Health Care Delivery Services Research Paper

This research paper will focus on defining and elaborating the dimensions of health care delivery services in a manner that is generally consistent with the literature on health services research, and comparable to discussions of ‘health care delivery systems’ in the United States and most developed nations. Commonly accepted definitions of health care delivery system emphasize the formal arrangements constructed to deliver health care services to specific populations, identified either by market, geographic location, type of service, or subpopulation characteristics (such as age or gender). Thus, this is a level of structure that is slightly more narrow than Ruggie’s treatment of ‘health care systems,’ and represents a specific substructure within Frenk and Murray’s definition of a ‘health system.’ Further, there are multiple types of health care delivery systems within any health system, depending on the type of health care service being delivered, whether preventative, diagnostic, or therapeutic, and the type of population or subpopulation being served.

This research paper will explore, in order: (a) the principle actors or components within health care delivery systems; (b) the variety of system types often present in highly developed health systems; (c) major characteristics of contemporary health care delivery systems; and (d) strategies for assessing health care delivery system performance. A number of recent trends in the health sector and among health care organizations will be examined, particularly since they highlight the difficulties in assessing delivery system performance in the twenty-first century, using standard measures of performance, most of which were developed during simpler times.

Given the brevity of this research paper, bibliographic emphasis will focus largely (although not exclusively) on US health care systems. Although the concepts to be explored in this research paper are applicable across most developed countries, the enormity of changes unfolding in many countries would require several chapters of dedicated comparative analysis. For example, economic and political turmoil in Eastern Europe is currently wreaking havoc with fragile public health and health care delivery systems. A prime example is Russia, where economic resources and basic medical supplies are scarce, government promises to cover basic health care go unfulfilled, and physicians must barter and beg to acquire needed medical equipment and drugs (Shishkin 1999). An ‘underground’ medical system has developed providing care for those few who can pay privately. Massive change also characterizes Latin American health care systems. In Chile free market reforms adopted during the Pinochet regime privatized much of what had been an extensive and effective government supported health care system. What remains now is a nonsystem with considerable problems of access (Reichard 1996). For more extensive comparative discussions of contemporary changes in health care systems, the reader is encouraged to consult recent work by Field (1989), Light (1999), or Day et al. (1998).

1. Components Of Health Care Delivery Systems

The primary actors involved in delivering health care services are the members of the health care workforce (physicians and non-MD professionals, technicians, paraprofessionals), various health care organizations where care is either delivered or coordinated, and the agencies or firms which finance the delivery of services. Throughout the last half of the twentieth century, the medical and health division of labor has expanded dramatically, an expansion that has been fueled by the development of sophisticated medical technologies and specializations. Similarly, a variety of health care organizations deliver or coordinate care services along every step of the care continuum, and the number and type of provider organizations mushroomed during the 1980s and 1990s. Diversification of health care organizational forms has both produced new organizational types (ambulatory surgery centers, women’s health centers) and led to the adoption of new product lines by traditional organizational forms. For example, hospitals have diversified by adding a component of geriatric care, or vertically integrated into a comprehensive health care system, complete with ambulatory clinics and long-term care units (Fennell and Alexander 1993).

The agencies and firms which finance health care ser ice delivery are also part of this system. In the US, a mix of actors, from both public and private sectors, play this role. Insurance carriers and the federal government have historically been important financiers of health care; more recently private sector corporations have been exerting considerable control over service delivery as major purchasers of health care for their employees. Toward the end of the 1990s the US health system came to embrace the concept of ‘managed care,’ an arrangement in which the financial partner (the health plan) becomes directly linked to both the providers of care and the client, through risk contracts. These arrangements have obfuscated the roles of the providers of care and the third-party payers of care, health insurance carriers or plans (Scott et al. 2000). Managed care arrangements contractually link providers to health plans, ensuring that an enrolled group of patients will seek care only from contracted (and somewhat controlled) providers. The providers are often paid a preset per capita rate for treating enrolled patients, and agree to ‘gate-keep’ or control the patient’s use of services through utilization management strategies. Large employers seek contracts with health plans that can promise low premiums and a variety of covered services; health plans compete for large employee groups to enroll as they are the most preferred, low-cost, healthy patient panels. Variations on this general strategy have resulted in a range of complex managed care organizational structures, in which the health plan is mediator between patients and providers, and between providers and payment. Managed care organizations combine provider and plan functions into one structure (Flood et al. 1998).

