Question

1. Which health care systems serve as organizational archetypes? Why?
2. Which is the difference between looking at Health Expenditures in relation to GDP and per capita? Essential concepts to analyze a health care system
3. How did the organized medical profession in the U.S. manage to remain free of control by business firms, insurance companies, and hospitals until the latter part of the 20th century?
4. Describe the process of formation of the hospital in the U.S. and mention its organizational antecedents.

Answer 1

ANSWERS

1. Which health care systems serve as organizational archetypes? Why?

Archetypes are recurring patterns of behavior that give insights into the structures that drive systems. They offer a way of deciphering systems dynamics across a diversity of disciplines, scenarios, or contexts.

System Archetypes are a common way to analyze an organization. The archetypes provide a look at the behaviors occurring and link them to the underlying structure of an organization.

Prospective archetypes can be used for planning to predict how a system may perform

System Archetypes are a common way to analyze an organization. This provide a look at the behaviors occurring and link them to the underlying structure of an organization.

An organization can implement the archetypes diagnostically or prospectively.

Diagnostic use examines present behaviors to discover why the organization functions how it does or why certain problems occur.

Prospective archetypes can be used for planning to predict how a system may perform. Health organizations can use any of the archetypes to apply to their organization for examination or planning of a new project.

Eight system archetypes

The eight most common system archetypes are:

1. System that fail—A solution is rapidly implemented to address the symptoms of an urgent problem. This quick fix sets into motion unintended consequences that are not evident at first but end up adding to the symptoms.

2. Shifting the burden—A problem symptom is addressed by a short-term and a fundamental solution. The short-term solution produces side effects affecting the fundamental solution. As this occurs, the system’s attention shifts to the short-term solution or to the side effects.

3. Limits to success—A given effort initially generates positive performance. However, over time the effort reaches a constraint that slows down the overall performance no matter how much energy is applied.

4. Drifting goals—As a gap between goal and actual performance is realized, the conscious decision is to lower the goal. The effect of this decision is a gradual decline in the system performance.

5. Growth and underinvestment—Growth approaches a limit potentially avoidable with investments in capacity. However, a decision is made to not invest resulting in performance degradation, which results in the decline in demand validating the decision not to invest.

6. Success to the successful—Two or more efforts compete for the same finite resources. The more successful effort gets a disproportionately larger allocation of the resources to the detriment of the others.

7. Escalation—Parties take mutually threatening actions, which escalate their retaliation attempting to “one-up” each other.

8. Tragedy of the commons—Multiple parties enjoying the benefits of a common resource do not pay attention to the effects they are having on the common resource. Eventually, this resource is exhausted resulting in the shutdown of the activities of all parties in the system.

The “systems that fail” archetype has the “squeaky wheel” as its main storyline. In this archetype, a quick fix is applied to a pain point (or “squeaky wheel”) to reduce its symptom and the “noise” generated by it.

Applications for system archetypes

• System archetypes can be used as a diagnostic tool to better understand the dynamics of a specific set of behaviors that have manifested an unwanted condition.
• The theory behind system archetypes is that situations with unwanted results or side effects can be mapped to the common behavior models.
• From a proactive perspective, system archetypes can be an important part of planning. A variety of strategies can be tested through the lens of archetypes to identify potential pitfalls and address them in the planning stages when they are easier to tackle.
• Additionally, system archetypes provide a language to communicate among members of an organization regarding how a particular system is expected to perform.
• Data and platforms can generate the insights needed for personalized, always-on decision-making in the new health ecosystem. These archetypes can serve as the backbone for the health care ecosystem of tomorrow.

1. Data conveners: Data-gathering organizations will have an economic model built around aggregating and storing individual, population, institutional, and environmental data. This data can be used to drive the future of health.

2. Science and insights engines: Some organizations will likely have an economic model driven by their ability to derive insights and define the algorithms that power the future of health. These organizations will likely conduct research, develop analytical tools, and generate data insights that go far beyond human capabilities in care delivery.

