Appunti Health Care Management

HEALTH CARE MANAGEMENT

Description of a “Health System”

All the organizations, institutions, and resources whose primary purpose is to improve

 health Organizations: hospitals, rehab centers etc.

o Institutions: Ministries, Regions etc.

o Resources

o Material: funds, technologies, transport etc.

 Immaterial: staff, knowledge, information etc.



Health organizations are knowledge-based organization. Providing all the services typical

of an hospital need the collection of a lot of knowledge within the hospital itself capacity to



perform the intervention, to organize the different sectors etc.

The healthcare system is really complex and the complexity is given by the numbers of

components and the diversity of them the Healthcare sector is articulated in a lot of



different organizations.

The functioning of the Healthcare sector depends on the interconnection of all those different

actors

Concepts to be considered

Defining “health”: health is a state of complete physical, mental and social

 wellbeing and not merely the absence of disease and infirmity

Defining “system”: a structure is defined by its parts and processes, and tends to

 function in the same way by transforming inputs (material, finances, etc.) in outputs

(products and services)

Patients are the main «input»

 Understanding social, cultural, political, and economic contexts



Es. one of the main issue with the patient conditions is due to the diet which is related to our

culture culture effect the type of treatment provided for the patient.



Money follow the patient patients are the most important thing they provide knowledge

 

for the system.

Input:

– Resources (materials, personnel, other)

– Patients and their needs

Throughput

– Technology

– Procedures

– Plans

– Coordinating mechanisms

Output

– Provision of health care

services

– Intra-hospital Mortality

– Complication rates

Feedback

– Comparison between service standards (objectives) and results

– Adverse events analysis

Multilevel Framework

The Healthcare system is a multi- level

system: Micro, Meso and Macro frameworks

Cascade effect: the decisions taken at the

macro level effect the decisions taken at the

meso level and this effect the micro level

But it is not only a top-down system, but a

bottom-up system too

Building Blocks of Health Systems

Medical technology is the most important one

Health information is based on an accurate understanding on how patients behave, and it is

related with all the activities related with it (drug prescriptions, visits, treatments etc.) How



we coordinate and integrate the health information? And how we disseminated the

information in the healthcare system?

Measurement of functioning of the health system

Cost (all the costs in the system: paid by patients, hospitals, private clinics, assurances

 etc.)

Quality

 Access (es. in Italy, a problem is that we have a lot of small islands, how do we provide

 care there? Es.2 how do we provide care to people who cannot afford it?)

 Innovation (not only new technology, but also innovation in organization innovative



way to face a problem)

Health Systems performance indicators

How to measure the performance in healthcare sector? It is multidimensional.

• Effective: high-quality services, based on scientific knowledge (EBM) It is measured

through evidence Evidence-Based Medicine



• Efficient: avoid waste

• Equitable: no variation due to ethnicity, gender, age, location, socio-economic status

• Patient centered: respectful, responsive care professionals have to collect, but also



share knowledge one with each other.

• Timely: reducing waiting and harmful delays

Health system + Social determinants and Health Behaviours = Health Outcomes

Our health is affected most of all by these 2 variables (the genetic one effect only the 5-10%)

Health care systems: Levels of care

• Type of activities delivered by healthcare systems

– Disease prevention

– Primary treatment

– Secondary treatment

– Tertiary treatment

Disease prevention: The process of enabling people to increase control over, and to

improve, their health. It moves beyond a focus on individual behavior towards a wide range of

social and environmental interventions.

– Disease prevention focuses on prevention strategies to reduce the risk of developing

chronic diseases and other morbidities.

– Health promotion and disease prevention programs often address social determinants

of health, which influence modifiable risk behaviors.

Typical activities for health promotion and disease prevention programs include:

– Communication: Raising awareness about healthy behaviours for the general public.

Examples of communication strategies include public service announcements, health

fairs, mass media campaigns, and newsletters.

– Education: Empowering behaviour change and actions through increased knowledge.

Examples of education strategies include courses, trainings, and support groups.

– Policy: Regulating or mandating activities by organizations or public agencies that

encourage healthy decision-making.

– Environment: Changing structures or environments to make healthy decisions more

readily available to large populations.

Primary Care

• A patient's main source for regular medical care, ideally providing continuity and integration

of health care services. All family physicians, and many paediatricians practice primary care.

they try to prevent problems to avoid other interventions.



• The aims of primary care are to provide the patient with a broad spectrum of preventive and

curative care over a period of time and to coordinate all the care that the patient receives.

