYSTEMS ORGANIZATION

• 6 February 2007

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HEALTHCARE ORGANIZATIONS
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INTERORGANIZATIONAL RELATIONSHIPS

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

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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 BONDS

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INTEGRATED ORGANIZATIONS

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

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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
• ATT

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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

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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

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INDEPENDENT PRACTICE ASSOCIATIONS

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

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SELF-REFERRAL

• ILLEGAL !
• DO YOU WORK FOR THEM OR ARE YOU BEING BRIBED ?
• (page 234)

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INSURANCE
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INSURANCE IS A CONTRACT

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

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INDEMNIFICATION INSURANCE

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

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DIRECT CONTRACTING

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

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SELF INSURANCE

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

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PAYORS

• FEDERAL GOVERNMENT
• EMPLOYERS
• STATE GOVERNMENT
• CHARITIES
• INDIVIDUALS

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MANAGED CARE
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MANAGED CARE ORGANIZATIONS

• INTEGRATION OF FINANCING AND SERVICE DELIVERY
• INSURANCE COMPANIES WITH CAPTIVE PROVIDERS
• USE SOME SYSTEM OF GATEKEEPING

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TYPES OF MCO

• HEALTH MAINTENANCE ORGANIZATIONS
• PREFERRED PROVIDER ORGANIZATIONS
• POINT OF SERVICE PLANS

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THE PURPOSE OF MANAGED CARE IS COST CONTAINMENT

• HAS IT WORKED?
• ACCESS TO CARE
• CONTROL OF PHYSICIANS
• PREVENTION

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CONSENT
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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

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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

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QUESTIONS OF ABILITY TO CONSENT

• YOU EITHER HAVE SOMEONE WITH THE LEGAL ABILITY TO
  CONSENT OR YOU DONT
• QUESTIONABLE SITUATIONS HAVE TO BE ADDRESSED BY A
  JUDGE
• BIG CITY HOSPITALS OFTEN HAVE THE JUDGES PHONE
  NUMBER POSTED IN THE ER

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INFORMED CONSENT

• MORE DETAILED THAN SIMPLE CONSENT
• MANY STATES HAVE STATUTES ON THIS
• THIS IS ABOUT NOT LOOSING A LAW SUIT

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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