| There are many types of hospitals but the
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| | Public policy must be written to support
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| most well known are the Public Hospitals.
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| | "safety net" institutions. They must be
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| What sets them apart is that they provide
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| | allowed to organize their own MCOs
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| services to the indigent (people without
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| | (Managed Care Organizations of patients),
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| means) and to minorities.Historically,
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| | to insure patients and to market their
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| public hospitals started as correction
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| | services directly to groups of potential
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| and welfare centres. They were poorhouses
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| | consumers. This way they will save the
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| run by the church and attached to medical
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| | 20% commission that they are paying HMOs
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| schools. A full cycle ensued: communities
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| | currently. If they become more efficient
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| established their own hospitals which
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| | and reduce utilization, they will absorb
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| were later taken over by regional
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| | the full benefits, instead of ceding them
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| authorities and governments - only to be
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| | to contracting groups of patients and
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| returned to the management of communities
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| | insurance companies or even to the
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| nowadays. Between 1978 and 1995 a 25%
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| | government's medical insurance plans. The
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| decline ensued in the number of public
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| | hospitals will thus be able to construct
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| hospitals and those remaining were
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| | their own networks of suppliers and share
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| transformed to small, rural facilities.In
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| | their risks with their physicians or with
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| the USA, less than one third of the
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| | the insurance companies as best suits
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| hospitals are in cities and only 15% had
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| | their objectives.An example: a Public
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| more than 200 beds. The 100 largest
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| | Hospital with its own healthcare plan is
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| hospitals averaged 581 beds.A debate
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| | likely to make use of all its specialists
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| rages in the West: should healthcare be
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| | and facilities, increase capacity
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| completely privatized - or should a
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| | utilization and profits - whereas today
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| segment of it be left in public
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| | only its primary care, less lucrative,
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| hands?Public hospitals are in dire
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| | services are used by independent HMOs.The
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| financial straits. 65% of the patients do
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| | government can limit the total number of
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| not pay for medical services received by
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| | healthcare plans available, so that the
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| them. The public hospitals have a legal
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| | one propagated by the public hospital
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| obligation to treat all. Some patients
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| | will stand out and not be swamped by
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| are insured by national medical insurance
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| | hundreds of other plans. Such a public
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| plans (such as Medicare/Medicaid in the
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| | hospital plan could also be declared the
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| USA, NHS in Britain). Others are insured
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| | "healthcare plan of default" - anyone who
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| by community plans.The other problem is
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| | has not selected a plan will be
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| that this kind of patients consumes less
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| | automatically referred to and included in
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| or non profitable services. The service
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| | the public hospital plan.Not every
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| mix is flawed: trauma care, drugs, HIV
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| | hospital can start an HMO plan. Only the
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| and obstetrics treatments are prevalent -
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| | big ones can support the necessary
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| long, patently loss making services.The
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| | insurance payments, the reserve
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| more lucrative ones are tackled by
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| | requirements and the marketing and
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| private healthcare providers: hi tech and
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| | administrative costs. The paradox is that
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| specialized services (cardiac surgery,
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| | big public hospitals are already
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| diagnostic imagery).Public hospitals are
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| | committed to HMOs, insurers, other
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| forced to provide "culturally competent
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| | patient groups, or government-sponsored
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| care": social services, child welfare.
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| | MCOs. These resist the inclusion of
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| These are money losing operations from
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| | hospitals which own competing healthcare
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| which private facilities can abstain.
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| | plans - in their networks. This is
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| Based on research, we can safely say that
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| | natural: a hospital with a plan - is a
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| private, for profit hospitals,
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| | direct competitor of a private provider
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| discriminate against publicly insured
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| | of healthcare management and insurance.
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| patients. They prefer young, growing,
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| | Another obstacle is that governments are
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| families and healthier patients. The
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| | very reluctant to encourage the public
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| latter gravitate out of the public
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| | sector on account of the private one.
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| system, leaving it to become an enclave
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| | This is definitely out of fashion
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| of poor, chronically sick patients.This,
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| | nowadays.So, an alternative strategy
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| in turn, makes it difficult for the
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| | looks more viable:Public hospitals can
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| public system to attract human and
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| | act as direct contracting networks. They
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| financial resources. It is becoming more
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| | can team up, pool their resources,
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| and more destitute.Poor people are poor
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| | exercise political lobbying, relegate
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| voters and they make for very little
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| | administrative and audit functions (data
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| political power.Public hospitals operate
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| | processing, claim processing, payment
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| in an hostile environment: budget
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| | system, accounting, legal services) to a
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| reductions, the rapid proliferation of
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| | common centre. This will eliminate the
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| competing healthcare alternatives with a
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| | need for middlemen like the HMOs. These
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| much better image and the fashion of
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| | joint networks will be able to negotiate
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| privatization (even of safety net
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| | contracts with other contractors:
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| institutions).Public hospitals are
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| | physicians, pharmacies, specialized
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| heavily dependent on state funding.