Secondary Care

• If you have ever seen a specialist after being referred by a primary care provider, then you

have been referred for secondary care. Secondary care simply means you will be taken care of

by someone who has more specific expertise in whatever problem you are having.

• Specialists focus either on a specific body system or on a specific disease or condition. For

example, cardiologists focus on the heart and its pumping system. Oncologists work on

cancers.

Tertiary Care

• Tertiary care requires highly specialized equipment and expertise such as coronary artery

bypass surgery, renal or haemodialysis, some plastic surgeries or neurosurgeries, severe burn

treatments or any other very complex treatments or procedures.

• A small local hospital may not be able to provide these services and you may need to be

transferred to a medical center (typically, a teaching hospital) that provides these highly

specialized tertiary level services.

Disease and Health

• Measurement of disease

– Prevalence: number of individuals with a disease in a given population at a

discrete point in time

– Incidence: number of new cases of a disease in a population over a specified

period of time

– Disease-specific mortality (disease severity): number of people who die of a

given disease in the population as a whole over a specified period of time

Case fatality rate: rate of death for a particular disease reported per 1,000 or

 100,000 people with a disease

Mortality rates: often reported based on age groups or other demographic

 variables

Our health condition is affected by a lot of variables: genetic, environment, economics and behaviour

Andersen’s model

‘Behavioral Model for Vulnerable Populations’

Predisposing factors

 – Demographics, social structure, health

beliefs

Enabling factors

 – Family resources, community resources

• Need factors

Illness, response to illness

–

Education and Health Aging and Health

The aging of the population is proportional to the health problem of the population

 To understand the needs of the population we have to consider the age level

Burden of Disease

Concept that as to do to the impact a disease have on a population (in terms of disability and

the loss of productivity/income the disability generates)

Reporting the burden of disease

Statistics that attempt to determine the impact of disease on a population

 through measuring disability and healthy life years lost.

Application of cost-benefit analyses:

Cost to a population to prevent and treat diseases versus the cost that a

 population pays for years lived with disability and/or early mortality from those

same diseases

– Health expectancy

– Healthy life years

– Disability-adjusted life years (DALY)

– Quality-adjusted life years (QALY)

When we want to invest in healthcare, we have different parameters to evaluate. One is the

increment in income and productivity the investment will generate through the time

This graph is useful to understand what the increase

of productivity of people is, with or without an

intervention

Es. A policy maker has to decide to vaccinate people

or not

Es.2 We have to decide if to build a new hospital

building or not will the increase in revenues and



care for people cover the costs?

Chronic vs Communicable Diseases

Differences between communicable and noncommunicable disease

– World Health Organization projection

Deaths from infectious diseases will decline by about 3% over the next 10 years

 Deaths caused by chronic diseases are projected to increase by 17% (the most

 important are cancer, Parkinson, cardiovascular disease, diabetes) 

Chronic Diseases

Emergence of noncommunicable diseases: Heart disease, Stroke, Cancer, Chronic respiratory

disease, Mental illness

Infectious Disease

Definition: diseases that are spread from person to person

Transmission: some require an intermediary host, some spread through direct contact

Immunization and other intervention programs:

Preventable infectious disease

 Mechanisms for reducing mortality



Conclusion

• Requirement for constant disease surveillance

• Requirement for high-level coordination (e.g. WHO, US Center for Disease Control)

• Other strategies

– Immunization programs

– Community education

– Early identification by primary care providers

Convergence of Problems and Responses Access to care

Convergence of variations in health organizations that a

policy maker has to take into account – Disadvantaged

subpopulations

– Cost containment – Informal payments

– Access to care (bribes)

– Impact of new technologies – Political instability

– Quality of care – Economic crisis

– Measuring health outcomes Quality of care considerations

Impact of new technologies – Technologic complexity

– Cost and complexity – Enable the aggregation of

data

– Balance between old and new (overlap of – New information

technologies) technology

• Eg, Traditional, laparoscopic and robotic

surgeries

– Economic and ethical conflict Achieving sustainability

Measuring health outcomes – Quality and safety

– standardization

Potential benefit of health IT –

– Resource deployment

Consensus about existing problems – Innovation

Sustainability: Growing financial stress on public and – Adaptability

private sectors

Healthcare costs and Increasing Portion of GDP

– Expenditures are rising

– The healthcare industry is a desired component of local economy

Aging Population

An emerging issue globally

– Increasing health care costs

– Inability to replace elderly in the workforce

– Pensions finance

– end-of-life costs

Comparative Health Systems

Financing and providing a service are different

– USA: Medicare/Medicaid plus private finance; Private provision

– Germany: Quasi-public finance of healthcare; Private provision

– UK: Public finance; Public provision

Healthcare systems are varieties of capitalism

– USA: private goods – individual determines utility and preference scale, opportunity

costs private, rationing by price, healthcare as investment (R&D, jobs)

