A taxonomy of health networks and systems: bringing order out of chaos.
OBJECTIVE: To use existing theory and data for empirical development of a taxonomy that identifies clusters of organizations sharing common strategic/structural features. DATA SOURCES: Data from the 1994 and 1995 American Hospital Association Annual Surveys, which provide extensive data on hospital involvement in hospital-led health networks and systems. STUDY DESIGN: Theories of organization behavior and industrial organization economics were used to identify three strategic/structural dimensions: differentiation, which refers to the number of different products/services along a healthcare continuum; integration, which refers to mechanisms used to achieve unity of effort across organizational components; and centralization, which relates to the extent to which activities take place at centralized versus dispersed locations. These dimensions were applied to three components of the health service/product continuum: hospital services, physician arrangements, and provider-based insurance activities. DATA EXTRACTION METHODS: We identified 295 health systems and 274 health networks across the United States in 1994, and 297 health systems and 306 health networks in 1995 using AHA data. Empirical measures aggregated individual hospital data to the health network and system level. PRINCIPAL FINDINGS: We identified a reliable, internally valid, and stable four-cluster solution for health networks and a five-cluster solution for health systems. We found that differentiation and centralization were particularly important in distinguishing unique clusters of organizations. High differentiation typically occurred with low centralization, which suggests that a broader scope of activity is more difficult to centrally coordinate. Integration was also important, but we found that health networks and systems typically engaged in both ownership-based and contractual-based integration or they were not integrated at all. CONCLUSIONS: Overall, we were able to classify approximately 70 percent of hospital-led health networks and 90 percent of hospital-led health systems into well-defined organizational clusters. Given the widespread perception that organizational change in healthcare has been chaotic, our research suggests that important and meaningful similarities exist across many evolving organizations. The resulting taxonomy provides a new lexicon for researchers, policymakers, and healthcare executives for characterizing key strategic and structural features of evolving organizations. The taxonomy also provides a framework for future inquiry about the relationships between organizational strategy, structure, and performance, and for assessing policy issues, such as Medicare Provider Sponsored Organizations, antitrust, and insurance regulation. (+info)
Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group.
OBJECTIVE: To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infarction or angina. DESIGN: Randomised controlled trial; stratified random allocation of practices to intervention and control groups. SETTING: All 67 practices in Southampton and south west Hampshire, England. SUBJECTS: 597 adult patients (422 with myocardial infarction and 175 with a new diagnosis of angina) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996. INTERVENTION: Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up. MAIN OUTCOME MEASURES: Serum total cholesterol concentration, blood pressure, distance walked in 6 minutes, confirmed smoking cessation, and body mass index measured at 1 year follow up. RESULTS: Of 559 surviving patients at 1 year, 502 (90%) were followed up. There was no significant difference between the intervention and control groups in smoking (cotinine validated quit rate 19% v 20%), lipid concentrations (serum total cholesterol 5.80 v 5.93 mmol/l), blood pressure (diastolic pressure 84 v 85 mm Hg), or fitness (distance walked in 6 minutes 443 v 433 m). Body mass index was slightly lower in the intervention group (27.4 v 28.2; P=0.08). CONCLUSIONS: Although the programme was effective in promoting follow up in general practice, it did not improve health outcome. Simply coordinating and supporting existing NHS care is insufficient. Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus. (+info)
The cost of coverage: rural health insurance in China.
China has undergone great economic and social change since 1978 with far reaching implications for the health care system and ultimately for the health status of the population. The Chinese Medical Reform of the 1980s made cost recovery a primary objective. The urban population is mostly protected by generous government health insurance. A high share government budget is allocated to urban health care. Rural cooperative health insurance reached a peak in the mid-1970s when 90% of the rural population were covered. In the 1980s rural cooperative health insurance collapsed and present coverage is less than 8%. The decline has been accompanied by reports of growing equity problems in the financing of and access to health care. This article is the first in a four-year study of the impact on equity of the changes in Chinese health care financing. The article examines the relationship between rural cooperative health insurance as the explanatory variable and health care expenditure, curative vs. preventive expenditure and tertiary curative care expenditure as dependent variables using a natural experimental design with a 'twin' county as a control. The findings support the hypothesis that cooperative health insurance will induce higher growth of health care expenditure. The findings also support the hypothesis that cooperative health insurance will lead to a shift from preventive medicine to curative medicine and to a higher level of tertiary curative care expenditure. The empirical evidence from the Chinese counties is contradicting World Bank health financing policies. (+info)
Regulating the private health care sector: the case of the Indian Consumer Protection Act.
