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HEALTH SYSTEMS ORGANIZATION

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

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HEALTH SYSTEMS ORGANIZATION

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  1. HEALTH SYSTEMS ORGANIZATION 18 February 2008

  2. HEALTHCARE ORGANIZATIONS • In-patient • Out-patient • Home services • Day care • Equipment/Supplies • Spa

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

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

  5. 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

  6. VERTICAL INTEGRATION • LINKING ORGANIZATIONS SO THAT SUCCEDING TRANSACTIONS STAY WITHIN THE SYSTEM • MEDICAL EXAMPLE • OCHSNER CLINIC • MONOPOLY EXAMPLE • STANDARD OIL

  7. 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

  8. 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

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

  10. SELF-REFERRAL • ILLEGAL ! • DO YOU WORK FOR THEM OR ARE YOU BEING BRIBED ? • STRATEGIC ALLIANCES (page 234)

  11. PAYORS • FEDERAL GOVERNMENT • STATE GOVERNMENT • EMPLOYERS • CHARITIES • INDIVIDUALS

  12. INSURANCE • ARE THEY PAYORS? • SINGLE PARTY PAYOR • NATIONAL HEALTH

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

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

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

  16. DIRECT CONTRACTING • TAKES OUT THE INSURANCE COMPANY • SAVES MONEY • CREATES ISSUES FOR FOLLOW-UP

  17. MANAGED CARE ORGANIZATIONS • INTEGRATION OF FINANCING AND SERVICE DELIVERY • INSURANCE COMPANIES WITH CAPTIVE PROVIDERS • USE SOME SYSTEM OF GATEKEEPING

  18. TYPES OF MCO • HMO - HEALTH MAINTENANCE ORGANIZATIONS • PPO - PREFERRED PROVIDER ORGANIZATIONS • POS - POINT OF SERVICE PLANS

  19. THE PURPOSE OF MANAGED CARE IS COST CONTAINMENT • HAS IT WORKED? • ACCESS TO CARE • CONTROL OF PHYSICIANS • PREVENTION

  20. CONSENT

  21. 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

  22. 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

  23. 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

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

  25. 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

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