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| | laboratories and so on. This will assist
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| Governments foot the bulk of the
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| | the public hospitals to preserve a loyal
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| healthcare bill. Public and private
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| | and stable (low churning) patient
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| healthcare providers pursue this money.
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| | base.Finally, public hospitals are large
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| In the USA, potential consumers organized
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| | employers with political muscle. All they
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| themselves in Healthcare Maintenance
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| | lack is the will to exercise it. They
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| Organizations (HMOs). The HMO negotiates
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| | should do it to force governments to
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| with providers (=hospitals, clinics,
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| | adopt some unpopular decisions: offer
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| pharmacies) to obtain volume discounts
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| | incentives to HMOs which will refer
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| and the best rates through negotiations.
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| | patients to public hospitals, require
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| Public hospitals - underfunded as they
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| | HMOs to use all the range of services
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| are - are not in the position to offer
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| | (both primary and speciality), compensate
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| them what they want. So, they lose
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| | public hospitals directly for nonpaying
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| patients to private hospitals.But public
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| | patients.But the public hospitals must
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| hospitals are also to blame for their
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| | begin to behave as public entities: they
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| situation.They have not implemented
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| | must open their decision making processes
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| standards of accountability. They make no
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| | and make them community-oriented. They
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| routine statistical measurements of their
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| | must shift from relying on contractual
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| effectiveness and productivity: wait
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| | language to relying on administrative law
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| times, financial reporting and the extent
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| | (regulations) - except when it comes to
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| of network development. As even
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| | employment. In a nutshell: they should be
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| governments are transformed from "dumb
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| | business oriented, on the one hand - and
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| providers" to "smart purchasers", public
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| | publicly accountable on the other.There
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| hospitals must reconfigure, change
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| | is the little matter of Public Relations
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| ownership (privatize, lease their
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| | and advocacy. Public Hospitals have a
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| facilities long term), or perish.
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| | terrible image and they are doing very
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| Currently, these institutions are (often
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| | little to change it. They do not even
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| unjustly) charged with faulty financial
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| | collaborate with researchers trying to
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| management (the fees charged for their
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| | establish a factual fundament concerning
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| services are unrealistically low),
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| | "safety net medical and social care". In
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| substandard, inefficient care, heavy
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| | a world where images count more than
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| labour unionization, bloated bureaucracy
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| | realities this may well be the public
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| and no incentives to improve performance
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| | hospitals biggest mistake.Eight Ways to
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| and productivity. No wonder there is talk
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| | Improve the Operation of Public
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| about abolishing the "brick and mortar"
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| | HospitalsA public hospital can lease
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| infrastructure (=closing the public
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| | physical space or temporal slots, or
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| hospitals) and replacing it with a
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| | computer equipment or any other equipment
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| virtual one (=geographically portable
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| | which suffers capacity underutilisation -
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| medical insurance).To be sure, there are
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| | to their physicians for private
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| counterarguments:The private sector is
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| | practice.The lessee physicians will
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| unwilling and unable to absorb the load
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| | undertake to pay the hospital - either in
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| of patients of the public sector. It is
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| | the form of fixed fees or in the form of
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| not legally obligated to do so and the
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| | participation in the income (franchise
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| marketing arms of the various HMOs are
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| | arrangements).They will also commit
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| interested mainly in the healthiest
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| | themselves to provide community-oriented,
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| patients.These discriminatory practices
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| | non profit services in return for the
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| wreaked havoc and chaos (not to mention
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| | right to use what is, essentially,
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| corruption and irregularities) on the
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| | community property.Another method of
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| communities that phased out the public
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| | using the excess capacity is to sell it,
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| hospitals - and phased in the private
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| | rent it, or lease it to entrepreneurs who
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| ones.True enough, governments perform
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| | are not members of the hospital staff.