Private medical provision is an important constituent of health care delivery services in India. The quality of care provided by this sector is a critical issue. Professional organizations such as the Medical Council of India and local medical associations have remained ineffective in influencing the behaviour of private providers. The recent decision to bring private medical practice under the Consumer Protection Act (COPRA) 1986 is considered an important step towards regulating the private medical sector. This study surveyed the views of private providers on this legislation. They believe the COPRA will be effective in minimizing malpractice and negligent behaviour, but it does have adverse consequences such as an increase in fees charged by doctors, an increase in the prescription of medicines and diagnostics, an adverse impact on emergency care, etc. The medical associations have also argued that the introduction of COPRA is a step towards expensive, daunting and needless litigation. A number of other concerns have been raised by consumer forums which focus on the lack of standards for private practice, the uncertainty and risks of medicines, the effectiveness of the judiciary system, and the responsibility of proving negligence. How relevant are these concerns? Is the enactment of COPRA really appropriate to the medical sector? The paper argues that while this development is a welcome step, we need to comprehensively look into the various quality concerns. The effective implementation of COPRA presumes certain conditions, the most important being the availability of standards. Besides this, greater involvement of professional organizations is needed to ensure appropriate quality in private practice, since health and medical cases are very different from other goods and services. The paper discusses the results of a mailed survey and interview responses of 130 providers from the city of Ahmedabad, India. The questionnaire study was designed to assess the opinion of providers on various implications of the COPRA. We also analyze the data on cases filed with the Consumer Disputes and Redressal Commission in Gujarat since 1991. Four selected cases filed with the National Commission on Consumers Redressal are discussed in detail to illustrate various issues affecting the implementation of this Act. (+info)
Integrating MCH/FP and STD/HIV services: current debates and future directions.
The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach. (+info)
The relationship and tensions between vertical integrated delivery systems and horizontal specialty networks.
This activity is designated for physicians, medical directors, and healthcare policy makers. GOAL: To clarify the issues involved with the integration of single-specialty networks into vertical integrated healthcare delivery systems. OBJECTIVES: 1. Recognize the advantages that single-specialty networks offer under capitated medical care. 2. Understand the self-interests and tensions involved in integrating these networks into vertical networks of primary care physicians, hospitals, and associated specialists. 3. Understand the rationale of "stacking" horizontal networks within a vertical system. (+info)
The three dimensions of managed care pharmacy practice.
Our goal is to provide a framework for pharmacy in an evolving healthcare marketplace by identifying and discussing the three dimensions of pharmacy practice: (1) pharmacy practice across the continuum of care; (2) the major elements of pharmacy practice; and (3) the evolution of pharmacy during the five stages of the development of managed care. The framework was devised under the proposition that there is a substantial consistency in what patients need or should expect from pharmacists. As integrated health systems develop, pharmacists must apply their skills and knowledge across the continuum of care to ensure that they play an integral part in the systems. In a managed care environment characterized by change and the development of integrated health systems, pharmacists have opportunities to become involved directly in patient care in such areas as disease prevention, home healthcare, primary care, and subacute care. Information systems, hospital drug distribution, clinical pharmacy, and the fiscal environment comprise the major elements of pharmacy practice within an integrated health system, and the way in which each of these elements evolves as the healthcare market adapts to managed care is critical to pharmacy practice. If the pharmacy profession can demonstrate its ability to manage disease and health, improve outcomes, and reduce costs within the evolving healthcare system, pharmacists will play a vital role in the managed healthcare market in the approaching new millennium. (+info)
Using a multidisciplinary automated discharge summary process to improve information management across the system.
We developed and implemented an automated discharge summary process in a regional integrated managed health system. This multidisciplinary effort was initiated to correct deficits in patients' medical record documentation involving discharge instructions, follow-up care, discharge medications, and patient education. The results of our team effort included an automated summary that compiles data entered via computer pathways during a patient's hospitalization. All information regarding admission medications, patient education, follow-up care, referral at discharge activities, diagnosis, and other pertinent medical events are formulated into the discharge summary, discharge orders, patient discharge instructions, and transfer information as applicable. This communication process has tremendously enhanced information management across the system and helps us maintain complete and thorough documentation in patient records. (+info)