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Rational planning for health care delivery : aspects of supply, demand, and evaluation Strohmaier, Ronald Murray 1972

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RATIONAL PLANNING  FOR HEALTH CARE DELIVERY:  ASPECTS OF SUPPLY, DEMAND, AND EVALUATION by RONALD MURRAY STROHMAIER University  of British  Columbia,  1968  MSc, U n i v e r s i t y  of B r i t i s h  Columbia,  1970  BSc,  A T H E S I S SUBMITTED  I N P A R T I A L FULFILMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF BUSINESS  ADMINISTRATION  in the Division of Management We .accept t h i s required  Science  t h e s i s as c o n f o r m i n g  to the  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA M a r c h , 1972  In p r e s e n t i n g  this thesis in partial  an advanced degree at the the  University  f u l f i l m e n t of th-i: requirements f o r of B r i t i s h Columbia, I agree  L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e  and  that  study.  I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may by h i s r e p r e s e n t a t i v e s .  he  granted by  permission.  Department o f  ^[j^.  The U n i v e r s i t y of B r i t i s h Vancouver 8, Canada  Head of my  Department or  I t i s understood t h a t copying or  of t h i s t h e s i s f o r f i n a n c i a l g a i n written  the  Columbia  s h a l l not  be  publication  allowed w i t h o u t  my  Rational planning f o r the delivery of health care services i s the primary concern of t h i s t h e s i s .  Various aspects of the  demand f o r , and the supply and c h a r a c t e r i s t i c s of these services are discussed, since an understanding of these topics i s e s s e n t i a l to r a t i o n a l planning. Chapter I examines the r e l a t i v e importance of the i n fluences of health care services, socio-economic  structures and  l i f e styles on i n d i v i d u a l and s o c i e t a l health status.  Various  c r i t e r i a f o r the evaluation of health care services and f o r the a l l o c a t i o n of s o c i e t a l resources between health care services and other s o c i a l services influencing health and well-being are discussed. Chapter II deals with consumer behaviour and the demand f o r medical services.  This discussion e n t a i l s Individual per-  ception of medical needs, factors influencing health knowledge, sources and effectiveness of health information dissemination, and various factors which i n h i b i t u t i l i z a t i o n . Chapter I I I i s concerned with the supply of health care services, t h e i r financing and i n t e r r e l a t i o n s h i p s .  In p a r t i c u l a r ,  the r o l e , c h a r a c t e r i s t i c s , and costs of physician and h o s p i t a l services are examined. Chapter IV discusses the resolution of supply and demand with an emphasis on f i n a n c i a l considerations and the organizat i o n a l arrangements between the various components of supply. Chapter V reviews and discusses some of the major problems of various techniques which have been employed to forecast future health care service  requirements.  iii Various  aspects  of f u t u r e modes of h e a l t h  care d e l i v e r y are  discussed. Chapter VI presents an a i d In r e g i o n a l , p l a n n i n g Chapter VII lated conditions  a s i m u l a t i o n model which may  planned.  as  of h e a l t h care s e r v i c e s .  illustrates  several r e s u l t s f o r various  simu-  and s t r a t e g i e s .  Chapter V I I I suggests f u t u r e improvements t o the model and  be used  simulation  d e s c r i b e s s e v e r a l p o s s i b l e experiments which are  being  TABLE OP CONTENTS CHAPTER I  PAGE 1  MEDICAL CARE AND HEALTH A.  Introduction  1  B.  Medical Care  1  C.  1.  Entry  2.  In-Treatment  3.  End-Result  .  . .  4 6  . . .  Socio-Economic Structures, L i f e Styles, 'and 8  Health 1.  Individual L i f e Styles  10  2.  Pollution  11  3.  Occupational Hazards to Health  . . . . 11 12  Stress  II  3  D.  Measurement of Health  E.  Evaluation of Health Care Strategies  F.  Conclusions  13 . . . . 15 16  CONSUMER BEHAVIOR AMD THE DEMAND FOR MEDICAL SERVICES  18  A.  Introduction  18  B.  Individual Perception of Need  19  C.  Factors Influencing Health Knowledge  D.  Sources and Effectiveness of Health  . . . . 20  Information Dissemination ( i n a developed country) E.  Health Service "Wants"  F.  Factors Influencing U t i l i z a t i o n of Health Services  21 22  22  V  CHAPTER  III  PAGE 1.  Distance  22  2.  Economic Factors  23  3.  S o c i a l Factors  24  G.  U t i l i z a t i o n Modes  24  H.  Patients' Compliance With Doctors' Advice  I.  Conclusions  . .  26  THE SUPPLY OP HEALTH SERVICES A.  27  Health Services, An I n t e r r e l a t e d Network of Component Services  B.  25  27  Community Care and Shelter F a c i l i t i e s and Services As Related to Health  27  C.  Public Financing Of Health Services  34  D.  Scope of Planning  35  E.  Physician Services  35  1.  The Role of the Physician  2.  The Supply and C h a r a c t e r i s t i c s of 36  Physician Services 3.  Modes of Reimbursement and the E f f e c t of 4l  Third Party Payment F.  43  Hospital Services 1.  The Development and C h a r a c t e r i s t i c s of Hospital Services  2.  35  ....  43  The Necessity and Urgency -of H o s p i t a l i zation  54  3.  Behavioral Aspects of Hospital Services  55  4.  Internal Structure and Control  56  5.  The Cost of Hospital Services  58  vi CHAPTER  PAGE G.  IV  THE RESOLUTION OF SUPPLY AND  77  DEMAND  77  A.  Introduction  B.  Distinguishing Features of the Health Services  C.  Market  77  1.  Monopoly Aspects  77  2.  Product Uncertainty and Competition  3.  Externalities  78  4.  P r o f i t Motive  78  77  ...  78  Market Resolution 1.  V  76  Conclusions  F i n a n c i a l Considerations  .  78  D.  A Surplus of Medical Treatment  79  E.  Interaction Between Suppliers  8l  F.  The E f f e c t of Supply on Demand  86  G.  Short Run Resolution  87  H.  Long Run Resolution  87  I.  Conclusion  88 90  RATIONAL PLANNING FOR HEALTH CARE SERVICES A.  A Framework for Planning  90  B.  Problems Encountered  91  C.  Techniques Employed i n Predicting Future  i n Planning  Requirements for Health Care Delivery  D.  ...  92  1.  U t i l i z a t i o n Models  92  2.  Methods Based on Mortality  98  3.  Approaches Based on Morbidity  99  The Need for Alternatives i n Health Care Planning  100  vii  CHAPTER  PAGE 1. E.  101  Systems Analysis Approach .  Changing Patterns of Health Care Delivery . . . . (a) Ambulatory Care  103 104  (b) Geographical and I n s t i t u t i o n a l d i s t r i b u t i o n 105  of f a c i l i t i e s and personnel (c) Greater use of paramedical personnel F.  . . . 106 108  Conclusion  VI' REGIONAL HEALTH PLANNING MODEL  109  A.  Objectives  109  B.  I n t e r - I n s t i t u t i o n a l Policy Simulation  110  1.  Population and Demographic Submodel . . . .  110  2.  Economic Submodel  110  3.  Transportation Submodel  I l l  4.  Land U t i l i z a t i o n Submodel  I l l  5.  Health Systems Submodel . .  I l l  6.  Pollution Submodel  Ill  7.  Human Ecology Group  112  8.  Land C l a s s i f i c a t i o n Group  112  9.  Data Management Group  112  10.  Resources and Public Services Group  . . . .  112  C.  System P r i o r i t i e s and Evaluation  112  D.  Delegation Assumptions  114  E.  Data Base  115  1.  Incidence Data  2.  Demands on Physician Resources  115  3.  Bed Requirements  117  4.  Graduate Nurses  117  5.  Other Considerations  117  115  viii CHAPTER  PAGE P.  VII  VIII  Model L o g i c  118  1.  Overview  o f the Model  2.  Description  .  118  of Subroutines  120  EXPERIMENTS  135  Experiment  1  135  Experiment  2  139  Experiment  3  1 M  Experiment  4  5  146  FUTURE IMPROVEMENTS AND EXPERIMENTS  150  A.  E x t e n s i o n and R e f i n e m e n t s  150  B.  Future Experiments  152  BIBLIOGRAPHY  155  APPENDIX A  161  APPENDIX B  16^  APPENDIX C  165  APPENDIX D  167  APPENDIX E  169  APPENDIX F  •  170  APPENDIX G  171  APPENDIX H  172  LIST OP TABLES TABLE 1  PAGE Health and Health-Related Services and F a c i l i t i e s i n the Greater Vancouver area  2  29  Patient Categories and Levels of Care i n the Greater Vancouver Region  3  Non-Public  30  Care F a c i l i t i e s and Organizations i n the 33  Greater Vancouver Region 4  Estimates of Output per Physician 1935-1951 . . . .  38  5  C l a s s i f i c a t i o n of Hospitals  45  6  F a c i l i t i e s and Services Associated with C l a s s i f i cations of Hospitals  47  7  Plant Fund - Source, 1968  8  Operating Expenditures  9  Expenditures  (Public General Hospitals)  of Budget Review Hospitals .  (Public General Hospitals) i n B.C.  10  Selected Empirical Hospital Costs Studies  11  Evaluation of Three Approaches of Predicting Resource Requirements  12  . .  97  Resource Growth 135  Percentage Increases i n Population and Resource Requirements for Projected Population Growth  . .  142  Percentage Increases i n Population and Resource Requirements for Zero Population Growth  15  65  Obstetrician/Gynecologist and Urologist Resource  Policy  14  64  74  ....  Surpluses for a 4$ Constant  13  63  Bed Day Requirements/total regional population  144  population for projected 145  LIST OP FIGURES PAGE Figure  1  Alternative Decisions  f o r Perceived  Needs . . .  2  LRAC and LRMC as a F u n c t i o n o f H o s p i t a l S i z e  3a  Centralized  3b  C e n t r a l R e f e r r a l System  82  3c  System T y p i c a l o f North America  84  4  The E f f e c t of V a r i o u s L i n e a r Growth Rates ( f o r  Admission System  . .  137  The E f f e c t of V a r i o u s Compound Growth Rates ( f o r A l l Resources) on the S o c i a l  Impact  Index 6  61 8l  A l l Resources) on the S o c i a l Impact Index 5  .  22  S o c i a l Impact  140 Index f o r 1 and 2% Compound  Growth In A i r P o l l u t i o n R e l a t e d M o r b i d i t y  . .  147  ACKNOWLEDGEMENT The cooperation and assistance of the U.B.C. Health Systems Group i s g r a t e f u l l y acknowledged. The contributions of the following persons are greatly  appreciated: Dr. I. Vertlnsky, under whose supervision t h i s thesis  was written, f o r his guidance and many h e l p f u l suggestions. Dr. D. Uyeno f o r h i s many comments and suggestions i n the preparation of t h i s t h e s i s .  ; CHAPTER I: A.  MEDICAL CARE AND HEALTH  Introduction In examining the health care system, we must determine  what i t i s that the consumer seeks and what benefits he derives from the health care system.  This chapter examines the role of  the health care and other systems and t h e i r relationships to health.  Various measures of health status and the quality of  medical care are discussed, for i t i s only through such measures that the impact  of the health care system on health and the  quality of l i f e may B.  be objectively evaluated.  Medical Care It i s commonly accepted that medical care services exist  for the prevention and treatment  of disease and  disability.  However, a substantial proportion of patient v i s i t s to physicians are i n search of reassurance and psychological support.  The  consumer of medical care services seeks expected benefits i n terms of improved or Insured physical and mental well-being, rather than medical services per se. Medical care i s not a single service, but a mix of component services which include drug p r e s c r i p t i o n , epidemic control, reassurance, h o s p i t a l care, physiotherapy, physician advice, and p s y c h i a t r i c a i d .  These services, unlike the goods  or services of most other i n d u s t r i e s , are largely of an informational nature, either i n the form of physician advice or skilled  care.  2  The effectiveness of medical care services and the s a t i s f a c t i o n or d i s s a t i s f a c t i o n derived from them, by the consumer, depend on a number of d i f f e r e n t  attributes.  