Although health care workers, organizations, and financing agencies constitute the major actors of health care delivery systems, there are a number of external factors which exert very important influences on these actors. Some influences are so important that it is sometimes difficult to separate the system actors from the external influences. Medical technology, for example, is both part of the environment of health care delivery and part of the health care organizations delivering the care. Continued expansion of medical diagnostic and treatment equipment, medications, biological agents, and devices has driven medical costs upward. The new technologies have created new types of technical and patient care jobs and professions within the health delivery system, which in turn lead to more demand for those technologies (Osterweis 1996). Both medical professionals and patients still expect new technologies to be available, despite their certain impact on costs, and their sometimes uncertain effect on outcomes. The availability of new technologies is used as a primary marketing device by health care organizations to attract patients, professionals, and health plan contracts.

Several other environmental forces influence the major delivery system actors, including changes in the age structure of the population, shifts from acute to chronic illnesses as the leading causes of morbidity and mortality, the explosion of information and telecommunications technologies, and the role of the state as both purchaser and regulator of health services delivery. Each of these factors has shaped delivery system structures and performances, and interact with system structures and processes so as to change expected outcomes and performances (Fennell and Flood 1998). Although a full discussion of their impact is beyond the scope of this research paper, the reader is encouraged to consult recent work by Scott and coauthors for a comprehensive case study of change in one local health care system. Using an institutional theory perspective, these authors examine both the material resources (technologies, population characteristics, economic shifts, market characteristics) and the institutional structures and expectations surrounding health care (regulatory changes, norms about care delivery, cultural beliefs) in the San Francisco Bay Area from 1945 through 1995. They conclude that material resources and institutional environments have interacted to change the local health system over time, with different factors more or less dominant during the historical eras of professional dominance, federal involvement in health systems, and the current era of market-oriented delivery. Scott et al. (2000) remind us that it is difficult to draw boundaries around systems in the process of change, as one set of changes begets other changes, which then churn into new combinations of forces, counterforces, and evolving structures (see also Light’s discussion of countervailing powers, 1993). Further, change at the local level is influenced by changes in national policy as well as changes in social and cultural norms.

2. Varieties Of Health Care Delivery Systems

Within any given health system there can be a variety of delivery systems, identified by the type of health service being delivered. For example, care systems can be defined by where in the continuum of care the service is located, such as primary care, secondary, tertiary, rehabilitative, and/or custodial care. Two frequently made dichotomous distinctions, based on the general type of care, are acute vs. chronic care and mental vs. physical health systems. Additionally, care systems have been described on the basis of where that care is provided, and by which actors. Categorization by location used to be a fairly reliable and straightforward method. For example, complex surgical care was once always provided in the hospital. Ambulatory care meant that care happened in clinics and doctors’ offices. Long-term care always occurred in nursing homes. Hospice care at the end of life was most often provided in freestanding hospice centers or by a home care team working with the family (Watt 1996).

More recently, however, those clear boundaries of care location have faded out of focus, and the sectors of care often blend into each other. What used to be considered inpatient care is now routinely delivered on an outpatient basis (many surgical procedures, for instance, and their adjuvant treatments), and significant rehabilitative care following an acute hospital episode is delegated to either the skilled nursing facility, the rehabilitation facility, or home with nursing visits. Early innovations in hospice care as an alternative setting for end of life care, which moved the dying patient away from the technically-oriented hospital setting, first developed in the United Kingdom in the late 1960s, and then spread to the US in the 1970s (Boling and Lynn 1998, Keay and Schonwetter 1998). More recently in the US, hospice services are increasingly provided by special units embedded within hospitals or nursing homes. Efforts to evaluate the quality of hospice care within such a broad range of care settings are, of course, made more complex given the inevitable clash between the goals of acute care settings and end-of-life care (Mor 1987).

Similarly, the traditional definitions of acute, subacute, or postacute care services can no longer be made on the basis of care setting. Hospitals are increasingly providing more long-term care related services, and nursing homes have been providing care for more acute and subacute patients. It has even become more difficult to clearly differentiate the type of care services provided in particular care settings on even the most basic of distinctions: medical vs. mental health care. The prevalence of depression, for example, among older patients, whether located in primary care settings, inpatient settings, or long-term care settings has come under closer scrutiny. Some estimates suggest that up to 65 percent of elderly patients in nursing homes suffer from depression. Whether those institutionalized elderly actually receive appropriate mental health diagnoses or mental health care, however, is not at all certain.

