wrap-up: creating & managing new models of care in thailand
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Creating & Managing New Models of Care in Thailand, CMMU MGMG 548, Wk#13 Wrap-up 2014.8.10TRANSCRIPT
Wrap-up: Creating & Managing New Models of Care in Thailand
Borwornsom Leerapan, MD PhD
MGMG 548: Health Service Systems and Health Systems
CMMU, Mahidol University Aug 10, 2014
Pix source: ra.mahidol.ac.th
Format
Pix source: online.wsj.com
F/U
Mini-lecture
Presentation Discussion
Q&A
Wrapup
To-do list
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Housekeeping Issues
1) Guest lecturer on Aug 10th (week 13): – Thaworn Sakunphanit. MD, MSc (Social Policy Financing),
Director of Health Insurance System Research Office (HISRO)
2) Course papers will be due on Aug 17th (week 14)
– Both of your writing and your presentation will be graded.
– More importantly, it’d be better to aim for sharing your learning experiences with your classmates and providing constructive feedbacks to your classmates. Hopefully, each of your course papers will provide valuable lessons to your future careers.
• How has Thailand financed and organized health services?
• How has Thai health systems performed? • How would Thai healthcare system in the
future look like? • What would be “our” lessons learned for the
whole course? • Discussions/Q&A
Outline for Today
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MGMG 548 • Major issues in the organization of a health services system • The role of values in the development of health care policy • Methods for assessing the health status of populations • Analysis of need for, access to and use of services; current supply
and distribution of health resources • Analysis of health care costs and expenditures • Sociopolitical, economic, and moral/ethical issues confronting the
public health and medical care system • Trends in service provision, human resources, financing and health
services organization, and implications for the public’s health.
Course Description
Source Prattana Punnakitikashem. PhD; Pix source: online.wsj.com
Up and Down the Ladder of Abstraction
Abstract: • Concepts
• Theories • Principles
• Strategies
Concrete: • Case studies • Data, Evidence
• Analysis, Synthesis
• Presentations
What Level of Our Learning?
• Why Wisdom
• How Knowledge
• What, Who, When, Where Information
• Number, Text, Picture, Sound, etc. Data
Pretest (in-class exam, no grade)
Pix source: online.wsj.com
Considering the provided VDO presentation, please give your best answers to these two following questions: 1. What “health systems issues” are dominated in the
provided VDO presentation? (Please describe.) 2. As a (future) administrators in your healthcare
organizations, what could you do to address such issues? (Elaborate more on what, why, and how.)
(30 min)
Pre-test Exam
“How could we improve our health & healthcare systems?”
Pix source: online.wsj.com
Source: WHO (2000). The World Health Report 2000. Pix source: buelahman.files.wordpress.com
Health System’s Performance
Pix source: WHO (2000). World Health Report 2000.
AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11
Quality Care 2 9 8 7 5 4 11 10 3 1 5
Effective Care 4 7 9 6 5 2 11 10 8 1 3
Safe Care 3 10 2 6 7 9 11 5 4 1 7
Coordinated Care 4 8 9 10 5 2 7 11 3 1 6
Patient-Centered Care
5 8 10 7 3 6 11 9 2 1 4
Access 8 9 11 2 4 7 6 4 2 1 9
Cost-Related Problem 9 5 10 4 8 6 3 1 7 1 11
Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5
Efficiency 4 10 8 9 7 3 4 2 6 1 11
Equity 5 9 7 4 8 10 6 1 2 2 11
Healthy Lives
4 8 1 7 5 9 6 2 3 10 11
Health Expenditures/Capita, 2011** $3,800 $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508
COUNTRY RANKINGS
Top 2*
Middle
Bottom 2*
EXHIBIT ES-1. OVERALL RANKING
Notes: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity); Australian $ data are from 2010.Source: Calculated by The Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, Nov. 2013).
Pix source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror
The Commonwealth Fund’s Ranking of Healthcare Systems: Overall Ranking (2014)
“Health System”
Pix source: WHO’s framework for action. (2007)
• “The Six Building Blocks” and their interconnections
WHO’s Health System Building Blocks
Pix source: WHO’s framework for action. (2007)
Social Determinants of Health
Pix source: greenpeace.org; twirlit.com; who.int/bulletin; cha-amcity.go.th
• Health is not merely the absence of disease or infirmity. • Health promotion and disease prevention • Health promotion strategies have to go beyond health services
sector.