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| poorly as cost conscious purchasers of
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| | There are many such possibilities: small
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| medical services. It is also true that
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| | laboratories, speciality medical
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| they lack the resources to reach a
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| | services, primary care and specialist
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| substantial segment of the uninsured
| |
| | practitioners. All these would love to
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| (through subsidized expansions of
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| | use the superior infrastructure of the
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| insurance plans).40,000,000 people in the
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| | hospital. The right to use this
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| USA have no medical insurance - and a
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| | infrastructure can be given in the form
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| million more are added annually. But,
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| | of a concession, a franchise, a rental
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| there is no data to support the
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| | arrangement, or any other arm's length
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| contention that public hospitals provide
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| | mode of collaboration. Professionals are
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| inferior care at a higher cost - and,
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| | likely to jump on the bandwagon when they
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| indisputably, they possess unique
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| | realize that the hospital provides them
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| experience in caring for low income
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| | with a "captive market" of patient. This
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| populations (both medically and
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| | is very much like the relationship
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| socially).So, in the absence of facts,
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| | between an "anchor" in a shopping mall
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| the arguments really boil down to
| |
| | and the small retail shops surrounding
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| philosophy. Is healthcare a fundamental
| |
| | it. The small shops benefit from the
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| human right - or is it a commodity to be
| |
| | business diverted in their direction from
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| subjected to the invisible hand of the
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| | the big "anchor" outlets.The next logical
|
| marketplace? Should prices serve as the
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| | step would be to sell products and
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| mechanism of optimal allocation of
| |
| | services to the community on a
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| healthcare resources - or are there
| |
| | commercial, competitive basis. The
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| other, less quantifiable, parameters to
| |
| | hospital does not have to limit itself to
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| consider?Whatever the philosophical
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| | the sale of medical goods and services.
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| predilection, a reform is a must. It
| |
| | It can also sell medical legal services,
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| should include the following
| |
| | use its print shop to offer print jobs,
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| elements:Public hospitals should be
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| | organize its social services as a profit
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| governed by healthcare management experts
| |
| | centre and sell them to the community or
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| who will emphasize clinical and fiscal
| |
| | to individuals, offer medical consultancy
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| considerations over political ones. This
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| | on a fee per service basis, even sell
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| should be coupled with the vesting of
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| | food from the hospital kitchen through a
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| authority with hospitals, taking it back
| |
| | catering service or data to researchers
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| from local government. Hospitals could be
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| | from its archives. A natural extension of
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| organized as (public benefit)
| |
| | this approach would be "internal
|
| corporations with enhanced autonomy to
| |
| | privatization".A hospital is a collection
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| avoid today's debilitating dual effects:
| |
| | of small (to medium) size businesses
|
| politics and bureaucracy. They could
| |
| | operating under one organizational roof.
|
| organize themselves as Not for Profit
| |
| | Laundry, cleaning, kitchen, the provision
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| Organizations with independent, self
| |
| | of television sets and telephones to
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| perpetuating boards of directors.But all
| |
| | patients, a business centre for the
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| this can come about only with increased
| |
| | hospitalized businessmen - these are all
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| public accountability and with clear
| |
| | profit or loss generating
|
| measuring, using clear quantitative
| |
| | centres.Internal privatization entails
|
| criteria, of the use of funds dedicated
| |
| | the transformation of the hospital into a
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| to the public missions of public
| |
| | holding company. This holding company
|
| hospitals. Hospitals could start by
| |
| | will own and operate a host of
|
| revamping their compensation structures
| |
| | corporations. Each corporation will
|
| to increase both pay and financial
| |
| | constitute a separate contractor which
|
| incentives to the staff.Current
| |
| | will provide the hospital with a service
|
| one-fits-all compensation systems deter
| |
| | or a product. Thus, all laundry will be
|
| talented people. Pay must be linked to
| |
| | done by a corporation which will charge
|
| objectively measured criteria. The
| |
| | the hospital for its services. The same
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| Hospital's top management should receive
| |
| | will go for the kitchen, the printshop,
|
| a bonus when the hospital is accredited
| |
| | the legal services and so on. These
|
| by the state, when wait times are
| |
| | corporations will employ the former staff
|
| improved, when disrollment rates go down
| |
| | of the hospital. This way, the knowledge
|
| and when more services are provided.To
| |
| | and experience accumulated within the
|
| implement this (mainly mental)
| |
| | hospital will not be lost. The
|
| revolution, the management of public
| |
| | corporations owned by the former
|
| hospitals should be trained to use
| |
| | employees will have a "right of first
|
| rigorous financial controls, to improve
| |
| | refusal" in the first five years
|
| customer service, to re-engineer
| |
| | following the transformation. The
|
| processes and to negotiate agreements and
| |
| | employee-owned corporations will be
|
| commercial transactions.The staff must be
| |
| | allowed to match the best offers in
|
| employed through written employment
| |
| | yearly tenders that the hospital will
|
| contracts with clear severance provisions
| |
| | conduct for the services that they are
|
| that will allow the management to take
| |
| | offering.These corporations will also be
|
| commercial risks.Clear goals must be
| |
| | allowed to offer their services to other
|
| defined and met. Public hospitals must
| |
| | clients. Thus, they will reduce their
|
| improve continuity of care, expand
| |
| | dependence on one employer, the hospital.
