Wrap-up: Creating & Managing New Models of Care in Thailand

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

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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)

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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?”

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•  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?”

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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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