• Health is among “social values” that are the common missions of social entrepreneurs or social enterprises.
• Social values in health systems:
– To providing quality of care in an efficient and equitable fashion to people with health needs. (“Health Services/Healthcare”)
– To create social values that lead to healthy behaviors, healthy lifestyle, and ultimately a better health of people. (“Health Promotion”)
Social Entrepreneurship & Health
Control Knobs Framework for Health Reform
Source: Adapted from Roberts et al. (2003).
“What exactly should we aim for?”
Pix source: online.wsj.com
• A great health services system should be: 1. Equitable 2. Efficient 3. Safe 4. Timely 5. Effective 6. Patient-centered
Characteristics of Desirable Healthcare
Source: Adapted from IOM (2001)
“STEEEP”
Quality
“The Constraints Management window is like looking at the forest from a hot air balloon and selecting the best tree from which to pick fruit. The Lean window shows the simplest way to pick the low-hanging fruits as well as the fruit on the floor with very little effort. And the Six Sigma window shows how to consistently pick the bulk of the sweeter fruits, without bruising them, at higher, difficult-to-reach branches of the tree.”
Source: Inuzu et al. (2012); Pix source: magic-mural-factory.com
Integrated Healthcare Quality Management
• Two approaches to improve efficiency: 1. Technical efficiency 2. Allocative efficiency
Technical vs. Allocative Efficiency
• Health technology assessment (HTA): “a structured analysis of health technology, a set of related technologies, or a technology-related issue that is performed for the purpose of providing input to a policy decision” (Goodman 2004).
• Economic evaluation is a part of health technology assessment
Health Technology Assessment
Pix source: http://ecsphysics.webs.com/
HTA
Decision making
Scientific Evidence
Types of Economic Evaluation
• All costs are in the same monetary unit. • Type of outcomes determines type of analyses:
Health Outcomes Type of Analysis
Findings
Clinical/Health effects CEA ICER
Utility/Quality of life CUA ICER
Monetary benefits CBA Net benefits, or Benefit-cost ratio
Health effects in non-aggregated format
CCA Lists of health effects gained/lost and resources used
Source: Adapted from Brouselle and Lessard (2011)
Equity vs. Equality
Pix source: twicsy.com/i/TwC76c
• Equity means equality of opportunity (“justice as fairness”). • Equality is not always justice.
Equality Equity
Contrasting Paradigms of Justice
Source: Aday et al. (2004). Table 6.1, p.192
Contrasting Paradigms of Justice
Source: Aday et al. (2004). Table 6.1, p.192
Integrating Equity into “STEEEP”
Source: Adapted from Mayberry et. al (2006)
“How should we organize healthcare for certain populations?”
Pix source: online.wsj.com
Disability-Adjusted Year Lost (2004)
Injury NCD
Infec/on
0-‐4 5-‐14 15-‐29 30-‐44 45-‐59 60-‐69 70-‐79 80+ 0-‐4 5-‐14 15-‐29 30-‐44 45-‐59 60-‐69 70-‐79 80+
Males Females
1,600
1,400
1,200
1,000
800
600
400
200 0
Sour Source: Adapted from: WHO (2008), http://www.who.int/healthinfo/global_burden_disease
Dealing with the Care Cycle
32 Source: Tishihiko Hasegawa (2013)
Concepts in Palliative Care
33 Care provided based on patient & family needs & goals and independent of prognosis
Managing Chronic Care
Figure Source: www.improvingchroniccare.org
Managing Palliative Care
35 Pix source: www.politico.com
Hospice care & End-of-the-life care
Source: Adapted from Feldman, Nadash & Gursen (2008) 36
1) Chronic Care
2) Palliative Care
3) Rehabilitative Services
• Activities of Daily Living (ADL) • Instrumental Activities of Daily Living (IADL)
4) Supportive services
• Care plans, appointment arrangement • Coordination between providers & patients-caregivers • Logistics and supply of necessities
5) Care Management
Managing Long-term Care
Managing Acute Care
37 Source: Hirshon et al. (2013)
Managing Emergency Care
Pix source: adapted from www.ems.gov/wha/sems.htm
Prehospital care
Emergency care
Specialty care & RehabilitaFon
PrevenFon & Public EducaFon
Managing Primary Care
Pix source: www.free-ed.net/free-ed/HealthCare/Physiology/default.asp
— Structure & Organizations of primary care system (in urban settings) • Patient Care Teams • PCUs/Clinics • Systems/Networks • Governance policies
— Four Cardinal Functions of primary care services (in urban settings) • First Contact/Access • Continuity • Coordination • Comprehensiveness
“Anatomy of Primary Care” “Physiology of Primary Care”
“How our healthcare should be financed & organized?”
