Getting the right treatment to the right people at the right time and by the right care giver
Models of Organizing Care
Primary, Secondar, & Tertiary Care
Primary: basic immediate health problems (80-90%)
Secondary: more specialized clinical care
Tertiary: management of rare and complex disorders
Organization
Dawson regionalized model: emphesizes primary care and works upwards as needed
More fluid model: allows patients to go where they please, puts emphasis on the tertiary care experties
The Regionalized Model: The British National Health Service
Primary care level dominated by GPs (2/3 of all physicians in the UK)
Secondary care based on specialists who deal with patients on an ambulatory basis but refer them back to their GPs for ongoing care--also deal with hospitalized patients
Tertiary care are specialists located at a few tertiary care medical centers
All referals through GPs
The Dispersed Model: Traditional United States Health Care Organization
No limit on referals--the physician goes to any level they want whenever they want
Primary care spred amoungst specialists to a large extent
1/3 of physicians in the US are general internists or general pediatricians--well below the 50% in Cnanda--20% of patients get their primary care from non generalists
Which Model is Right?
The US system is more top heavy and costly and more disorganized and may provide worse care in some instances (low volume procedures) but it gives convienent acccess to the latest and greatest
Balancing the Different Levels of Care
Common disorders commonly occur and rare ones rarely--would suggest more GPs and fewer specialists are needed
Most people’s health care needs are at the primary care level, but most of the resources go into the tertiary and secondary care (cost)
Defining Practiioner Roles
Primary care is not so simple or basic that specialists should do it--GPs should deal with: first contact care, longitudinality (continuity), comprehensiveness, and coordination.
Good primary care improves the perception of health care
Costs lower with good and pervasive primary care through GPs
Gatekeeping & Structured patient Flow
Core function of primary care--not just to prevent access but to encourage it and manage different specialists
Accountability for Health Care
Multiple payers, fee-for-service discourages community or population based care--also no well definined and responsible gate keeper
Forces Driving the Organization of Health Care in the United States
The Biomedical Model
It has worked, dramatically!
Financial Incentives
More hospitals and specialization--less ambulatory and primary care
Initial insurance covered hospital but not physician costs (Blue Cross)--encouraged hospital expansion
Physician costs (Blue Shield) were higher for more time consuming specialist treatments, but as they became rutine the costs remained high creating an incentive to specialize
Hospital Construction Act of 1946
Medicare linked to inpatient service
Hospitals are by defeinition secondary and tertiary care institutions so their expansion did not increase primary and GP care
Professionalism
Lack of governemnt control prevented a rational system
Conclusion
Biomedical model has encouraged good science
Professional model has encouraged good doctors rather than just buisnessmen
Vast resources which can get the right care to the right patient
Does not address the needs of the whole patient--over specialization and lack of primary and preventetive and community care