3. Data and platform infrastructure builders: This new world of health will need infrastructure and platforms that can serve highly empowered and engaged individuals in real time (someone will need to lay the pipes).

Well-being and care delivery represent new virtual and physical communities that can provide consumer-centric delivery of products, care, wellness, and well-being.

4. Health product developers: The economic model of these organizations is driven by their ability to enable well-being and care delivery. While there will continue to be organizations that develop products, those products won't likely be limited to pharmaceuticals and medical devices. They can also include software, applications, and wellness products.

5. Consumer-centric health (virtual home and community): Along with companies that develop health products, other organizations can provide the structure that supports virtual communities.

6. Specialty care operators: Two decades from now, we will likely still have disease, which means we will still need specialty care providers and highly specialized facilities where patients can receive care.

7. Localized health hubs: While there will be some specialty care, most health care will likely be delivered in localized health hubs. Localized health hubs can serve as centers for education, prevention, and treatment in a retail setting. Additionally, local hubs can connect consumers to virtual, home, and auxiliary wellness providers.

Care enablement includes the connectors and facilitators that can make the new health engine run.

8. Connectors and intermediaries: These are the logistics providers that will run the just-in-time supply chain, facilitate device and medication procurement operations, and get the product to the consumer.

9. Individualized financiers: Unlike the health insurers of today, these organizations will create the financial products that individuals can use to navigate their care. These organizations will likely offer tailored modular and catastrophic care-coverage packages. They can drive reductions in care costs by leveraging advanced risk models, consumer incentives, and market power.

10. Regulators: While we will still have regulators, we probably won't view them as governmental traffic cops. They will set the standards for business transactions. The regulators of the future can influence policy in an effort to catalyze the future of health and drive innovation while promoting consumer and public safety.

2. Which is the difference between looking at Health Expenditures in relation to GDP and per capita? Essential concepts to analyze a health care system

Health expenditure consists of all expenditures or outlays for medical care, prevention, promotion, rehabilitation, community health activities, health administration and regulation and capital formation with the predominant objective of improving health.

Gross domestic product (GDP) is the value of all goods and services provided in a country by residents and non-residents. This corresponds to the total sum of expenditure (consumption and investment) of the private and government agents of the economy during the reference year.

Overall Economy Rapidly rising health care spending is considered to lower the rate of growth in GDP and overall employment, while raising inflation. However, some economists view increases in health care spending as a neutral, if not positive, impact on the economy.

Among the EU member states, seven had spending on health at 10% or more of GDP, with France (11.5%) and Germany (11.3%) having the highest shares of GDP spent on health. Nevertheless, these shares remain well below that of the United States, where health expenditure accounted for 17.2% of GDP in 2017.

Health expenditure per capita. The amount that each country spends on health, for both individual and collective services, and how this changes over time can be the result of a wide array of social and eco- enomic factors, as well as the financing and organisational structures of a country's health system.

Per capita expenditures refers to market value( price at which they are sold in the market) of all goods purchased by households divided by population of country.

Essential concepts to analyze a health care system

· Health services have the functions to define community health problems, to identify unmet needs and survey the resources to meet them, to establish SMART objectives, and to project administrative actions to accomplish the purpose of proposed action programs.

· For maximum efficacy, health systems should,

• Rely on newer approaches of management as management-by-objectives,
• Risk-management, and
• Performance management with full and equal participation from professionals and consumers.

· The public should be well informed about their needs and what is expected from them to improve their health.

· Inefficient use of budget allocated to health services should be prevented by tools like performance management and clinical governance.

· Data processed to information and intelligence is needed to deal with changing disease patterns and to encourage policies that could manage with the complex feedback system of health. E-health solutions should be instituted to increase effectiveness and improve efficiency and informing human resources and populations.

· Suitable legislations should be introduced including those that ensure coordination between different sectors.

· Competent workforce should be given the opportunity to receive lifetime appropriate adequate training. External continuous evaluation using appropriate indicators is vital.

· Actions should be done both inside and outside the health sector to monitor changes and overcome constraints.

3. How did the organized medical profession in the U.S. manage to remain free of control by business firms, insurance companies, and hospitals until the latter part of the 20th century?