Pix source: online.wsj.com
Major Mechanisms of Healthcare Financing
Healthcare Regulator(s)
2) Taxes Payers
4) Employer-based private
health insurance
3) Individual private health
insurance
Hospitals
Medical Specialists
Generalists & PCPs
1) Out-of-pocket
Payments
Ambulatory Facilities
Payment Mechanisms: Salary, Fee-for-Service,
Global Budget, Capitation, etc.
British National Health Service System (the model after recent reforms)
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach
Most Providers in the Public Sector
Taxes Payers
Canadian National Health Insurance System
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach
Most Providers in the Private Sector
Taxes Payers
German National Health Insurance System
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach
Employer-based private
health insurance
Most Providers in the Private Sector
Federal Government
(e.g. Medicare, VA, Indian)
Taxes Payers
Employer-based private
health insurance
Individual private health
insurance
Hospitals
Medical Specialists
Generalists & PCPs
Uninsured Patients paying out-of-pocket
Ambulatory Facilities
Payment Mechanisms: Salary, Fee-for-Service,
Global Budget, Capitation, DRGs, etc.
US Healthcare System
Most Providers in the Private Sector
Commercial Health Plans/
HMOs (private health
insurance companies)
State Government (Medicaid,
CHIP)
Taiwanese Healthcare System
Most Providers in the Public Sector
Taxes Payers
Govt-run, Single fund,
National Health
Insurance
Japanese Healthcare System
Source: Bodenheimer TS, Grumbach K (2009). Understand health policy: a clinical approach
Most providers are in the private sector, most small
facilities are private, but large facilities are in the public sector.
Taxes Payers
Negotiated standardized payment rates
(e.g. FFS, per diem)
Corporates
Central govt.
Local govt.
Employers &
Employees
Retirees & (ex-employers) Self-employed, Farmers,
Fishermen, etc.
Compulsory Savings Scheme
(Employees &
Employers)
Individual Insurers
Taxes payers
“Corporatized” public hospitals
& Private hospitals
Medical Specialists
Generalists & PCPs
Patients paying out-of-pocket
Ambulatory Facilities
Singaporean Healthcare Systems
Providers in Public & Private Sector
Medical Saving Accounts
(Medisave)
Catastrophic insurance program
(Medishield)
Central Provident Fund(CPF)
Public assistant program
(Medifund)
Severe disability insurance program
(Eldershield)
“3M”, “Means-testing”
CGD (CSMBS),
NHSO (UCS)
Taxes Payers
Employer-based private health
insurance
Individual & Employer’s
private health insurance
(Voluntary)
Hospitals
Medical Specialists
Generalists & PCPs
Patients paying out-of-pocket
Ambulatory Facilities
Payment Mechanisms: Salary, Fee-for-Service,
Global Budget, Capitation, DRGs, etc.
Thai Healthcare Systems
Providers in Public & Private Sector
Commercial Insurance
Companies
Social Security
Office (SSS)
Motor vehicle’s owners (Mandatory by the Motor
Vehicle Victim Protection Law)
Financing of Thai Healthcare System CSMBS SSS UCS Motor Vehicle
Victim Protection Law
Private Health Insurance
Feature State/Employer welfare
Compulsory heath insurance with state subsidies
State welfare Compulsory heath insurance for vehicle owners
Voluntary health insurance
Targeted groups of beneficiaries
Civil servants, state enterprise employees and dependents
Employees in private sector and temporary employees in public sector
Thai citizens without the coverage of CSMBS & SSS
Victims of vehicle accidents
General public
Source of financing
Govt. budget
Tri-party (Employee, employer and govt. budget)
Govt. budget
Vehicle owners Household
Method of payment to health facilities
Fee-for-service Capitation and Fee-for-service
Capitation and Fee-for-service
Fee-for-service Fee-for-service
Major problems Rapidly and constantly rising costs
Covering while being employed only
Inadequate budget
Redundant eligibility and slow disbursement
Redundant eligibility and slow disbursement
Source: Adapted from Wibulpolprasert et al. (2011). Thailand Health Profile 2008-2010.