The i n d i v i d u a l consumer i s unable to adequately judge the q u a l i t y of medical care services.  Consequently  the medical  profession and various public agencies have been charged with the r e s p o n s i b i l i t y of insuring and improving the quality of medical care services.  E f f o r t s to do so involve an* evaluation 1  of various aspects of medical care services which are f e l t to be e s s e n t i a l to the provision of good or adequate medical care. Unfortunately, there i s no c l e a r l y defined and accepted of  standard  'good health' nor i s medical science advanced to the state of  always being able to render a proper and exact diagnosis or to recommend with certainty a best course of treatment.  These  inherent d i f f i c u l t i e s have, to a large extent, precluded an objective measure of the e f f i c a c y of medical care services and evaluation has been primarily based on normative judgements and standards of the medical profession. In attempting to r a t i o n a l i z e the evaluation processes, various approaches have been made at quantifying attributes of medical care services.  Vfhile i t i s desirable to be able to  derive, from the quantified attribute values, an o v e r a l l numerical evaluation score as a surrogate f o r the quality of a medical care system, such attempts are complicated by the conceptual d i f f i c u l t y of assigning appropriate weightings to the non-homogeneous a t t r i b u t e s .  There I s , as yet, no  s a t i s f a c t o r y quantifiable objective function for the macro evaluation of a medical care system.  Since any  weightings  . 3 employed i n weighted measures w i l l i n c o r p o r a t e s u b j e c t i v e b i a s e s o f the e v a l u a t o r s and may methodology and  obscure  important  a s p e c t s , the  assumptions should be e x p l i c i t l y  spectrum of i n d i v i d u a l subcomponent e v a l u a t i o n s In e v a l u a t i n g the q u a l i t y of a m e d i c a l c o n s i s t i n g of p h y s i c i a n s , h o s p i t a l i n p a t i e n t  care system,  and o u t p a t i e n t  and  other s e r v i c e s , p a t i e n t p r o g r e s s through  system may  serve as a l o g i c a l means t o segregate categories for analysis: entry,  and e n d - r e s u l t .  A l t e r n a t e c r i t e r i a may  of the system at any and e v a l u a t i o n may different 1.  exist  the  presented.  facilities  three d i s t i n c t  s t a t e d and  the  the system i n t o  in-treatment, f o r the e v a l u a t i o n  of these t h r e e stages o f p a t i e n t p r o g r e s s  e n t a i l combinations  of c r i t e r i a from the  stages.  Entry At the stage of e n t r y t o components o f the m e d i c a l  care  system, the two most f r e q u e n t l y c o n s i d e r e d e v a l u a t i v e c r i t e r i a are the c a p a b i l i t y  of the system to p r o v i d e n e c e s s a r y  and  demanded s e r v i c e s and the t i m e l i n e s s with which these s e r v i c e s are  provided. The  regarded  t i m e l i n e s s of r e c e i v i n g m e d i c a l s e r v i c e s may  as important  be  not only i n terms of a p a t i e n t ' s m e d i c a l  c o n d i t i o n , but a l s o i n terms o f h i s s a t i s f a c t i o n with the system f o r other than m e d i c a l reasons. d i s a b i l i t y , and  Prolonged  discomfort, anxiety,  a l o s s of Income while w a i t i n g to r e c e i v e  m e d i c a l s e r v i c e s c o n t r i b u t e to a p a t i e n t ' s d i s s a t i s f a c t i o n the m e d i c a l  care system.  A proper e v a l u a t i o n of the importance of delays  and  unmet demands should focus on the s e r i o u s n e s s of p o s s i b l e  with  4 consequences a n d ' a l t e r n a t i v e  treatment p a t t e r n s  as w e l l as the  number o f p a t i e n t s i n v o l v e d and the time p e r i o d of d e l a y . A measure o f the q u a l i t y of m e d i c a l s e r v i c e s , i n the context  o f system c a p a b i l i t y , c o u l d be the percentage o f the time  which the system i s able t o provide delay  c e r t a i n s e r v i c e s without  o r the percentage of the time f o r which v a r i o u s  are p r o v i d e d  w i t h i n a given waiting  services  time.  Many o f the c r i t e r i a chosen f o r adequate o r good care are norms o f a s u b j e c t i v e nature and are open t o q u e s t i o n , impact of the delays 2.  considered.  In-treatment The  is  i s not f u l l y  s i n c e the  q u a l i t y o f care r e c e i v e d while  often evaluated  undergoing treatment  on the b a s i s o f the s e r v i c e s a v a i l a b l e , the  q u a l i f i c a t i o n s and competence of the p e r s o n n e l z a t i o n a l processes  involved.  In terms o f the p h y s i c i a n ' s other  o r the o r g a n i -  such f a c i l i t i e s  o f f i c e , the h o s p i t a l or  c e r t a i n standards may be r e c o g n i z e d or  deemed t o be necessary f o r the p r o v i s i o n of an adequate of care. United  level  Such an e v a l u a t i o n of h o s p i t a l s i s employed i n the  States by the J o i n t Commission f o r the A c c r e d i t a t i o n of  H o s p i t a l s , which has s e t minimum acceptable f a c i l i t i e s , equipment, a d m i n i s t r a t i v e  standards f o r  and p r o f e s s i o n a l o r g a n i -  z a t i o n and p r o f e s s i o n a l q u a l i f i c a t i o n s . T h i s e v a l u a t i o n process  does not measure p a t i e n t  d i r e c t l y , however i t does measure the e x i s t e n c e of v a r i o u s  components of care which are f e l t  proper p a t i e n t  care  and a v a i l a b i l i t y  t o be necessary f o r  care.  One assessment o f the q u a l i t y of p a t i e n t care may be  made In terms of-the sonnel,  competence o f m e d i c a l and  however, the emphasis has  physicians  and  opinion  u s u a l l y been p l a c e d  t o a l e s s e r extent n u r s e s .  Palk et a l (23)  have d e r i v e d  and  r e h a b i l i t a t i o n i n the  diagnosis,  l i g h t of present day  p o t e n t i a l r e s o u r c e s i n p e r s o n n e l and  various  and  i n the  treatment,  or and  i n terms of  diagnostic  the  categories  q u a n t i t i e s of s e r v i c e s ,  aspects of competence i n the d e l i v e r y of these  serve as an i n d i c a t o r of the q u a l i t y of p a t i e n t  these l i n e s , P r i c e et a l (52)  done  knowledge, s k i l l s  q u a n t i t i e s of s e r v i c e s f o r some 230  and  lines,  should be  facilities"  In a d d i t i o n t o the proper mix  may  Along these  of a team of s e l e c t e d c l i n i c a l e x p e r t s —  per-  on  q u a n t i f i e d what "  as good m e d i c a l care f o r p r e v e n t i o n ,  mix  ancillary  have devised  a profile  services  care.  Along  f o r the  measurement of p h y s i c i a n performance, based on a number of factors.  In h o s p i t a l s , m e d i c a l a u d i t s  f o r such an e v a l u a t i o n . h o s p i t a l records  the  r a t e s , by  incidence  t a t i o n s and  a u d i t w i l l examine  f o r i n d i c a t i o n s of d i a g n o s t i c e r r o r s and  j e c t i v e e s t i m a t e s of the various  T y p i c a l l y the  serve as the major means  q u a l i t y of care p r o v i d e d , as w e l l  diagnostic  be and  be  of s p e c i f i c c o m p l i c a t i o n s ,  certain tests,  the removal of normal t i s s u e i n  regarded as  i n d i c a t o r s of q u a l i t y .  concerned with the number and mix professional organizational  records  and  functioning  consul-  operations. the h o s p i t a l ,  These i n d i c a t o r s  of p e r s o n n e l ,  may  administrative  s t r u c t u r e s , the manner In which  are maintained, admission and  existence  as  c a t e g o r y , such as p r e v e n t a b l e deaths  Various organizational processes, w i t h i n may  sub-  d i s c h a r g e p o l i c i e s , and  of t i s s u e committees,  r e f r e s h e r courses, i n t e r n a l medical audits,  etc.  libraries,  the  6 These.evaluations institutional  standards.  the  of medical  determine within these 3.  the  the  degree  The  are  i n achieving  comparison to  r e s u l t s , but  t o which good t r e a t m e n t  judge  to  is  administered  and  whether or  not  adequate.  o f t h e most  q u a l i t y of a s e r v i c e i s the fulfilling  results end  are  of p r e v e n t i v e  reliably  readily  care  some a s p e c t s ,  measured  such  as  of health  remedial  as  drug  and  end  results  various  ratio  operation  by  the  deaths  to operations neurosurgery. evaluated  on  after  10  desired  end  can  i n d i c a t o r s of  the  well defined  r a t e s , the  the  However, v a r i o u s Sheps as  d a y s and risk,  (64)  10  as  of operative  of  of persons  points  to  days  of  have the  equal  mortality ratios category  This  an This weightings  dental extractions  procedure  with  such measure.  performed.  naively gives  such  rates,  measures which  one  deaths w i t h i n  and  incidence  rehabilitation  Clearly, postoperative basis  effective  d e l i v e r y , the  fatality  number o f o p e r a t i o n s  of v a r y i n g  the  be  surgical  always v a l i d .  dividing  total  valid  can  operative mortality ratios  i s d e r i v e d by  ignores  and  a l c o h o l problems.  of post  care  judging  system.  complications,  b e e n e m p l o y e d were n o t  for  p r o g r a m s , when t h e y  t h e most  perinatal mortality rates, puerperal preventable  criteria  i s , whether or not  area  and  measured, serve  of a h e a l t h In  In the  relevant  degree t o which i t i s  i t s purpose, that  attained.  results  quality  use  or In  f o r e v a l u a t i o n i s not  c o n s t r a i n t of a v a i l a b l e resources  resources  inter-  End-result  the  be  made i n t e r m s o f  basis  science  S e e m i n g l y , one  In  be  or i n t e r - p h y s i c i a n a l comparisons  to accepted ability  may  and  should and  be  should  7 account  f o r deaths a f t e r  10 d a y s . i f  While some outcomes and w e l l d e f i n e d ,  they are r e l a t e d t o  of treatment may be r e a d i l y measured  others may be d i f f i c u l t  such as s o c i a l r e s t o r a t i o n and p a t i e n t long p e r i o d s of time before determine the  final  follow-up  to define  satisfaction studies  o r measure, or may r e q u i r e  can v a l i d l y  outcome.  Although v a r i o u s  c r i t e r i a f o r e v a l u a t i o n may be w e l l  d e f i n e d and e a s i l y measured, the r e l e v a n c y sometimes be c o n t r o v e r s i a l , such as the p r o l o n g a t i o n of l i f e  under c e r t a i n  of these c r i t e r i a may  ' I s s u e concerning  influence  on outcomes  the  circumstances.  F a c t o r s other than m e d i c a l care treatment appreciable  treatment.  may have an  and end r e s u l t s may vary as  to  the degree of success f o r a g i v e n t r e a t m e n t .  Comparative  under c o n t r o l l e d c o n d i t i o n s , t h e r e f o r e ,  as the only means  of studying  and drawing v a l i d c o n c l u s i o n s  of p a r t i c u l a r t r e a t m e n t s . treatment  serve  patterns,  In s t u d y i n g  c o n c e r n i n g the  outcomes,  i n c l u d i n g non-treatment,  exercise'd t o ensure the v a l i d i t y  studies  under  effect alternative  care must be  of c o n t r o l and that the  treatment  s t u d i e d has been r i g o r o u s l y p r o v i d e d . These outcome measures may serve degree t o which m e d i c a l s c i e n c e c o n d i t i o n s and as r e f e r e n c e of h e a l t h  care  is  capable  conduct  history  of e n d - r e s u l t  course  studies  the p h y s i c a l ,  during w e l l defined  r o l e of p r e v e n t i v e the  the  various  the  performance  delivery.  