Diversified health systems market their superiority over other health care providers, of course, on the basis of the ‘seamless delivery system,’ where all needed services are available in one location or from one large, multiunit provider (Shortell et al. 1996). Theoretically, the diversified system should be able to ensure better coordination of care and a much smoother transferal of information from one division to another. But whether or not this type of delivery system structure actually results in net gains for care quality or continuity has yet to be demonstrated in any conclusive fashion. In fact, whether diversified delivery systems actually result in shared or compatible patient record systems, thus, assuring coordination of information about the patient within the system, still needs to be examined. Recent work on the difficulties of guaranteeing security and privacy of electronic patient records revealed that the systems presumed to coordinate electronic information across health care organizations are much further behind in development than expected. When health care organizations merge or are acquired by corporate systems, the details of developing shared information systems through which patient care can be coordinated across care settings are only attended to as an afterthought or far later in the merger process (National Research Council 1997).

3. Characteristics Of Contemporary Health Care Delivery Systems

Traditional studies of the structure and process of health care organizations have provided a model for the study of health care delivery systems. The basic structural characteristics of size, ownership, profit orientation, range of service provision, and primary governance structure provide a template for plotting variation in delivery systems. Similarly, process characteristics describe systems in terms of what is done to and for the patient over the course of treatment. Key variables of process include system coordination mechanisms, information flows, decision-making processes, quality control, and communication flows between practitioners and patients. In the past two decades, health care delivery systems have been characterized by three major trends, the first of which was mentioned earlier: (a) an increase in the diversification of structural types and products; (b) change in traditional ownership and management configurations; and (c) the development of new interorganizational patterns of care delivery and complex multitiered governance structures.

Changes in ownership and management patterns of delivery systems and their component organizations over the past two decades have drastically changed how we think about the delivery of health care services. There have been basically four major facets of ownership management reconfiguration, affecting different health care organizations and systems in various ways: (a) an increased concentration of the acute care delivery system, through hospital closures and mergers; (b) a rise in the prevalence of corporate restructuring across both acute and long-term care sectors, and the spread of managed care philosophy and organizational structures; (c) a blurring of the once basic distinction between profit and not-for- profit ownership; and (d) a drastic and pervasive change in the management ‘climate’ of most health care organizations, from an emphasis on nonprofit service and community responsibility to an emphasis on competitive business strategies. These trends have been discussed at length elsewhere.

The development of new interorganizational patterns of care delivery and more complicated governance structures is best exemplified by the growth in multihospital systems, loosely structured provider networks or coalitions, and formally structured ownership arrangements linking hospitals, physician groups, health plans, and other care settings (best exemplified by the proliferation of managed care organizations, as discussed above). Both horizontally and vertically integrated forms have made substantial inroads in most health care markets, and they vary by size, composition, and level of integration. The governance structures that have developed along with these complicated multiunit structures are generally described as business-oriented, no matter what their profit status. Governing boards within integrated delivery systems often take a two-level form: the separate units (such as a hospital) may retain an internal board, with at least some members drawn from the community. But these local boards tend to focus only on community fund raising and local public relations. Significant strategic planning and investment decisions are usually under the control of the ‘corporate’ board of the system.

4. Assessing Health Care Delivery System Performance

Two criteria for evaluating the performance of health care delivery systems and the organizations within them have dominated the health services literature: the quality of care received by patients (including their satisfaction with services) and the cost efficiency with which health care services are delivered. Quality of care can be evaluated by examining actual care outcomes (changes in health or functioning) or by benchmarking, that is, comparing actual performance or structures to state-of-the-art standards. Evaluations of care delivery focused on processes or structures assume, of course, that an excellent structure in place enhances the likelihood of high-quality processes being performed and, consequently, the likelihood of better outcomes occurring. These assumptions therefore rest on correctly identifying state-of-the-art standards or validating that their use does in fact lead to improved outcomes.

Fueled by physician profiles and public report cards, the 1990s have brought about an increased sophistication in measuring outcomes. Most health services researchers are also careful to control for the myriad of patient-level differences that can affect appropriate accountability for care delivered within a single organization within the delivery system, such as adjusting for patient health factors while assessing outcomes following surgical care. Very sophisticated measures attempt to include post-hospital outcomes to assess hospital care. Nonetheless, most of these outcome measures have been designed to focus on health statuses typical of young and middle-aged patients, and rarely do they focus on the most commonly seen age group of health service users—the elderly. Outcome measures are also most likely to be built around acute medical problems, and rarely are they modeled on the health problems of the elderly or of the chronically ill, who typically have several concurrent, complex, interrelated chronic diseases with the potential for acute episodes. Nor are they able to measure accurately the outcomes for people with interrelated mental and physical health problems, people who are facing end-of-life scenarios, or people for whom the goals of care delivery need to emphasize pain relief, palliation, or functional maintenance (Lamers 1990).