Four Major Types of Healthcare Systems
Source: Adapted from Roemer (1993).
US Singapore Germany Japan Canada Taiwan UK Cuba
The least !market interventions"
-Private financing "-Private providers "
Socialist !Health Systems"
Entrepreneurial Health Systems"
Comprehensive !Health Systems"
Welfare-oriented !Health Systems"
The most !market interventions"
-Public financing "-Public providers "
“Why should we concern about health & healthcare systems?”
Pix source: online.wsj.com
Simple, Complicated, Complex Problems
Source: Glouberman and Zimmerman (2002)
“Simple Logic Model”
Source: W.K. Kellogg Foundation (2004)
Source: Patricia Roger (2008)
“Complicated Systems”
Source: Patricia Roger (2008)
“Complex Systems”
Pix source: Don de Savigny and Taghreed Adam (2009).
Health Systems as An Example of Complex Adaptive Systems
Source: Gilson, editor (2012). Health Policy and Systems Research: A Methodology Reader.
Decision-making in Healthcare
Decision-makers in Healthcare
Source: Adapted from: Lessard et a. (2009)
Macro • Policy level • Policymakers
Meso • Administrative level • Organizational administrators
Micro • Clinical practices level • Clinicians
Pix source: hMp://hbr.org/2008/01/the-‐five-‐compe//ve-‐forces-‐that-‐shape-‐strategy/ar/1
Strategic Analysis
Stakeholder Analysis
Pix source: Start and Hovland (2004) Tools for Policy Impact: A Handbook for Researchers
Force Field Analysis
Gap Analysis
Pix source: www2.ifm.eng.cam.ac.uk/
Strengths Advantages
Financial reserves, likely returns Qualifications, certifications Competitive advantages
Capabilities Location and geography Innovative aspects
Resources, Assets, People Processes, systems, IT, communications Culture, attitudes, behaviours Management cover, succession Experience, knowledge, data Strong brand names
Marketing - reach, distribution, awareness Unique selling points “USP” Price, value, quality
Weaknesses Lack of competitive strength
Gaps in capabilities Disadvantages of proposition Weak brand name
Financials Cash flow, start-up cash-drain High cost structure
Our vulnerabilities Timescales, deadlines and pressures
Reliability of data, plan predictability Continuity, supply chain robustness Processes and systems, etc
Management cover, succession Morale, commitment, leadership
Opportunities Market developments
Competitors vulnerabilities Niche target markets New USP's New markets, vertical, horizontal Partnerships, agencies, distribution Geographical, export, import Unfulfilled customer need New technologies Loosening of regulations Changing of International trade barriers
Business and product development Seasonal influences Technology development and innovation
Threats Environmental effects
Seasonal, weather effects Economy - home, abroad Political effects Legislative effects
Market demand New technologies, services, ideas IT developments Shifts in consumer preferences
Obstacles Sustainable financial backing Insurmountable weaknesses Competitor intentions New policies or regulations Emergence of substitute products
PosiFve NegaFve
Inte
rnal
Ex
tern
al
SWOT Analysis
Figure source: Adapted from conceptdraw.com
Looking Forward
Pix source: online.wsj.com
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Financing of Healthcare Systems
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Desirable Healthcare Systems
• Systems Thinking • Focus on quality,
efficiency & equity • Responsive (esp. to
health needs of certain disease and certain populations)
• Good governance in all level of health system
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Towards a Better Healthcare System
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Towards a Better Healthcare System
Source: Mills A. Health Care Systems in Low- and Middle- Income Countries. N Engl J Med. 2014;370:552-7.
Towards a Better Healthcare System
Ø Learning about health systems: “Experience, not explanation.”
Picture source: commonsenseatheism.com; variety.thaiza.com
Adult Learning
EXPERIENCE
Food-for-Thought
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“If I had asked people what they wanted, they would have said faster horses.”
--Henry Ford
Pix source: www.dennisgruending.ca
“The best way to predict the future is to create it.”
--Peter F. Drucker
Q& A Discussions
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