The structure of medical practice in the United States has been based on private enterprise. Once the medical profession became organized, it was in a much better position to resist control from outside entities.

The organized medical profession managed to remain free of control by business firms, insurance companies, and hospitals by keeping physicians' abilities to remain free of control from hospitals and insurance companies remained a prominent feature of American medicine; individual physicians who took up practice in a corporate setting were castigated by the medical profession and pressured into abandoning such practices; also the independence from corporate control enhanced private entrepreneurship and put American physicians in an enviable strategic position in relation to these organizations

Technological, social and economic factors created the need for health insurance

• Technology created new and better treatments for delivering medical care
• The availability of new treatments was desirable and created demand
• The costs (and need) for the treatments was unpredictable

In general, it increased the desire and, at the same time, made the care less affordable creating the opportunity for insurance to help spread the cost risk across a pool.

4. Describe the process of formation of the hospital in the U.S. and mention its organizational antecedents.

The main ways in which the current delivery of health care has become corporatized is by managed care, integrated health care services, advanced telecommunication, medical tourism, foreign dire investment in health services benefits foreign citizens, the creation of jobs overseas and medical care by the U.S. is in demand overseas

In the context of globalization in health services, the main economic activities that are discussed are the global exchange of information, production of goods and services in economically developed countries, and increased interdependence of mature and emerging world economies.

From the late 1950s to the early 1980s, health planning formed a major theme of American health policy. Seen by its advocates as a “movement,” planning aimed to make widely available coordinated health facilities and services, especially hospitals, and to foster their orderly and efficient development, that is, to meet need without duplication.

Planning programs provided grants or loans to develop private and governmental planning bodies and health facilities, supported research to establish scientific foundations for planning, and eventually invoked regulation through certificate (or certification) of need (CON) to align the development of hospitals with planning goals. Although planning ideas had already influenced health policy during the first two-thirds of the last century, only in the 1960s and 1970s (labeled here “the planning era”) did advocates of planning undertake major efforts to realize their agenda.

Planning heavily occupied analysts and policymakers at all levels of government, in the voluntary-hospital sector, the medical profession, the nascent profession of health planning, and the emergent field of health services research.

Planning began as a private, voluntary effort to induce the self-governing elites of the hospital world to engage in self-limitation in the public interest, as reformers conceived it; but the characteristic features of planning gradually changed over the course of the planning era, and, toward its end, the movement lost legitimacy and came to an inglorious end.

At first, planning stressed community-based, voluntary institutions, but it took wing through federal and state legislation—from Hill-Burton in 1946 through Comprehensive Health Planning (1966) and its successor under the National Health Planning and Resources Development Act (NHPRDA) of 1974.

Planners initially engaged local social and economic elites, philanthropists (originally individual or familial and later corporate), and local or locally oriented nonprofit institutions (chiefly hospitals and Blue Cross), but later regional and national economic forces loosened community ties and set planning adrift.

Both early in the movement and near its end, planners tried sanctions to enforce decisions, but hospitals, physicians, and the planning-agency boards they dominated refused to bow to the planners' ideas of the public interest.

Moreover, experts' public-interest orientation diminished as they increasingly resembled economic agents selling their professional services. At the same time, market advocates discredited disinterestedness, regulation in the public interest, and indeed the very idea of the public interest as an expression of collective values.

By the early 1980s, planning had failed to devise rational foundations for its practice, to escape politics, to stem cost escalation, and to preserve its practitioners' legitimacy; the movement fizzled out. Planning of health care facilities and services would become the work of private providers of medical care operating in public markets; and the providers' economic success would be the measure of public service and acceptability. Not surprisingly, planning has since been little lamented.

Its major parameters were voluntary institutions, community settings, and professional self-regulation; (2) its actors were experts qua reformers, who saw themselves as either wholly disinterested or enlightened servants of the prevailing interests; (3) its domain of activities for such experts included identifying problems of public concern, envisioning solutions, translating them into practical goals, and organizing local coalitions to achieve change; and (4) its presupposition was that reformers, often in alliance with government, could elicit socially enlightened behavior from the interests.