4.1 Problems With Outcome Measure Validity

Indeed, the convergence of several recent trends in health care delivery structures and environments (discussed briefly above) are of particular concern when assessments of service delivery system performance are considered: the graying population of most developed countries, shifts in the prevalence of acute and chronic diseases, the proliferation of new interorganizational patterns of care delivery, and the spread of managed care. A variety of methodological and design issues need to be addressed in order to properly model and evaluate health care delivery system performance under this confluence of conditions. As an example, consider the situation of terminally ill patients: what outcomes should be used to evaluate hospices, which are designed to provide psychological, social, and spiritual care for dying persons and their families? Evaluations in the past have typically focused on the costs of care and the range of services provided (Mor 1987). Quality of hospice care is usually defined in terms of its effect on the quality of life for the patient receiving hospice services and is often ‘customized’ to reflect differences in each state’s goals for the hospice program. But what truly constitutes a ‘positive outcome’ for dying patients? Whose care needs to be assessed—should we also consider the care of the dying patient’s family? How should ‘quality of life’ be modeled? What is the set of ‘costs’ that needs to be included in evaluating the cost-effectiveness of hospices themselves or hospices compared to other sites where people die?

In addition to these issues regarding the proper ‘outcomes’ to measure, terminally ill patients receive their care from a wide range of providers and in a variety of settings. Despite the typical complexity of care for any given patient, evaluations of the performance of health care delivery systems almost always have focused on a particular portion of that care attributable to a single provider or organization. Common examples include the Resident Assessment Instrument (RAI ) for nursing homes (Morris et al. 1990), accreditation standards for hospitals, and NCQA standards for managed care organizations (Zinn and Mor 1998). How well, in fact, have these measures identified the portion of care that can be attributed to a single provider, when the true process of health care delivery involves multiple actors?

What is needed most is a reliable and valid measure of continuity of care, which should take into account the extent to which care is coordinated across care settings, care providers, and transitions between providers and settings. Even outcome measures based upon an illness episode (rather than a specific and standard unit of time, or service consumption event) do not necessarily capture care outside of a particular setting, such as when a hospitalization is the unit of analysis for an episode.

4.2 Problems In Defining The Unit Level Of Analysis For System Performance

Although there are obviously many possibilities for defining levels of systems of care delivery, it is conventional to identify at least three: (a) a single health care organization; (b) a larger, socially defined unit that contains the health care organization, such as a community or a system of health care organizations; and (c) the subunits contained within the organization, such as individual departments or practitioners. Researchers examining organizational issues typically inspect only one facet of care delivery at a time, or one level of analysis. All complex systems, however, tend to be nested units, that is, systems within systems within systems. While most analyses of delivery system performance attempt to bypass these issues by focusing on one or more of the standard three levels, they can instead fail to identify fully the processes and outcomes they are intended to study. The critical point is not that all nested levels must always be studied, but that one should be as clear as possible in identifying the level of analysis selected and about ensuring that the choice of level is aligned with the characteristics of the type of care delivered, the subpopulation of patients, and the goals of the delivery system under examination.

It is also important to recognize that system performance at any given level may not be analyzable as a simple aggregation of performance at lower levels. This is one of the principal features of any system: its performance is determined as much (if not more) by the arrangement of its parts, the types of coordination and integration achieved across units, as by the performance of the individual components. Specifying the appropriate levels within the model, however, is not a simple matter, since multiple contexts can influence patient outcomes simultaneously and those effects may be difficult to distinguish due to nesting or overlapping. For example, a physician’s clinical practice behavior can be nested within his her clinic’s setting, which itself may be nested within a particular diversified health care system, and a particular region or market with characteristic practice patterns.

5. Conclusion

Continuity of care, or clinical integration, has been recommended by Shortell and other researchers as the model on which managed care should be based, so that providers are explicitly recognized as able to bridge care settings along with the patient, so that information is coordinated and shared explicitly across care setting transitions, and so that the care manager may change with these transitions, even if the same actors are involved. Managed care at its best would embrace such a model, and by creating effective mechanisms such as case managers, real integration and coordination would result, presumably leading to better delivery outcomes. Similarly, the multiinstitutional, multiprovider, diversified health care delivery system should, on the face of it, make the sharing of information a matter of routine, through uniform patient records and centralized record systems across care settings and providers, thus improving care continuity and a variety of outcomes.