of d i s e a s e ,  of d i s e a s e  of  of t r e a t i n g  c r i t e r i a i n evaluating  "Probably no more fundamental the  as I n d i c a t o r s  than knowledge  of the  s o c i a l and economic  intervals  and t h e r a p e u t i c  of d i s e a s e .  i n f o r m a t i o n would  following  facilitate natural  consequences  onset,  and the  m e d i c a l care i n a l t e r i n g  T h i s i d e a has been  recognized  x  for a long time, but the methodological problems and the personnel and time requirements have proven to be formidable b a r r i e r s to undertaking studies that deal comprehensively  with  the issue." (63) Medical audits, accreditation of h o s p i t a l s , and other evaluations of the quality of medical care provide a control mechanism and also a stimulus f o r improving the quality of health care delivery.  As progress and changes i n the delivery  of health care occur, r e v i s i o n and v a l i d a t i o n of the c r i t e r i a used i n evaluating quality are necessitated. There i s a need f o r further research into developing v a l i d and r e l i a b l e c r i t e r i a as indicators of the quality of health care delivery.  In addition, "there i s need f o r developing  methods that review the quality of the entire episode of care  —  and that review the contributions of a l l the care-providing personnel  .  Since the methods now  i n use are almost  entirely  retrospective, i t also i s important to develop methods that rapidly provide information about deviations from  accepted  practice so that interventive action can be taken while care i s s t i l l i n progress." (18) C.  Socio-Economic  Structures, L i f e Styles, and Health  As has already been stated, the expected benefits of a medical care system are improved or insured p h y s i c a l and mental being or health.  The t r a d i t i o n a l health care system has been  primarily concerned with diagnosis and treatment  i n the pre-  c l i n i c a l and c l i n i c a l stages of disease, and i s but one of the factors influencing the health of a population. Individual and s o c i e t a l health status are influenced by  9  a number of other f a c t o r s , of which some are considered  natural  such as b a c t e r i a l and v i r a l i n f e c t i o n s , whereas others such as alcoholism and malnutrition stem from socio-economic structures and l i f e  styles. The influence of these other factors on the health status  of a population i s such that i t has led Win^elstein and French (75) to conclude that the health status of a population i s largely unrelated to the quality and quantity of medical services at i t s disposal.  Furthermore, "much of the t o t a l use of health services  i s accounted f o r by the r e l a t i v e l y small portion of the t o t a l population with serious I l l n e s s episodes,  —  people with Illnesses  requiring h o s p i t a l i z a t i o n s account f o r about one-half private expenditures f o r health 8 percent  of the population."(2)  of a l l  ( i n the U.S.) but amount to only Thus, the health status of a  r e l a t i v e l y small percentage of the population i s s i g n i f i c a n t l y affected by the medical care system. While medical services may not have an appreciable  impact  on the health status of a population they may be considered e s s e n t i a l f o r the improvement or maintenance of the health of certain i n d i v i d u a l s .  When considering the medical care system as  one component factor contributing to the health status and quality of l i f e of i n d i v i d u a l s and of a population, i t i s necessary to assume a broader perspective. A number of psychological and p h y s i c a l stresses, many of which have been shown to have a v i s i b l e impact on morbidity, d i s a b i l i t y and mortality are a consequence of s o c i e t a l styles.  life  "Symptoms such as alcoholism, mental disorder, crime,  s u i c i d e , absenteeism, and chronic maladjustments are only the  10  more obvious consequences crisis  .  of l i f e  s t y l e s which are v u l n e r a b l e t o  The cumulative d i r e c t e f f e c t  physical health levels  of l i f e  of the p o p u l a t i o n , though  s t y l e s on  i n v i s i b l e should  be the major concern f o r the f u t u r e . " (73) While t h e r e are a number of r e l e v a n t most important have been chosen individual l i f e  f a c t o r s , f o u r o f the  f o r d i s c u s s i o n here, namely;  s t y l e s , p o l l u t i o n , o c c u p a t i o n a l hazards and  stress. 1.  Individual Life Pratt  Styles  ( 5 1 ) i n a study o f p e r s o n a l h e a l t h care p r a c t i c e s  r e p o r t e d "that the h i g h e r the q u a l i t y of p e r s o n a l h e a l t h care p r a c t i c e s the h i g h e r the l e v e l of h e a l t h and the fewer the (past) h e a l t h problems r e p o r t e d by the respondent". Individual l i f e  s t y l e s c h a r a c t e r i z e d by such f a c t o r s as  hygiene, e x e r c i s e , d r i v i n g h a b i t s , a l c o h o l consumption,  diet,  s l e e p i n g h a b i t s , and smoking are t o a l a r g e e x t e n t i n f l u e n c e d by acceptance and standards o f the s o c i a l groups with which an individual identifies The  effects  and documented.  or a s s o c i a t e s .  of a number of these p r a c t i c e s are w e l l known  Evidence i s c o n t i n u a l l y  coming t o l i g h t  on the  e f f e c t s of a number of widely used drugs and t o x i c s , both and i l l e g a l , and has r e c e n t l y caused  legal  concern over the use o f  h a l l u c i n a t o r y drugs and the consumption  of food a d d i t i v e s .  While  v a r i o u s evidence p o i n t s t o p o s s i b l e h a z a r d s , the evidence i s o f t e n i n c o n c l u s i v e and c o n t r o v e r s i a l .  I t w i l l probably be some  time b e f o r e the e f f e c t s of a number of these substances, by themselves  and i n combination, w i l l be adequately known.  11  2.  Pollution S o c i e t a l l i f e styles are largely responsible for the  ever increasing amounts of p o l l u t i o n .  I n d u s t r i a l i z a t i o n and  rapid population growth have led to demands f o r increased production and natural resource consumption.  Accompanying the  resultant i n d u s t r i a l , a g r i c u l t u r a l and population growth have been an increase i n pollutants from these sources, and the introduction of heretofore unknown chemicals  and t o x i c s .  Many  of these pollutants have been recognized as being harmful to human health, and i n extreme cases have been known to cause deaths. The effects of various pollutants depend on t h e i r c h a r a c t e r i s t i c properties, concentration, duration and pattern of exposure and retention and accumulation  by b i o l o g i c a l  cells.  In examining the effects of p o l l u t a n t s , great care must be exercised i n i d e n t i f y i n g s y n e r g i s t i c e f f e c t s of multiple pollutants and of other variables influencing health. Data on the adverse e f f e c t s of pollutants i s fragmentary and inconclusive.  Often the only conclusive data i s on exposures  at high concentration l e v e l s . of prolonged  L i t t l e i s known about the effects  exposure to low concentration levels of most  pollutants. A b r i e f discussion of the major pollutants and t h e i r effect on b i o l o g i c a l systems i s given i n Appendix A. 3. 'Occupational Hazards to Health Individuals are subject not only to the hazards of community environment and personal l i f e styles but also to the hazards of t h e i r occupation.  The i n d i v i d u a l may be exposed to  12  such actual or p o t e n t i a l hazards as thermal s t r e s s , various forms of r a d i a t i o n , noise, accidental hazards from various types of equipment, chemicals either through skin contact or as a i r contaminants, mechanical v i b r a t i o n s , and various p a r t i c u l a t e a i r contaminants. stress.  Repetitive tasks may  S h i f t work may  induce physical and mental  produce p h y s i o l o g i c a l , psychological  and  s o c i a l adjustment problems. In addition to direct occupational hazards, changing patterns i n employment often r e s u l t i n occupational  obsolescence.  The resultant displacement, r e l o c a t i o n , r e t r a i n i n g , unemployment, etc. may  lead to f i n a n c i a l and emotional hardships. In the past, various e f f o r t s and l e g i s l a t i o n have been  concentrated  on the prevention  and treatment of physical hazards  through the development of safety standards and the provision of various treatment programs. focused  being increasingly  on the p r e c l i n i c a l detection of occupational metabolic  body disturbances  and the reduction and prevention  psychological consequences of 4.  Attention i s now  of deleterious  occupation.  Stress Prolonged or recurrent stress may  u l c e r s , kidney damage, hypertension,  induce g a s t r o i n t e s t i n a l  various other psychosomatic  disorders and a number of psychoneuroses. As many of the stresses to which man  i s subjected  are a  product of s o c i e t a l structures and l i f e s t y l e s , to eliminate or s i g n i f i c a n t l y reduce such stresses c a l l s f o r a r a d i c a l s o c i a l re-evaluation and a restructuring of man's s o c i e t a l environment. In designing the future state of health care services, factors other than the health care system should be taken into  13  account as much as p o s s i b l e , both i n predicting t h e i r e f f e c t on the demand f o r health care services and of alternative benefits to be derived under d i f f e r e n t strategies f o r the a l l o c a t i o n of resources i n and between the health care system, control, and other s o c i e t a l coping mechanisms.  environmental  This broader  perspective considers the health care system as one component factor contributing to health status and quality of l i f e . D.  Measurement of Health In order to evaluate the benefits of medical care services  and other programs designed to improve mental and physical being, i t Is desirable to have a quantifiable measure of Individual and s o c i e t a l health.  Unfortunately, there i s no clear and absolute  measure of health nor i s i t always easy to d i s t i n g u i s h between states of i n d i v i d u a l health lying along a continuum varying from excellent health to normality, abnormality, p r e c l i n i c a l disease, c l i n i c a l morbidity, d i s a b i l i t y , and death.  I t i s therefore  necessary to employ proxies f o r the measurement of health status. At one time, l i f e expectancies and various death rates could adequately be employed as crude indicators of i l l n e s s prevalence even though no account was made of morbidity conditions (not r e s u l t i n g i n death) but which caused discomfort, impairment, etc. for  Changes i n these values provided a u s e f u l proxy  evaluating the impact  of medical treatment  and health related  programs. In most developed  countries, l i f e expectancies have been  prolonged such that h a l f the female population can be expected to survive to over 75 and h a l f the male population to over 70. While l i f e expectancies have been prolonged, and natal mortality  rates reduced, such progress may have a negative impact on the health status of a population as measured by the prevalence of chronic and genetic i l l n e s s e s and impairments. Deaths among the aged population, are usually not attributable to a single cause.  A degeneracy of one physio-  l o g i c a l system may t r i g g e r malfunctions  i n other related systems  which no longer possess the s t a b i l i t y and r e s i l i e n c e that they once may have had, cummulating i n death bearing l i t t l e ship to s p e c i f i c morbidity conditions.  