– Germany: right/entitlement – redistributive policies, opportunity costs collective,

rationing through provider decisions, healthcare as social welfare instrument and mixed

rationales for investment/savings

– U.K.: public goods – government/health officials determine availability and choices,

opportunity costs on national budget level, rationing by queue, healthcare as a cost

US: HMOs (private insurers) hospital are



profit driven and there is no government

intervention in rationing/budgeting and

prices

HMOs make agreements (about prices etc.)

with physicians and providers, so an

insured person can only choose between

the ones in the HMO’s agreements lists.

The Obama’s project had the purpose to

make insurance mandatory for everyone

and make private insurance not to refuse

people

Germany: Sickness funds: very big

insurance companies run by government

UK: Health insurance is a right

NICE is the same as the AIFA in Italy, is the

association that gives the okay to commercialize a drug

A way of reducing cots and improving quality at the same time was the mangerialization of

hospitals that is why in hospitals we can find all the documents we can find in a company



Politics of Healthcare Reform

Germany: center-right coalition governments increasing role of the state in pricing of care,

insurance “rationalized ” by mergers; core Bismarck principles remain, but autonomy of

insurance and delivery is declining.

In Germany the intervention of government improved (for both public and private insurance),

they tried to make mergers between insurance company to have less, but bigger, companies

and physicians are independent.

U.K.: reform on the margins and relentless cost focus; comparatively little ‘politics’ of

healthcare, even in elections or during current budget cost-cutting

U.S.A.: Healthcare will remain politicized in the future, with default compromise between left

(put government in charge) and right (put markets/individuals in charge) leaving employers in

charge of providing (hence managing) insurance – United States is underwriting pharma,

biotech, and device innovation for the world…will that continue?

In USA there was some discrimination and companies sometimes decided not to cover some

people (es.south americans) the government intervened, but just for this factor.



US: the system is conceived as a market it works when there is a lot of activity



What are the differences between health care market and a free market?

Characteristics of a free market

Buyers and sellers act independently

 Unrestrained competition on the basis of price and quality

 Information about service options

 Information on prices and quality for each provider

 Patients bear the cost of services received

 Consumers make decisions about the purchase of healthcare services



Market imperfections in health care

Health care industry products and services differs significantly from those of other industries

in one very particular way

The product or output of the industry is not often as tangible and measurable.

 Uncertainties

 Asymmetric information (buyers cannot have all the information about what they are

 buying)

Principal

 Agent relationships

 Externalities (es. I get vaccinated I don’t infect other people)

 

Market domination (hospitals and physicians merge together to become dominant)



Market Domination

Need Demand Supply

 

Need Demand Supply (Physician) Demand

  

It is the physician who decide what to supply to a patient (to take a specific drug, have an

intervention etc.)

In UK and Italy, government intervenes between demand and supply to regulate

In US, government decided that the healthcare market must be self-regulated and do not

intervene

In Germany there are Sickness Funds that are highly government regulated

Italian NHS – The SSN

In the Italian SSN, third party payers are represented by the regional governments (with

respect to public funding) and private insurance companies (with respect to nonpublic

funding)

Public funding accounts for about 70% of total health care expenditure and private insurance

companies account for about 11%

Out-of-pocket payments and co-payments account for the remaining part of expenditures

“Il complesso delle funzioni,

The law 833/1978 establishes the Italian NHS defined as:

delle strutture, dei servizi e delle attività destinati alla promozione, al mantenimento e al

recupero della salute fisica e psichica di tutta la popolazione, senza distinzione di condizioni

individuali o sociali e secondo modalità che assicurino l’eguaglianza dei cittadini nei confronti

dei servizi” (art. 1)

Universalistic system, in which health is considered a citizen’s «right»

• Solidarity

• Equal Access

• Equal distribution of resources (independent from the geographical location)

• Human dignity

Municipalities are responsible for health services, which are directly delivered by Local Health

Authorities («USL» Unità Sanitarie Locali) to the local population

A «Comitato di Gestione» leads the LHA. Its members, which are representative of political

parties, do not have specific skills in the healthcare field

NHS state balance (1978-1991)

– Strong correlation between management and politics

– Lack of control of health expenditures

– Well-documented inefficiencies (waiting lists, service quality)

– Lack of knowledge regarding characteristics of population characteristics and demand

(epidemiological characteristics, costs, qua