|
| primary care capacity, reduce lengths of
| |
| | They will become truly entrepreneurial
|
| stay (=increase turnaround) and meet
| |
| | entities, competing for profits in a
|
| budgetary constraints imposed both by the
| |
| | market environment.A part of the
|
| state and by patient groups or their
| |
| | re-engineering process is to determine
|
| insurance companies.All this cannot be
| |
| | which of the functions that the hospital
|
| achieved without the full collaboration
| |
| | fulfils are "core functions",
|
| of the physicians employed by the
| |
| | indispensable functions without which the
|
| hospitals. Hospitals in the USA form
| |
| | hospital will cease to exist or will
|
| business joint ventures with their own
| |
| | change its identity to such an extent
|
| physicians (PHO - Physicians Hospital
| |
| | that it will no longer will be
|
| Organizations). They benefit together
| |
| | recognizable as a hospital. All other,
|
| from the implementation of reforms and by
| |
| | "noncore", functions should be tendered
|
| the increase of productivity. It is
| |
| | out (a concept called "outsourcing").
|
| estimated that productivity today is 40%
| |
| | They should be awarded in a tender to the
|
| less in the public sector than in the
| |
| | most competitive bidders, regardless of
|
| private one. This is a dubious estimate:
| |
| | their identity and previous allegiance.
|
| the patient populations are different
| |
| | The hospital is likely to benefit from
|
| (sicker people in the public sector). But
| |
| | the transfer of functions, in which it
|
| even if the figure is incorrect - the
| |
| | has no relative competitive advantage, to
|
| essence is: public hospitals are less
| |
| | outsiders whose expertise these functions
|
| efficient.They are less efficient because
| |
| | are. This is somewhat akin to
|
| of archaic scheduling of patient-doctor
| |
| | international (free) trade, where each
|
| appointments, laboratory tests and
| |
| | nation optimizes its resources and passes
|
| surgeries, because of obsolete or
| |
| | the (beneficial) results of this
|
| non-existent information systems, because
| |
| | optimization process to its trading
|
| of long turnaround times and because of
| |
| | partners.To control this kind of
|
| redundant lab tests and medical
| |
| | transformation, medical information
|
| procedures. The support - which exists in
| |
| | management systems need to be introduced.
|
| private hospitals - from other (clinical
| |
| | Many are available and they improve both
|
| and nonclinical) personnel is absent
| |
| | the quality and the quantity of data
|
| because of impossibly complex labour
| |
| | available to the management of the
|
| rules and job descriptions imposed by the
| |
| | hospital and, as a result, the decision
|
| unions. Most of the doctors have split
| |
| | making process. This will make it easier
|
| loyalties between the medical schools in
| |
| | for the management to pinpoint which
|
| which they teach and the various hospital
| |
| | areas require doing what. For instance:
|
| affiliates. They would tend to neglect
| |
| | the management of the hospital will be
|
| the voluntary affiliates and contribute
| |
| | able to determine what kind of incentives
|
| more to the prestigious ones. Public
| |
| | should be provided to which members of
|
| hospitals would, therefore, be well
| |
| | the staff, where could costs be cut and
|
| advised to hire new staff, not from
| |
| | where and how could productivity be
|
| medical schools, share risks with its
| |
| | improved.Finally, a novel concept is
|
| physicians through joint ventures, sign
| |
| | emerging. Universities and hospitals are
|
| contracts with pay based on productivity
| |
| | two important repositories of human
|
| and put physicians in the governing
| |
| | knowledge and experience. Virtually every
|
| boards. In general, the hospitals must
| |
| | hospital somehow collaborates with an
|
| shrink and re-engineer the workforce.
| |
| | academic institution, or with a medical
|
| About half the budget is normally spent
| |
| | school.There is symbiosis between
|
| on labour costs in private hospitals -
| |
| | hospital and medical and social
|
| and more than 70% in public ones. It is
| |
| | researchers.Hospitals should actively
|
| no good to reduce the workforce through
| |
| | encourage this. It improves their image,
|
| natural attrition, mass layoffs, or
| |
| | it contributes to their ability to
|
| severance incentives. These are "blind",
| |
| | provide quality services. But should not
|
| nondiscriminating measures which affect
| |
| | do it for free. They should be
|
| the quality of the care provided by the
| |
| | contractual partners to the commercial
|
| hospital. When compounded by work rules,
| |
| | exploitation of the results of research
|
| seniority systems, job title structures
| |
| | conducted within their premises or with
|
| and skewed grievance procedures - the
| |
| | their co-operation. There is a vast field
|
| situation can get completely out of
| |
| | for pharmaceutical, medical, genetic and
|
| hand.The government must contribute its
| |
| | bioengineering research - and a lot of
|
| part. Public hospitals cannot comply or
| |
| | opportunities to make money for the
|
| compete with the demands of national,
| |
| | benefit of the entire community. By not
|
| publicly traded HMOs with political clout
| |
| | getting commercially involved - hospitals
|
| and the capacity to raise capital to
| |
| | give up money which really is not theirs
|
| finance hyper-sophisticated marketing.
| |
| | to give up.
|