relation-  Under such conditions,  l i f e expectancies and mortality rates, by themselves, can no longer serve as adequate measures of health or i l l n e s s i n a population.  A more appropriate assessment of community health  must, i n addition to mortality rates and l i f e  expectancies,  involve other measures such as morbidity and impairment. Logan (4'4) suggests  a number of p h y s i c a l , mental and  biochemical tests and indices f o r which a range of v a r i a b i l i t y may be used to p a r t i a l l y define a state of normality f o r given age, sex and, possibly, other c h a r a c t e r i s t i c s .  These measures  may then serve as crude indicators of community health by i d e n t i f y i n g the proportion of the population which f a l l within the range of accepted normal v a r i a t i o n . Such an evaluation i s merely a measure of the extent to which the surrogate measure of health status deviates from the often subjectively defined l i m i t s of v a r i a t i o n of 'good' or 'normal health', rather than a measure of positive  'well-being'.  "In trying to obtain anything more r e a l i s t i c than the crudest of guesses at the prevalence  of health, we are forced  back into a variety of i n d i r e c t measurements, which probably  15  r e f l e c t to some extent an Impression of healthiness of the community without providing much of a measure of I t . " ( 4 4 ) One  of the f i r s t p o s i t i v e approaches to measuring health  i s due to Sanders ( 6 0 )  who  l i f e expectancy be used. S u l l i v a n (68)  who  proposed that the years of " e f f e c t i v e " This concept was  further extended by  proposed that general d i s a b i l i t y , r e l a t i v e to  the s o c i a l context, should serve as the basis f o r a health  index.  Various other research e f f o r t s concentrating on the a b i l i t y to perform d a i l y a c t i v i t i e s and to function within society have been (See Sokolow and Taylor ( 6 5 ) ,  attempted. et a l (40)  and Panshel and Bush  Hagner et a l ( 3 4 ) ,  (24).  An appropriate health status index should r e f l e c t socio-economic consequences of m o r t a l i t y , morbidity, and ability.  Katz  the dis-  However constructed, such an index i s a subjective  evaluation on the basis of available information.  Thus the use  of such measures i s not absolute, but rather an attempt to r a t i o n a l i z e a subjective evaluation E.  process.  Evaluation of Health Care Strategies Different c r i t e r i a may  be employed i n the evaluation of  strategies for the a l l o c a t i o n of resources based on changes which can be made i n a health status index.  Some strategies may  be more desirable because they provide an improved or comparable value of a health status index than other more expensive strategies.  In other cases a more expensive strategy may  more a t t r a c t i o n when pain, discomfort  hold  and other s o c i a l values  are  considered. One method which has been employed has been an economic cost-benefit analysis, which considers the cost of the provision  16  of various services and the economic losses i n production morbidity  due  to  and premature death.  The use of productivity losses i s questionable,  since i t  gives no weighting.to persons not d i r e c t l y contributing to national productivity, and weights the value of other Individuals solely on t h e i r r e l a t i v e contributions to GNP.  In an economy  with less than f u l l employment, i t i s probable that the calculated losses i n productivity are highly overstated,  since production  is  l i k e l y to be geared to a l e v e l which takes Into account absenteeism and other such factors which the analysis naively considers losses i n  as  production.  The use of purely economic c r i t e r i a i s highly inappropriate to the evaluation of health care provision.  Ideally the  analysis should consider pain, loss of s o c i a l function, psychol o g i c a l s t r e s s , etc. which are not measureable i n monetary terms, as well as the economic consequences of m o r t a l i t y , morbidity,  and  disability. P.  Conclusions It i s recognized  that medical care services are  important factor which Influence  an  certain i n d i v i d u a l s ' health  status, however t h e i r e f f e c t on population health status may be  not  appreciable. In modelling a health care system, the interactions and  influences of the various factors contributing to health  status  must be examined to determine the relevant factors to be modelled, t h e i r interactions and t h e i r influence on health. There are numerous problems involved i n the measurement of health status and of the influence of the factors contributing  t o mental and p h y s i c a l h e a l t h .  There i s , however, a need f o r  q u a n t i f i a b l e measures or s u r r o g a t e measures of the above, i f a r a t i o n a l i z a t i o n of the e v a l u a t i o n processes In d e v e l o p i n g  c r i t e r i a f o r the a l l o c a t i o n of  r e s o u r c e s , i t i s necessary as one both  i s t o be  t o c o n s i d e r the m e d i c a l  sought. societal  care system  component of the m i l i e u which c o n t r i b u t e to h e a l t h s t a t u s ,  of an i n d i v i d u a l and  of a p o p u l a t i o n .  CHAPTER I I . A.  CONSUMER BEHAVIOUR AND THE DEMAND FOR MEDICAL SERVICES  Introduction In studying the delivery of health care services, the  demand-supply  interactions and c h a r a c t e r i s t i c s of the  various  services should be investigated, as to the r o l e they play i n determining which services are performed, how they are delivered, in what q u a n t i t i e s , and who consumes them. Underlying  the demand f o r medical s e r v i c e s , are the needs  and desires which motivate individuals to seek medical services. The  concept of need for medical services must d i f f e r e n t i a t e between  medically  determined need and s o c i e t a l and i n d i v i d u a l perceptions  of need.  These needs may be defined i n terms of the quantities of  various medical services which would be required to f u l f i l l them. The  services required to f u l f i l l medically  determined needs  depend on the state of e x i s t i n g medical knowledge and standards of the medical profession and are, thus, normative judgments of the profession. Individual perception s t a n t i a l l y from medically  of medical needs may d i f f e r sub-  determined needs, as the consumer Is not  always aware of medical needs or of p o t e n t i a l benefits which may be derived from u t i l i z i n g various medical services. S o c i e t a l perceived  needs may be defined as the quantities  of various medical services which i t believes i t should consume on the basis of i t s perceived  needs.  I t should be noted that  these needs are not well defined i n terms of e i t h e r the  quantity  or the category of medical services, but are a general desire for  19  medical services and not f o r the mix and quantity of services which may  be received or required, as w i l l be elaborated i n  Chapter I I I . The demand f o r medical services i s the result of actions taken to s a t i s f y wants.  The transformation of wants Into demands  i s not homomorphic, i n that many wants f a i l to materialize as demands because of various i n h i b i t i n g f a c t o r s . In order to analyze demand, one must investigate the possible impact of those variables which influence perception, needs, wants and the t r a n s l a t i o n of wants into demands. B.  Individual Perception of Need Medically determined needs may  not be perceived by an  i n d i v i d u a l , i n some instances because of the asymptomatic nature of an I l l n e s s or i n other cases through a lack of knowledge of symptoms or 'warning signals' which are present.  The extent to  which medical need exists and i s not perceived has been documented i n a number of studies.  Feldman ( 2 5 )  refers to a  University of Michigan Medical School and I n s t i t u t e of I n d u s t r i a l Health report, i n which 4 l percent of a group of 5 0 0 business executives taking a company paid check-up had abnormalities of health of which they were not aware and which required medical treatment. Population interviews compared with c l i n i c a l examinations of a sample population point out both the extent of unperceived i l l n e s s and also the u n r e l i a b i l i t y of population interviews as a means of determining Trussell (20)  the prevalence of medical needs.  E l i s o n and  reported that only "about one-fourth of the  conditions found- on a thorough c l i n i c a l examination;:  and  judged by these c l i n i c i a n s to have been present at time of interview, were reported previously i n the family interview  .  For example, one-third of the cases of diabetes, over one-half of the cases of heart disease, and nine out of ten cases of neoplasms (both benign and malignant) were not reported i n the family interview." The extent to which i n d i v i d u a l s perceive various conditions as requiring professional medical attention without  a  knowledge of the p a r t i c u l a r diagnosis to which the symptoms pertain, i s i l l u s t r a t e d by Feldman (25).  The percentage of the  surveyed public which f e l t a physician v i s i t was required f o r various common symptoms appeared to correspond the percentage of the surveyed  fairly  closely to  physicians who also f e l t that a  physician v i s i t was required. An i n d i v i d u a l ' s knowledge of symptomatic indicators of i l l n e s s plays a s i g n i f i c a n t role i n h i s perception of need.  To  a lesser extent, the knowledge and awareness of those he associates with, sometimes, also, plays a role i n perceiving h i s need.  This i s especially the case of small children whose need  for medical care i s perceived by t h e i r parents. C.  Factors Influencing Health Knowledge Age, sex, urbanization, socio-economic status, and  education have been shown to be correlated with health knowledge. The interdependencies  among these variables often have created  problems i n determining  the e f f e c t s of the separate v a r i a b l e s .  Feldman (25) suggests that the amount of health knowledge possessed  by an i n d i v i d u a l i s largely a result of general  medical  21  Interests and aptitudes and that "information materials generally reach and are assimilated by the better educated and most i n terested groups i n the population  .... the better educated are  able to (and do) keep themselves better informed about health  and  i l l n e s s because of e s s e n t i a l l y the same factors which underlie t h e i r superiority i n almost a l l other realms of knowledge a greater capacity and a greater desire f o r learning i n general." D.  Sources and Effectiveness of Health Information  Dissemination  (in a developed country) Mere exposure to health information Is hardly  sufficient  to ensure increased u t i l i z a t i o n since i t often does not reach the majority of the population or i s not assimilated by them. The main source of health Information i s the mass media. Organized campaigns and news coverage of new announcements such as Nixon's war  advancements or  on cancer appear to have the  most e f f e c t on the public's awareness of health problems and  of  symptomatic indicators of i l l n e s s . Mendelsohn (45) states that "Research evidence has shown that rather than converting  audiences, the mass media serve  e s s e n t i a l l y to reinforce what they would l i k e to believe or do. Furthermore, the mass media r e i n f o r c e , more often than not, what audiences already  l i k e or d i s l i k e , and they serve to underpin  what audiences have already learned i n the  past."  