This is the basis of the ‘seamless delivery system.’ But whether or not such changes in care structures actually result in net gains for care quality or continuity has itself yet to be demonstrated in any conclusive fashion. Understanding the complexity of service delivery systems, and the other systems within which they are embedded, will not simplify this task. But it will lead to better measurement and modeling, and thus, perhaps, to a more realistic assessment of what is needed to achieve ‘seamless’ system functioning.

Bibliography:

1. Boling A, Lynn J 1998 Hospice: Current practice, future possibilities. Hospice Journal 13(1–2): 29–32
2. Day P, Klein R, Miller F 1998 Hurdles and Levers: A Comparative US–UK Study of Guidelines. Nuffield Trust, London
3. Fennell M, Alexander J 1993 Perspectives on organizational change in the US medical care sector. Annual Review of Sociology 19: 89–112
4. Fennell M L, Flood A B 1998 Key challenges in studying organizational issues in the delivery of health care to older Americans. Health Services Research 33(2): 424–33
5. Field M G (ed.) 1989 Success and Crisis in National Health Systems: A Comparative Approach. Routledge, New York Flood A B, Fremont A M, Jin K, Bott D M, Ding J, Parker R C
6. Jr 1998 How do HMO’s achieve savings? The effectiveness of one organization’s strategies. Health Services Research 33(1): 79–99
7. Friedson E 1994 Professionalism Reborn: Theory, Prophecy and Policy. University of Chicago Press, Chicago
8. Gold M R (ed.) 1998 Contemporary Managed Care: Readings in Structure, Operations, and Public Policy. Health Administration Press, Chicago
9. Gray B H 1999 The changing face of health care. In: Clotfleter C F, Ehrlich T (eds.) Philanthropy and the Nonprofit Sector in a Changing America. Indiana University Press, Bloomington, IN
10. Keay T J, Schonwetter R S 1998 Hospice care in the nursing home. American Family Physician 57(3): 491–4
11. Lamers W M Jr 1990 Hospice: Enhancing the quality of life. Oncology-Huntington 4(5): 121–6
12. Light D 1993 Countervailing Power: The changing character of the medical professions in the United States. In: Hafferty F W, McKinlay J B (eds.) The Changing Medical Profession: An International Perspective. Oxford University Press, Oxford
13. Light D 1999 Future Challenges for the NHS: An International Perspective on the 50th Anniversary. Nuffield Trust, London
14. Mor V 1987 Hospice Care Systems: Structure, Process, Costs, and Outcomes. Springer, New York
15. Morris J N, Hawes C, Fries B E, Phillips C D, Mor V, Katz S, Murphy K, Drugovich M L, Friedlob A S 1990 Designing the National Resident Assessment Instrument for nursing homes. Gerontologist 30: 293–307
16. National Research Council: Committee on Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure 1997. For the Record: Protecting Electronic Health Information. National Academy Press, Washington, DC
17. Osterweis M, McLaughlin C J, Manasse H R, Hopper C L (eds.) 1996 The U.S. Health Workforce: Power, Politics, and Policy. Association of Academic Health Centers, Washington, DC
18. Reichard S 1996 Ideology drives health care reforms in Chile. Journal of Public Health Policy 17(1): 80–98
19. Shishkin S 1999 Problems of transition from tax-based system of health care finance to mandatory health insurance model in Russia. Croatian Medical Journal 40(2): 195–201
20. Scott W R, Ruef M, Mendel P J, Caronna C A (eds.) 2000 Institutional Change and Health care Organizations: From Professional Dominance to Managed Care. University of Chicago Press, Chicago
21. Shortell S M, Gillies R R, Anderson D A, Erickson K M, Mitchell J B 1996 Remaking Health Care in America: Building Organized Delivery Systems. Jossey-Bass, San Francisco
22. Watt K 1996 Hospice and the elderly: a changing perspective. American Journal of Hospital Palliative Care 13(6): 47–8
23. Wennberg J (ed.) 1998 The Dartmouth Atlas of Health Care in the United States. American Hospital Association, Chicago
24. Wholey D R, Burns L R 2000 Tides of change: the evolution of managed care in the United States. In: Bird C, Conrad P, Fremont A (eds.) Handbook of Medical Sociology, 5th edn. Prentice-Hall, Upper Saddle River, NJ
25. Zinn J S, Mor V 1998 Organizational structure and the delivery of primary care to older Americans. Health Services Research 33(2): 354–80