Health Systems: US Organization and Delivery

Question 1

describe the Dawson model (UK health care model)

Answer 1

• primary-secondary-tertiary care triangle structure
• distinct functions of care and specific provider roles
• gate-keeping essential component
• stepwise patient flow puts emphasis on primary care and population health

Question 2

describe the dispersed model (US health care model)

Answer 2

• multiple access points (patient choice or doctor referral)
• more fluid roles for providers (e.g. broadens role of internists and pediatricians)
• less distinction in hospital care
• higher value on tertiary care

Question 3

describe the impact of health care dispersion

Answer 3

• positive:
  
  • flexibility and convenience
  • direct access to specialists/tertiary care
  • autonomy in selecting services
• negative
  
  • higher costs involved
  • tendencies toward fragmentation
  • lack of organizational coherence
  • difficulty of integrating care and maintaining continuity
  • unnecessary procedures/risks of medical error

Question 4

describe new medical care structures

Answer 4

• multispeciality group practice
  
  • formally integrated specialists into a single clinic structure to encourage collaborative care
  • example: Mayo Clinic
• community health centers
  
  • emphasis on preventive care and general health; often maternal and child health
  • now number almost 2000 across the US

Question 5

describe HMOs for providers

Answer 5

• physicians provide services as part of a larger organization that manages patients’ care
• physicians must share–or give up–decision-making process for patient care

Question 6

describe HMOs for patients

Answer 6

• you receive most or all of your health care from a network provider
• you choose a primary care physician (internist, family doctor, pediatrician) responsible for managing and coordinating care
• specialist care diagnostic services require an approved referral

Question 7

describe first generation HMOs

Answer 7

• full-time salaried (staff model)
• vertical integration; e.g. Kaise-Permanente
• consolidated model, salaried physicians, global budget hospitals

Question 8

describe second-generation HMOs

Answer 8

• virtual integration
• group model
  
  • prepaid group practice
  • contracts with Independt Practice Associations (IPAs)
• network model
  
  • mix of IPAs, home health agencies, pharmacies, hospitals, etc.

Question 9

describe Independent Practice Associations (IPAs)

Answer 9

• an IPA is a loose collection of private doctors who work in their own practices
• IPA contracts with HMO on behalf of the doctors
  
  • the IPA receives a capitation payment from the HMO and pays its doctors either through capitation or fee-for-service
  • both usually involve fee-for-service referrals with bonus arrangements

Question 10

describe preferred provider organizations (PPOs)

Answer 10

• the PPO payer receives monthly premiums from subscribers and employers
• patients are required to select physicians and hospitals approved (“preferred”) by the payer
• providers discount their fees or allow payer to “manage” the care they give

Question 11

describe accountable care organizations (ACO)

Answer 11

• Affordable Care Act authorized Medicare to initiate ACO program
• private insurance and employers plans have also developed ACOs
  
  • emphasis on regionalized, integrated care

Question 12

describe challenges for physician in managed care settings

Answer 12

• risk sharing:
  
  • financial risk for care provided
  • ethical conflicts vs. efficient care
• gatekeeper function
  
  • problems of case management
  • HMOs as gatekeepers (provide continuity of care) or gateshutters (restrict access)