Health knowledge i s not necessarily accompanied by attitudes which are predisposed  to action.  While individuals may  believe certain health services should be sought under given conditions, t h e i r behavior i s often not consistent with t h e i r beliefs.  22  E.  Health'Service  "Wants"  Having perceived the need f o r some form of health t r e a t ment, an i n d i v i d u a l Is faced with the decision as to the course of action to take.  A subsequent t r a n s l a t i o n into 'wants' or  predisposition to action i s determined by the i n d i v i d u a l ' s b e l i e f s as to the seriousness of his condition and the possible consequences of the various courses of action.  This task i s reduced i f  the i n d i v i d u a l has formed some opinion of the possible diagnosis. The possible alternative decisions are i l l u s t r a t e d i n Figure 1. Beliefs Perceived Needs  Dec! sion  do nothing s e l f treatment desire treatment of some form outside the medical service system desire professional medical services  Figure 1:  Alternative Decisions for Perceived Needs  This decision process may be i t e r a t i v e , i n that the perception of needs and the b e l i e f s may a l t e r i n such a manner that subsequent decisions are made. F.  Factors Influencing U t i l i z a t i o n of Health  Services  Although an i n d i v i d u a l may desire professional medical treatment, there are often other factors which contribute to a decision to actually seek such services. 1.  Distance  Distance  appears to play an important role i n health  services u t i l i z a t i o n , u t i l i z a t i o n decreasing with an increase In distance from the sources' of provision of health services.  23 A study i n a metropolitan area by Weiss and Greenlick  (7*0  concludes that "distance affects the medical care process d i f f e r e n t i a l l y by s o c i a l class and interacts with s o c i a l class as an explantory variable." This study i s based on the distance between the sample population's place of residence and the nearest c l i n i c .  This  study and others which are based on the place of residence do not account for the effect of v i s i t s which may points such as the place of employment.  originate from other  Shannon et a l (62) note  that "The distance variable i s only a crude surrogate for the human phenomena which are involved i n t r a v e l .  Human involvement  i n terms of e f f o r t , the d i s t r i b u t i o n of e f f o r t over multiple purposes,  choice between a l t e r n a t i v e s , and ease of transportation  should be considered as these factors r e l a t e to medical care utilization.  There i s a pressing need to disentangle distance  factors from l o c a t i o n a l f a c t o r s , habitual paths, and  social  biases." 2.  Economic Factors  F i n a n c i a l considerations often represent a l i m i t a t i o n on health service u t i l i z a t i o n .  Family income, the cost of health  services and other consumer expenditures often influence a decision to seek professional medical services or not. Unlike many other needs, such as food and s h e l t e r , i n d i v i d u a l s ' f e l t needs for medical services often appear sporadically and may  represent an unexpected! f i n a n c i a l burden.  Various health insurance plans provide against unexpected f i n a n c i a l burdens and also make i t f i n a n c i a l l y feasible for some to greater u t i l i z e available health services,.  A number of  24 studies have shown that health insurance  programs have  Increased  u t i l i z a t i o n of health services, e s p e c i a l l y h o s p i t a l care. (53) i n a study of Canadian health insurance  Reed,  programs, found that  h o s p i t a l admissions and lengths of stay continued  to increase,  but at an accelerated rate with the Inauguration of universal h o s p i t a l insurance.  It was  found that increases In the  length  of stay were r e l a t i v e l y greater than those i n admissions. Another economic f a c t o r , which sometimes may e f f e c t u t i l i z a t i o n , i s a loss of wages incurred while making a v i s i t to a physician or receiving some form of treatment. of various sick leave and sick pay insurance security clauses may 3.  be of considerable  The  possession  schemes and job  importance i n this  context.  S o c i a l Factors  The decision to seek professional medical care, e s p e c i a l l y h o s p i t a l i z a t i o n , may  depend on the a v a i l a b i l i t y and a b i l i t y of  someone i n the home to provide size may  care.  M a r i t a l status and  play an important role i n t h i s  family  context.  It has been found that the single or widowed aged, as compared to the married aged, require more services not  only  because of a need for care but also because of psychological needs. G.  U t i l i z a t i o n Modes In seeking medical services, an Individual usually seeks  the services of a general p r a c t i t i o n e r who past.  In some cases, the i n d i v i d u a l may  treated him i n the  decide to seek the  services of a s p e c i a l i s t , although a patient i s generally referred to a s p e c i a l i s t by a general p r a c t i t i o n e r .  An important consi-  deration here, i s that under some medical insurance patient may  plans, the  have to bear p a r t i a l f i n a n c i a l r e s p o n s i b i l i t y unless  25  he has been referred through a general p r a c t i t i o n e r . The i n i t i a l contact f o r a given incidence may take the form of a telephone conversation, an appointment, an unscheduled v i s i t , or a house c a l l .  I t should be noted that t h i s last  category has become an infrequently provided service.  In seeking  services f o r which the condition i s perceived as requiring immediate medical attention, an i n d i v i d u a l may make an  unscheduled  v i s i t to the physician's o f f i c e , u t i l i z e the emergency services of a h o s p i t a l or request a physician house c a l l . In a study ( 7 4 ) of the Kaiser Foundation Health Plan, i t was found that the working class made more frequent use of h o s p i t a l emergency services than the middle class which were more l i k e l y to make unscheduled v i s i t s to the physician's o f f i c e .  I t was also  found that the middle class u t i l i z e d the telephone much more than the working class.  The study suggests that s o c i o l o g i c a l consi-  derations play an important role i n determining the manner i n which individuals u t i l i z e the health care system. H.  Patients' Compliance With Doctors' Advice Various studies indicate that from 15 to 93 percent of  patients are not compliant with doctors' orders (16).  Such  factors as the influence of others, s t a b i l i t y of conditions i n the home, complexity of regimen, and r e s t r i c t i o n s on personal habits appear to influence a patient's compliance with a doctor's suggested medical regimen. In a study, Davis (16) found "no s i g n i f i c a n t relationship between compliance and any of the demographic c h a r a c t e r i s t i c s investigated — occupation,"  age, sex, marital status, r e l i g i o n , education or  There was also found to be l i t t l e correlation be-  tween any interactions i n the primary v i s i t  and l a t e r  compliance.  26  The study suggests that compliance Is largely a result of patientphysician interactions on subsequent 1.  visits.  Conclusions The primary demand or the general demand of consumers f o r  medical services i s the end result of a process Involving perception of need, b e l i e f s as to the seriousness of the perceived need, b e l i e f s as to the possible consequences of the various courses of action, and the Influence of u t i l i z a t i o n - i n h i b i t i n g factors such as the distance from the source of medical care provision, and socio-economic  considerations. I t should be noted  that, some demands originate as prerequisites f o r employment, passports, etc. rather than i n the consumer seeking improved or insured health. Since many medically determined needs f a i l to materialize as demands, i t i s necessary to understand these processes i n order to predict or influence primary demand f o r medical care services. As has been noted, the general or primary demand of consumers f o r medical services i s not well defined i n terms of the quantity or mix of services.  I t i s the suppliers of medical  care services who determine the s p e c i f i c demands f o r the mix and quantity of services, based on the primary demands of the consumers.  CHAPTER I I I . A.  THE SUPPLY OP HEALTH SERVICES  Health Services, An Interrelated Network of Component  Services  The community health care delivery system may be viewed i n terms of the community's needs and demand^the services and f a c i l i t i e s required to provide s p e c i f i e d f u l f i l l m e n t , the supply of services and f a c i l i t i e s and the manner i n which services are provided. The component services of health care delivery must be considered  i n r e l a t i o n to one another since the degree of sub-  s t i t u t a b i l i t y , r e l a t i v e cost, organizational arrangements, and a v a i l a b i l i t y and effectivness among other factors influence the mix and r e l a t i v e u t i l i z a t i o n of the component services. Coordinated  planning and the e f f i c i e n t u t i l i z a t i o n of  various care and treatment services are complicated  by the  involvement of numerous organizations which often act independently of one another i n the provision of health and health related services.  This s i t u a t i o n leads to a less than optimal  benefit from the resources employed. The complexity  of interactions and interdependencies  of  various components of health services requires that p o l i c i e s and procedures within and between component parts must be viewed i n the context  of the t o t a l system i n order to y i e l d a meaningful  appraisal of community health care services. B.  Community Care and Shelter F a c i l i t i e s and Services As Related To Health Within most large communities, numerous services and  28 facilities  e x i s t t o p r o v i d e care and  These s e r v i c e s and  facilities  s h e l t e r to i t s d i t i z e n s .  range from p r e v e n t i v e p u b l i c h e a l t h  and home care s e r v i c e s t o such m e d i c a l treatment and  c e n t e r s as  acute  chronic h o s p i t a l s . The manner i n which v a r i o u s components are d e l i m i t e d ,  r e g u l a t e d , c o o r d i n a t e d and Although  different  f i n a n c e d may  vary between communities.  o r g a n i z a t i o n a l s t r u c t u r e s and p a t i e n t category  d e f i n i t i o n s e x i s t , the f o l l o w i n g t a b l e s are f e l t t a t i v e , They are chosen here G r e a t e r Vancouver r e g i o n .  t o be  represen-  s i n c e they have been employed i n the  2.9  T a b l e 1: Health and Health-Related S e r v i c e s and F a c i l i t i e s in the G r e a t e r V a n c o u v e r Region  Services  T y p e of C a r e  Preventive  Facilities  Immunization P h y s i c a l checkup E n v i r o n m e n t a l public health  D i a g n o s t i c and.  