Twenty years from now, we predict that the health care system we know today will look completely different.

We are already beginning to see the early stages of this transformation. Health care consumers are starting to demand greater transparency, accessibility, and personalization and that trend is likely to continue.

Consumers will want automated, actionable health insights that come from smart artificial intelligence (AI) applied to interoperable data that is seamless and integrated across all platforms and applications.

Many consumers will shop for modular and personalized health coverage and will receive care (mostly) where they are.

A wide range of companies—from inside and outside of the health care sector—are making strategic investments that could be the foundation for a future of health that is defined by radically interoperable data, open and secure platforms, and consumer-driven care.

These organizations illustrate early innovations that can help personalize health care, enable consumers to make more informed decisions about their health, and leverage AI and other emerging technologies to harness and share data.

The Antecedents

Reformers' Vision

• Voluntary community hospitals were the planners' original focus. Through the late nineteenth century, these hospitals had been charitable institutions serving the chronically sick poor. However, in the early twentieth century their transformation into providers of scientific, acute care for paying patients made them objects of broad community concern
• Some chronic patients continued to occupy beds in acute-care institutions, but most chronic care shifted to municipal and county hospitals, state mental institutions, and, eventually, a proprietary nursing-home industry .
• In the 1920s, a consensus among professional associations, such as the American Medical Association and the American College of Surgeons, supported by government and the courts, fostered “small-town [acute-care] hospitals as ideal American institutions—institutions which simultaneously demonstrated community initiative, professional altruism, and diffusion of medical technology to consumers throughout the population” .
• Responsibility for meeting the need for health care, analysts claimed, lay in the local communities. They had to provide capital for physical plant and equipment, encourage patients' self-reliance (and thus willingness to pay for services), and offer free care to the poor.
• The hospital was to be the central community institution for providing acute care, and it gradually absorbed and replaced many other kinds of acute-care facilities, notably specialty hospitals (e.g., maternity, infectious disease, and industrial hospitals) .
• Typically under voluntary, private ownership, the community hospital served as an eleemosynary institution, and its services resembled public goods. Public policy thus aimed to create, sustain, and nurture it .
• Intellectual antecedents of planning lie in the British Dawson Report of 1920 and its American echoes in the recommendations of the Committee on the Costs of Medical Care (CCMC) .
• Thereafter, the goals of planning, its potential utility, and its preferred form repeatedly found expression , especially under the broad but malleable perspective characterized by Fox as “hierarchical regionalism” .
• Both planning institutions and health facilities and services, analysts believed, were best distributed through regional hierarchies descending from the urban center and its medical schools and teaching hospitals, through smaller towns with their community hospitals, to the rural periphery with its clinics.
• Some practical antecedents for planning lay in scattered early projects that rested on public or philanthropic funds. They aimed to improve rural health care through professional exchanges and referrals of patients among institutions, particularly via connections between cities and rural areas .
• At Hunterdon, physicians in primary care specialties, who held full-time academic appointments and kept professionally up-to-date through frequent visits to New York, provided medical education for students, interns, and residents, as well as the supervision and training of primary care practitioners in the local community.
• This arrangement found echoes in some academic medical centers, which emphasized primary care and community medicine on their clinical campuses and avoided subordinating local practitioners to their clinical collaborators at the central medical center and private communication.
• In health care, many policy experts, including planners, espoused either a “collective welfare” model that viewed health care as something that society owed to individual citizens to support the well-being of all; or a “social conflict” model that anticipated the provision of health services to the subordinate classes only through struggle with the wealthy ones
• Although physicians were clearly profit-making professionals, their cultural authority competence to organize scientifically based services, and insistence on patients' free choice of physicians encouraged a pattern of deference that invested the medical profession with the aura of public service.

Planning agencies and their staffs similarly partook of these features of disinterested, voluntary public service. Planning professionals and their institutions thus exemplified enduring American patterns of disinterested, meliorative reform in the context of enlightened private interest.

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