Physician services  A m b u l a t o r y patient  Dental  " care  R a d i o l o g i c a l and other  services  Outpatient h o s p i t a l departments  diagnostic s e r v i c e s .Home c a r e  Voluntary  organizations  P u b l i c health nursing  •  Residential care  Hostels /Missions Boarding homes . P e r s o n a l care homes  Skilled nursing  Private hospitals Extended  care  care  hospitals Intensive  care  Public hospitals Federal hospitals  Teaching and  Universities  Re s e a r c h  Hospitals  30 Table 2 :  Patient Categories and Levels of Care In the Greater Vancouver Region  Types of Care ' ACUTE - A  Patient Groups  Examples of Cases Included  Levels of Accommodation Required  Critically i l l , Complex high r i s k Intensive Treathigh r i s k , r e medical and sur- ment areas, e.g. quiring conPost-anaesthetic g i c a l cases; tinuous roundRecovery Room severe multiple the-clock i n j u r i e s ; shock, (PAR), Postnursing and operative Reet c. possibly s p e c i a l covery Room resuscitative (POR), Intenand supportive sive Care Unit equipment. (ICU), etc. Acute medical and s u r g i c a l conditions ( i n cluding psychiatric) .  Routine acute medical and s u r g i c a l cases.  Ambulatory low r i s k patients.  Day Care, Might Reception areas Care, Short Stay A c t i v i t y areas Care and Outpatient .  REHABILITATION AND ACTIVATION  Patients r e quiring a planned physical r e h a b i l i t a t i o n program  Cases medically Special a c t i v i t i e s capable of imand Rehabiliprovement within t a t i o n h o s p i t a l . a reasonable period of time. Activation and Rehabilitation unit of acute hospital.  CONVALESCENT  Those patients Uncomplicated requiring more recovery phase than average of medical and length of time s u r g i c a l cases. f o r recovery, do not require specially arranged r e habilitative programs or acute care l e v e l of accommodation.  B  Regular wards and f a c i l i t i e s Acute General Hospital  Areas of lesser care within or without the general h o s p i t a l . W i l l require s k i l l e d nursing care.  31 Table 2 Types of  Care  LONG TERM CARE or CHRONIC CARE or EXTENDED CARE  (Continued)  P a t i e n t Groups  Examples of Cases I n c l u d e d  C o m p l e t e i n v a l i d , P a t i e n t s who a r e i n c l u d e s those continuing critically i l l continuing a n d need I n t e n critically i l l sive s k i l l e d and t h o s e who n u r s i n g care 2 4 have m a j o r h o u r s a day illnesses with l i m i t e d m o b i l i t y . (some m i g h t be quite mobile). Patients with a terminal illness - a l l those with major i l l n e s s and/or l o s s of mobility. Semi-Invalid may h a v e c o n P a t i e n t s who s i d e r a b l e i l l n e s s need s k i l l e d b u t be q u i t e nursing care, mobile. but predominately personal care. E l d e r l y and f r a i l p e o p l e who r e quire sheltered environment. (Custodial).  Explanatory  L e v e l s o f Accommodation Reauired Extended Care Unit Acute H o s p i t a l Extended Care Hospital Private Hospital ( N u r s i n g Home) These p a t i e n t s require s k i l l e d nursing care.  P e r s o n a l Care Home. P r i v a t e Hospital ( N u r s i n g Home-).  P a t i e n t s who a r e B o a r d i n g Homes ( R e s t Homes) up and l o o k (Substitute for a f t e r most of P t h e i r own n e e d s . a t i e n t ' s home) Limited personal care necessary.  Notes:  1.  I t i s d i f f i c u l t t o d e f i n e the c a t e g o r i e s of c h r o n i c i l l n e s s b e c a u s e of the g r e a t v a r i a t i o n i n the needs of each c h r o n i c I n v a l i d . Patients with chronic i l l n e s s do n o t u s u a l l y r e m a i n s t a t i c - T h e y a r e g e n e r a l l y i m p r o v i n g and d o i n g more f o r t h e m s e l v e s o r d e t e r i o r a t i n g and b e c o m i n g more d e p e n d e n t . A l t h o u g h B.C.H.I.S.* e s t a b l i s h e s a d m i n i s t r a t i v e c a t e g o r i e s o f i l l n e s s and d i s a b i l i t y f o r purposes of h o s p i t a l i z a t i o n coverage, i l l n e s s does n o t f a l l i n t o s u c h w e l l d e f i n e d c a t e g o r i e s . I t must be a c c e p t e d t h a t t h e r e be e a s e o f t r a n s f e r b e t w e e n d i f f e r e n t l e v e l s o f c a r e t o meet t h e c h a n g i n g needs of each p a t i e n t .  2.  S k i l l e d N u r s i n g Care - r e f e r s t o n u r s i n g s e r v i c e s , c o n t i n u a l l y a v a i l a b l e by q u a l i f i e d p e r s o n n e l p r o v i d e d to p a t i e n t s under r e g u l a r m e d i c a l s u p e r v i s i o n .  3.  P e r s o n a l Care - i n c l u d e s a l l c a r e o t h e r t h a n s k i l l e d nursing care: s p e c i a l help with d r e s s i n g , washing,  32  getting around, help with meals, etc. indicates 24-hour supervision.  Personal  care  4.  Extended Hospital Care - as defined by'B.C.H.I.S. A h o s p i t a l f a c i l i t y operated by a non-profit h o s p i t a l society or by the p r o v i n c i a l Government. By d e f i n i t i o n , the patients i n this f a c i l i t y must require 24hour nursing care under the c r i t e r i a established by B.C.H.I.S. (In essence, the patient requires a s s i s tance to be mobile).  5.  Private Hospital (Nursing Home) An i n s t i t u t i o n providing 24-hour s k i l l e d nursing services under regular medical supervision. It i s licensed by B.C.H.I.S. and subject to periodic i n spection by B.C.H.I.S.  * B.C.H.I.S. - B r i t i s h Columbia Hospital Insurance Service. Source:  Patterns of Care, Greater Vancouver Regional Hospital D i s t r i c t Advisory Committee - May, 1969.  Se rvices  F a c i l i t y or Organization  Type of Agency  Bed  Capacity  1968 *  Red Cross Canadian A r t h r i t i s and Rheumatism Society (CARS) Other voluntary organizations  Varied  Non-profit  ---  H o s t e l s / M issions  Food & Lodging  Non -profit  425  Boarding Homes  Food, Lodging and L i m i t e d Domestic Services  Proprietary Voluntary  P e r s o n a l Care Homes  Food, Lodging and a range of services intermediate between residential and private hospital care  Regulation  2, 089 994  Source of Operating Funds  ---  Donations  Welfare Institutions L i c e n s i n g Board  Public or Social Assistance Payment  Department of Social Welfare  Payments by users of facility  Public Voluntary Proprieta ry  58 12 53  and payment of welfare rates for  Private  Hospitals  Extended Care Hospitals  *  Skilled nursing care under the supervision of a practicing physician  Proprieta ry  Non-profit  1,932  695  Department of Health Services and Hospital Insurance Regional Hospital D i s t r i c t Board  A T o t a l Concept of Care United Community Services of The Greater Vancouver A r e a , October 1968  T a b l e 3: N o n - P u b l i c C a r e F a c i l i t i e s a n d O r g a n i z a t i o n s i n the G r e a t e r V a n c o u v e r  Region  qualifying patients BCHIS & $l/day from patients  In comparison to the 6,263 beds i n lower l e v e l care i n s t i t u t i o n s there were 4,390 beds i n r e h a b i l i t a t i o n , chronic care and acute general hospitals i n the same region, In 1968. C.  Public Financing  Of Health  Services  Some health care services may be regarded as c o l l e c t i v e goods for which benefits may accrue equally to everyone. goods are sometimes financed  Such  and provided as public goods.  This  may be e s p e c i a l l y true of services requiring high c a p i t a l investment, such as h o s p i t a l s . There are two major arguments for a policy of governmental intervention i n the provision of various health 1.  services.  The access to medical services has come to be regarded,  by many, as an i n d i v i d u a l right rather than a p r i v i l e g e of the wealthy.  Without intervention, i n e q u a l i t i e s i n Individual wealth  would prevent many people from seeking medical services which they need and desire, but which they also regard as f i n a n c i a l l y i n feasible . 2.  E x t e r n a l i t i e s , i n the absence of intervention, would  often result i n an underproduction of some services which are f e l t to be e s s e n t i a l , as i n the case where benefits of research and  communicable disease control may accrue not only to the  purchaser but everyone else i n the society. Public intervention and the i n s t i t u t i o n of regional planning of various  services requiring high c a p i t a l investment  may avoid costly duplication and u n d e r u t i l i z a t i o n of services  mort and allow f o r d i v e r s i f i e d and specialized services through the A  coordination  of resource a l l o c a t i o n .  35 D.  Scope Of  Planning  Of necessity, planning f o r the provision of health services must be limited to those areas over which a planning body has r e s p o n s i b i l i t y , while taking into consideration other f a c i l i t i e s and services outside i t s j u r i s d i c t i o n . In view of t h i s , the approach here Is limited to the provision of h o s p i t a l and related services under the j u r i s d i c t i o n of a Regional Planning Board and of physician services which are e s s e n t i a l to the provision of health care services. I t i s f i r s t necessary to consider the supply of these services and t h e i r c h a r a c t e r i s t i c s . E.  Physician Services 1.  The Role of the Physician  An i n d i v i d u a l seeking medical care seeks the knowledge, and s k i l l e d care of a physician.  advice,  The physician's role  i s to provide a s e r v i c e , i e . diagnosis, the p r e s c r i p t i o n of drugs, t e s t s , and therapy.,, the recommendation of h o s p i t a l admission, etc. In f a c t , a patient must employ the services of a physician i n order to gain non-emergency admission to a h o s p i t a l or to l e g a l l y obtain certain drugs. Once the i n d i v i d u a l has i n i t i a t e d a primary demand for health services by v i s i t i n g a physician, a secondary or 'prescribed' demand i s generated when the physician determines the service requirements for the patient. The determination  of a medical regimen depends on the  physician's perception of the patients needs, the state of medical technology, and on the i n t e r a c t i o n between physician and patient in a r r i v i n g at a treatment acceptable  to the patient.  In  choosing  among p o s s i b l e r e g i m e n s , t h e p h y s i c i a n may c o n s i d e r cost  t o t h e p a t i e n t and h i s p a s t knowledge o f t h e p a t i e n t ' s  preferences. ference,  U n l e s s a p a t i e n t ' i n d i c a t e s an o b j e c t i o n  considered. patient  as t o p o s s i b l e  ability  of the  a l t e r n a t i v e s and t h e s o c i a l and p r o f e s -  o f t h e m e d i c a l p r o f e s s i o n work t o l e a v e  differ  physician's  of various  Preferences  with  choice  resources  regard  of treatment involves  the selec-  the a v a i l -  and t h e a l t e r n a t i v e c o s t s  to cost, risk  to himself.  a v o i d a n c e a n d t i m e may  s u b s t a n t i a l l y between t h e p h y s i c i a n  and t h e p a t i e n t .  The  o f s e r v i c e s s p e c i f i e d by t h e p h y s i c i a n may be g o v e r n e d more h i s own p r e f e r e n c e s If a patient  he  are not  o f t h e r e g i m e n a l m o s t e n t i r e l y up t o t h e p h y s i c i a n . The  by  preferences  O f t e n t h e l a c k o f k n o w l e d g e on t h e p a r t  sional status tion  or pre-  t h e d e c i s i o n p r o c e s s u s u a l l y does n o t i n v o l v e t h e  p a t i e n t ' s p a r t i c i p a t i o n and h i s v a r i o u s  mix  t h e economic  than those of h i s p a t i e n t . f e e l s moderate d i s s a t i s f a c t i o n w i t h  t h e care  r e c e i v e s , he i s o f t e n r e l u c t a n t t o s e e k t h e s e r v i c e s o f a n o t h e r  p h y s i c i a n b e c a u s e o f t h e c o m m i t t m e n t he h a s made i n f o l l o w i n g a regimen, the delay  and i n c o n v e n i e n c e  of seeking  a n o t h e r p h y s i c i a n , and h i s u n c e r t a i n t y  the services of  as t o any i n c r e a s e d  bene-  fits.  are  2.  The S u p p l y and C h a r a c t e r i s t i c s o f ' P h y s i c i a n  The  supply  of physicians  n o t g o v e r n e d by c o m p e t i t i v e  l i m i t e d by r e s t r i c t i o n s right to practice. enrollment  and t h e c o s t market f o r c e s .  on e n t r y  cation, the screening  the high  process during  t o p r a c t i c e , and t h e g r a n t i n g  include cost  services  The s u p p l y i s  t o the profession  These r e s t r i c t i o n s  i n medical schools,  of t h e i r  Services  and on t h e  l i m i t a t i o n s on  of a medical  edu-  medical school, licensing  of hospital p r i v i l e g e s .  37 The m e d i c a l p r o f e s s i o n ' s right  to p r a c t i c e  t o guarantee  that  serves  r e g u l a t i o n of e n t r y and the  not only t o l i m i t c o m p e t i t i o n , but  also  c e r t a i n standards w i l l be m a i n t a i n e d by m e d i c a l  practitioners. Independent  and organized groups of p h y s i c i a n s  regarded as c o m p e t i t i v e  suppliers  normal economic context  of c o m p e t i t i o n .  mechanism i s g e n e r a l l y fession  and overt  of m e d i c a l s e r v i c e s P r i c e as a  cannot be i n the  competitive  c o n s i d e r e d to be u n e t h i c a l by the  advertising  of p r i c e s does not  pro-  occur.  In examining p r i c e b e h a v i o u r of p h y s i c i a n f e e s , G a r b a r i n o (31) suggests that  "the most important cause  behaviour has been the pressure m e d i c a l care on an i n e l a s t i c  services,  is difficult  as i t  account  visits  f o r the q u a l i t y  severity  of p a t i e n t  and on t h e i r  to d e f i n e  i n the  and o p e r a t i o n s of s e r v i c e s  cases attended  has attempted  p h y s i c i a n between  1935  and 1951  by 15 t o 20 of b i l l i n g s 1935  t o 87  that  collected per cent  in  1935  context  on the b a s i s  of  the  performed, but must  t o estimate  also  output  per  (Table  4).  i n output may be  overstated  and 19*14, s i n c e the  percentage  rose from approximately 1944.  of p h y s i c i a n  i n the U n i t e d States  the i n c r e a s e  per cent between  productivity.  to.  (31)  however,  both on the  rendered and the mix and  Garbarino  He n o t e s ,  i s dependent  cannot be measured s o l e l y  number of p a t i e n t  fee  services".  The supply of p h y s i c i a n s e r v i c e s  Productivity  observed  of a growing demand f o r more  supply of  number of p r a c t i c i n g p h y s i c i a n s  f o r the  74  percent  in  38 Table  4:  E s t i m a t e s o f O u t p u t p e r P h y s i c i a n , 1935-1951  Output/Physician Year  I  1935  100.0  1936  110.7  1937  Output/Physician II  Year  I  1944  212.7  n.a.  100.0  1945  234.4  213.9  114.3  99.5  1946  212.9  190.0  1938  110.8  93.2  1947  214.6  195.9  1939  114.0  94.9  1948  220.5  204.0  1940  119.8  99.9  1949  225.4  214.2  1941  133.4  115.2  1950  233.4  , 225.8  1942  167.8  n.a.  1951  242.1  228.7  1943  210 .6  n.a.  Notes:  II  V a r i a n t I — Calculated by d e f l a t i n g the i n d e x o f mean g r o s s i n c o m e p e r p h y s i c i a n by t h e i n d e x o f p h y s i c i a n s ' f e e s . Base — 1935  = 100  V a r i a n t I I — C a l c u l a t e d by s u b s t i t u t i n g m e d i a n n e t i n c o m e f o r mean g r o s s i n c o m e i n t h e above. B a s e — 1936 = 100 A l l income d a t a a r e f o r " n o n s a l a r i e d physicians." Source:  Garbarino  In a l a t e r productivity  (3D  s t u d y , h e f o u n d a 10 p e r c e n t i n c r e a s e i n  f o rthe entire period  -Time s e r i e s s t u d i e s introduced increased  1949-54 ( 3 2 ) .  such as t h i s  are subject  t h r o u g h changes and advancements use o f a u x i l i a r y  to error  i n t r e a t m e n t s and  p e r s o n n e l and s e r v i c e s .  I n t h e p a s t f e w d e c a d e s t h e l o c a l e o f much t r e a t m e n t h a s b e e n s h i f t e d f r o m p a t i e n t s ' homes t o p h y s i c i a n s ' h o s p i t a l , thus reducing in itself  should  physician  travelling  o f f i c e s and t h e  time.  This  factor  account f o r a s u b s t a n t i a l percentage o f the  39 increase i n p r o d u c t i v i t y . It Is no doubt t r u e t h a t the q u a l i t y o f m e d i c a l s e r v i c e s has  improved d u r i n g t h i s time and t h a t many other  as r e s e a r c h , t e a c h i n g  and c o n t i n u i n g e d u c a t i o n  activities  such  have i n c r e a s e d i n  importance and t h e i r demand on p h y s i c i a n time. Although throughput may be i n c r e a s e d , t h e supply of p h y s i c i a n s e r v i c e s may be regarded as very s h o r t - r u n , while  the supply  t o be p o s i t i v e l y s l o p e d , the supply  i n e l a s t i c , i n the  curve f o r p h y s i c i a n s e r v i c e s i s l i k e l y  i n the long-run  (4l).  I n the s h o r t - r u n ,  of p h y s i c i a n s e r v i c e s i s l i m i t e d by the number o f  p h y s i c i a n s and the time they are w i l l i n g t o devote t o t h e i r practices.  I n the long-run,  the number o f p h y s i c i a n s , i n a  p a r t i c u l a r r e g i o n , i s l i k e l y t o be i n f l u e n c e d by the r e l a t i v e a t t r a c t i v e n e s s of p r a c t i c i n g i n t h a t r e g i o n . of course,  Expected income i s ,  a major c o n s i d e r a t i o n .  An important development i n p h y s i c i a n s e r v i c e s i n the l a s t 20 t o 30 years has been the t r e n d towards s p e c i a l i z a t i o n and associated r i s e  i n the cost of m e d i c a l s e r v i c e s .  Among  other  t h i n g s the t r e n d towards s p e c i a l i z a t i o n has stemmed from a vast i n c r e a s e i n knowledge and technology. S p e c i a l i z a t i o n has l e d t o a d e c l i n e i n the number of g e n e r a l p r a c t i t i o n e r s and a c o n c e n t r a t i o n areas.  The c o n c e n t r a t i o n  of s p e c i a l i s t s  of p h y s i c i a n s  i n urban  i n urban areas i s  p a r t i a l l y a r e s u l t of the need f o r a l a r g e enough p o p u l a t i o n and r e f e r r a l system t o u t i l i z e The  specialists services.  1968 p r o v i n c i a l d i s t r i b u t i o n of s p e c i a l i s t s  i s shown  below, where metro r e f e r s t o M e t r o p o l i t a n Vancouver and V i c t o r i a and non-metro are a l l remaining r e g i o n s . there  (6l)  As may be seen,  are more s p e c i a l i s t s than g e n e r a l p r a c t i t i o n e r s i n the  metropolitan regions, whereas the opposite i s true of nonmetropolitan regions. G.P.  Specialists  Metro  884  1060  Non-Metro  544  238  The two major c r i t e r i a which appear to have governed physician location are available opportunity and size of community, with the smaller community being preferred The number of s p e c i a l i s t s i n p r o v i n c i a l  (.61).  non-metropolitan  regions appears to be correlated with the population size of the region.  The only p r o v i n c i a l region which shows a major deviation  from t h i s i s the Lower Mainland, excluding the Greater Vancouver region.  This i s explainable by i t s close proximity to Metropoli-  tan Vancouver, which serves as a. major r e f e r r a l centre not only for the Lower Mainland but also for the province as a whole ( 6 l ) . It i s i n t e r e s t i n g to note that h a l f of the general p r a c t i t i o n e r s have a s p e c i a l f i e l d of interest which accounts f o r as much as 30 percent of t h e i r practice time.  In addition,  s p e c i a l i s t s deal with cases outside t h e i r s p e c i a l i t y with  over  .15 percent also engaged i n general practice ( 6 l ) . In addition, various s p e c i a l i s t s such as pathologists, anaesthesiologists, and r a d i o l o g i s t s , as h o s p i t a l or private laboratory s t a f f , provide services f o r other physicians. Today, many physicians are engaged i n partnerships and group p r a c t i c e s .  In a B r i t i s h Columbia survey of medical man-  power ( 6 l ) , responses Indicated that 15 percent of ^private practice physicians were i n partnership and 49 percent were i n  41 group p r a c t i c e . felt  Of t h e s u r v e y e d p h y s i c i a n p o p u l a t i o n  t h a t g r o u p p r a c t i c e was b e t t e r t h a n s o l o p r a c t i c e .  m a j o r advantages o f group p r a c t i c e were g i v e n better  organization  patient  care,  o f manpower, i n f o r m a l  3.  a s ; more f r e e  time,  consultation, better  (6l)  Modes o f R e i m b u r s e m e n t a n d t h e E f f e c t o f T h i r d Party  G o v e r n m e n t a l and o t h e r medical indigents, while  sliding  The  c o n t i n u i t y o f c a r e , b e t t e r w o r k i n g f a c i l i t i e s and  f u l l e r use o f paramedical personnel.  for  70 p e r c e n t  scale  fees  Payment  a g e n c i e s h a v e o f t e n made  provisions  t h e m e d i c a l p r o f e s s i o n has employed  t o make a l l o w a n c e s f o r p a t i e n t s  of limited  f i n a n c i a l means. Although t h e use o f s l i d i n g  s c a l e f e e s may be r e g a r d e d as  a form o f p r i c e d i s c r i m i n a t i o n , Arrow practice  i s n o t one w h i c h m a x i m i z e s p r o f i t .  argument i s t h a t t h e p r i c e e l a s t i c i t y for  a l l income l e v e l s , b u t c o n s i s t e n c y  requires  (5) a r g u e s t h a t  that  the e l a s t i c i t y  this  The b a s i s  of h i s  o f demand i s l e s s t h a n one with  profit  o f demand be g r e a t e r  maximization t h a n one i n  each segmented market. In the past,  although various  w e r e made f o r i n d i v i d u a l s o f l i m i t e d individual financially  consumers o f p h y s i c i a n responsible  a l l o w a n c e s and p r o v i s i o n s financial  resources,  s e r v i c e s were l a r g e l y  f o r t h e s e r v i c e s t h e y consumed.  c o n s t i t u t e d the primary source o f p h y s i c i a n revenue. p a y m e n t s now a c c o u n t f o r a s i g n i f i c a n t p r o p o r t i o n received  This  Insurance  of t h e revenue  by p h y s i c i a n s . Under i n s u r a n c e  coverage o f the costs  payment " t h r e e c f m e d i c a l care  d i f f e r e n t methods o f have a r i s e n : p r e p a y m e n t ,  42 i n d e m n i t i e s a c c o r d i n g t o a f i x e d s c h e d u l e , and i n s u r a n c e a g a i n s t c o s t s , whatever they may e f f e c t i s paid i n kind The  other two  but i n one  be.  I n prepayment p l a n s , i n s u r a n c e i n that i s , d i r e c t l y i n medical s e r v i c e s .  forms both i n v o l v e cash payments t o the b e n e f i c i a r y ,  case the amounts t o be p a i d i n v o l v i n g a m e d i c a l con-  t i n g e n c y are f i x e d i n advance, w h i l e i n the other the i n s u r a n c e c a r r i e r pays a l l the c o s t s , whatever they may  be, s u b j e c t , of  course, t o p r o v i s i o n s , l i k e d e d u c t i b l e s and c o i n s u r a n c e . " In many cases the r a t e s of remuneration  (5).  are n e g o t i a t e d  between the p h y s i c i a n s i n v o l v e d and the i n s u r i n g p a r t y . In B r i t i s h  Columbia, governmental  and  governmentally  r e g u l a t e d t h i r d p a r t y payment plans p r o v i d e u n i v e r s a l i n s u r a n c e coverage  f o r physician services, various physician-prescribed  s e r v i c e s such as x - r a y s , p h y s i o t h e r a p y , and l a b o r a t o r y and other s e r v i c e s such as those of c h i r o p r a c t o r s . covered are e x t e n s i v e .  However, t h e r e are c e r t a i n  The  tests, services  limitations  on the usage of some s e r v i c e s and a few s e r v i c e s such as p h y s i c a l examinations not  r e q u i r e d f o r employment or i n s u r a n c e purposes  are  covered. Insurance p l a n s are of p a r t i c u l a r importance  effect  on the cost and q u a l i t y  in their  of m e d i c a l c a r e .  While m e d i c a l i n s u r a n c e coverage p r o v i d e s a means whereby c e r t a i n needed s e r v i c e s , which may i n d i v i d u a l s because  of f i n a n c i a l c o n s t r a i n t s , are o b t a i n e d , i t  a l s o induces elements insurance they may medically required.  have been foregone by v a r i o u s  c f abuse.  When p a t i e n t s are covered by  seek a d d i t i o n a l s e r v i c e s which are not Some p h y s i c i a n s may  really  overprescribe services  or s e l e c t a more expensive form of treatment than i s r e q u i r e d  either risk  at the p a t i e n t ' s r e q u e s t  o r reduce the On  other  the  third  and  effort  other hand, the  costs  of these  services.  the inecessary r e s o u r c e s of medical Other plans  provide  nature  provide  the  be F.  aspects  insurance  such  as t h e  research  reduce  the  a l s o have  of costs  in this  area  and  further discussed  i n the  care  area  next  prepayment  and  arrangements  K a i s e r Foundation f o r the  The  of  however  impact  of h o s p i t a l  Medical  development  services,  i s required.  i s g r e a t e s t i n the  as  group  strong motivation  e f f e c t i v e means o f p r o v i d i n g m e d i c a l  arrangements  c o n s u m e r s and  various  to  o r g a n i z a t i o n s have  o r g a n i z a t i o n a l arrangements such  Program may  impetus  t o improve  collective  individual  t o study  where p h y s i c i a n s f o r m  further  an  and  care.  of a p r o f i t - s h a r i n g Care  of governmental  s e r v i c e s and  These  g r e a t e r b a r g a i n i n g power t h a n  quality  involvement  of medical  reduce  required.  p a r t y payment p l a n s may  or c o n t r o l the quality  time  or to increase p r o f i t ,  of  care  these  and  will  section.  Hospital Services 1.  The  Development  And  Characteristics  of H o s p i t a l  Services The increased and  role  and  e f f e c t i v e n e s s of the  d u r i n g the  a n t i s e p s i s i n the  began the growth  from the  to  prominence.  of  Earlier the  last  century. quarter  in hospital  different one  last  almshouse  The  discovery  of the  of  one  and- s h e l t e r  facilities  c o u l d not  afford  anesthesia  nineteenth  s t a t u s from  h o s p i t a l s were r e g a r d e d  l e s s w e a l t h y who  h o s p i t a l have g r e a t l y  as  century  w h i c h was  care  not  f o r the  facilities  p r i v a t e nurses  and  far poor  for  other  home c a r e recent  services.  W i t h t h e improvement i n m e d i c a l s c i e n c e and  proliferation  o f complex and e x p e n s i v e equipment, t h e  h o s p i t a l grew i n s t a t u r e be  provided  and p r o v i d e d  i n p a t i e n t homes.  services which could not  Because o f t h e i n c r e a s e d  a number o f s e r v i c e s w h i c h w e r e p r e v i o u s l y provided  and s t i l l  i n t h e p a t i e n t ' s home o r p h y s i c i a n ' s  office  stature,  c a n be a r e now  l a r g e l y performed i n the h o s p i t a l . Hospitals diagnostic fication  services.  As educational  facilities  Vancouver  outline the classi-  and s e r v i c e s o f h o s p i t a l s  region.  and r e s e a r c h services.  contact.  provide  programs i n a d d i t i o n t o p a t i e n t  care  I n a d d i t i o n , h o s p i t a l s s e r v e as l o c a l  o f knowledge and p r o v i d e  physicianal  care and  c a n be s e e n f r o m t h e t a b l e s , some h o s p i t a l s  diagnostic  centres  The f o l l o w i n g t a b l e s  and a s s o c i a t e d  w i t h i n the Greater  and  o f f e r a wide v a r i e t y o f p a t i e n t  opportunities  f o r inter-  45  Table 5 : TERTIARY  C l a s s i f i c a t i o n of Hospitals  ; Major R e f e r r a l , Teaching and Research Centre Hospital f a c i l i t i e s of a complex, highly specialized nature acting as a major r e f e r r a l centre f o r a large population group  throughout  a widespread geographical area (the Province). These centres w i l l have a varying degree of teaching and research r e s p o n s i b i l i t y . SECONDARY  Regional R e f e r r a l Centres Regionalized h o s p i t a l f a c i l i t i e s of a less highly s p e c i a l i z e d nature than the major teaching, research and r e f e r r a l centres, but s t i l l providing more complex services and f a c i l i t i e s than w i l l be found i n the majority of the community type hospitals throughout  the area.  Regional r e f e r r a l centres w i l l provide specialized f a c i l i t i e s i n order to serve some of the s p e c i a l needs of a number of l o c a l communities. the regionalized h o s p i t a l centres w i l l to provide general treatment  Some of continue  f o r the populace  in the area Immediately adjacent to the centre, but i t s role i n t h i s respect should diminish i n . the future.  46 5  Table PRIMARY  (Continued)  Community H o s p i t a l s Hospitals  o f a community  type, designed  local  politan  Hospitals  of the  sub-communities  Disease  populace  o f t h e metrow  Entity Hospitals  i n w h i c h one  clinical  e.g.,  requirements  area.  Specialized  of  practice  t o serve the m a j o r i t y of  hospitalization of the  or g e n e r a l  or a very  special services  Obstetrics  and  limited  are  number  provided;  Gynaecology,  Cancer,  etc.  Jurisdictional Hospitals Hospitals  owned and  o p e r a t e d by  authority,  t o meet a s p e c i f i c  need.  location  any  The  particular  a government provincer-wlde  of these h o s p i t a l s  r e g i o n i s o f no  special  within benefit  t o t h a t r e g i o n , i n terms o f a v a i l a b i l i t y facilities,  since these h o s p i t a l s  province-wide limited  or broad  Tuberculosis Treatment  They may  scope  or Mental  Facilities  Facilities  such  as  provide  of services;  on  a  e.g.,  by V o l u n t a r y  C.A.R.S. Treatment  Agencies Centre,  Alcoholism Foundations  of  B.C.,  facilities  an  etc.  These  a  Hospitals.  Operated  the  operate  t h e N a r c o t i c s and  effective Source:  basis.  of  s h o u l d have  v/orking a r r a n g e m e n t w i t h  P a t t e r n s of Care, G r e a t e r Vancouver R e g i o n a l D i s t r i c t , A d v i s o r y C o m m i t t e e , May, 1969.  a  hospital.  Hospital  2,  7  Table 6:  F a c i l i t i e s and Services Associated with C l a s s i f i c a t i o n s of Hospitals  Major Referral and Teaching and Research Centres The work done should r e f l e c t the i n v e s t i g a t i o n and treatment of less commonly encountered i l l n e s s e s and also those requiring complex equipment and f a c i l i t i e s and multiple c l i n i c a l specialty personnel.  .  In-Patlent F a c i l i t i e s - general and s p e c i a l i z e d services Surgical Services Very specialized s u r g i c a l procedures such as organ transplants, open heart surgery, neurological, major abdominal,  cardio-  vascular, cancer procedures, e t c . Medical Services Diagnosis and treatment of complicated blood diseases Metabolic procedures Rehabilitation and a c t i v a t i o n treatments Etc. Obstetrics and Gynaecology Complication of maternity High r i s k o b s t e t r i c a l and gynaecological cases Paediatrics Neo-natal problem  cases  The high r i s k infant - transfusions - Rh f a c t o r Restorative surgery, cardiovascular case Multiple problem c h i l d , handicapped, speech problems,  cerebral  palsy, neurological, tumors, cancer, retarded children Major endocrine disorders, e t c .  48 Table Psychiatric  6  (Continued)  Services  A d v a n c e d p s y c h i a t r i c r e s e a r c h and Group Drug  treatment  therapy therapy  Rehabilitation  therapy  Etc. Physical  Medicine  P h y s i o - , o c c u p a t i o n a l and  i n h a l a t i o n therapy  facilities  Diathermy Gymnasium, p o o l Treatment of c a t a s t r o p h i c cases, s p i n a l cord  injuries  Etc. Lab o r a t o r y Complete f a c i l i t i e s complicated tests performed very  f o r the  carrying  out  of expensive  and  r e q u i r i n g e x t e n s i v e equipment which are  o f t e n — t h e core  of a r e g i o n a l r e f e r r a l  not  program  Cytology laboratory A c q u i r e and  t e s t hew  p i e c e s of equipment  '  Radiology Complicated  and e x p e n s i v e  r e s e a r c h and  treatment  investigative  facilities P r e p a r a t i o n of v i d e o  tape  Equipment f o r use  i n cardiology  procedures  Experimenting  testing  equipment  Nuclear  and  o f new  Medicine  Radio-isotope  l a b o r a t o r y and  referral function  facilities  appropriate to major  Table Direct  Care  Units  operative recovery  Hyperbaric Burn  (Continued)  Patient Services  Intensive Post  6  rooms  Chamber  Unit  Etc.  ;  Supportive  Services  Teaching  Areas  Research  Laboratories  Brace  .  Shops  Biomedical Library  Engineering  Department  Facilities  Volunteers Etc.  ;  ;  ' " '  '  Emergency 2 4 - h o u r emergency Out-Patient Complete  Ambulatory  range  o f d i a g n o s t i c and  patient,  ambulatory  medicine  and  Regional The  services in a l l specialties  surgery  Referral  commonly  and  and  short  Surgical Limited  an  c a r e , day  care  day/night  out-  stay.  reflect  less  the  investigation  commonly e n c o u n t e r e d  region. In-Patient  s e r v i c e s on  Centres  work done s h o u l d  the  b a s i s , e.g.  treatment  Facilities Services teaching  and  research  facilities  and  treatment  illnesses  of  the  of  Table Good s u r g i c a l  6  (Continued)  facilites,  procedures  including  some s p e c i a l i z e d  f o r n e u r o l o g i c a l and a b d o m i n a l  surgical  work.  Medical Services Similar  t o those  Centre  with  Of t h e T e a c h i n g ,  Research  the exception of treatment  and M a j o r  Referral  of complicated  blood  diseases Obstetrics Almost  and  Gynaecology  complete  range  of services.  Pediatrics G e n e r a l range logical, Few c a s e s  of services  b u t no c a r d i o v a s c u l a r work,  neuro-  tumor. of the m u l t i p l e problem  child  Etc. Psychiatric Services These and  a r e an e s s e n t i a l  part o f the r e g i o n a l h o s p i t a l  s h o u l d be i n a s e p a r a t e  General  range  Physical General  facilities  area.  of s e r v i c e s .  Medicine services  b u t no c a t a s t r o p h i c c a s e s ; t h e s e  w o u l d be  referred. Laboratory  Services  Good  of t e s t s ;  the  range  few v e r y  laboratory likely  expensive  automated - not c a r r y out  tests.  Radiology Good r a n g e Nuclear  of diagnostic  services  - limited  therapy.  Medicine  Radio-isotope functions  facilities  developed.  e s s e n t i a l when r e g i o n a l  referral  51  Table 6 (Continued) Direct Patient Services Intensive Care Unit, post-operative recovery room but no Hyperbaric Chamber or Burn Unit. Supportive Services Good physi- and occupational therapy, Volunteers, Bio-Engineering to a limited degree. Emergency 24-hour emergency services available i n a l l s p e c i a l t i e s provided by that h o s p i t a l . Out-Patlent Ambulatory Varying degrees of diagnostic and therapeutic services available, e.g., Day/Might Care, Day Care Medicine and Surgery, Short Stay. Community Hospitals The work done should r e f l e c t the investigation and treatment of the commonly and some less commonly encountered  i l l n e s s e s of  the region. In-Patient F a c i l i t i e s Surgical Services General procedures.  Referral of known high r i s k patients  requiring specialty f a c i l i t i e s and/or personnel. Medical Services General procedures.  Referral of known high r i s k patients  requiring specialty f a c i l i t i e s and/or personnel. Obstetrics and Gynaecology General procedures.  Referral of known high r i s k patients  requiring specialty f a c i l i t i e s and/or personnel.  Table  6  (Continued)  Paediatrics General  procedures.  requiring  R e f e r r a l o f known h i g h r i s k p a t i e n t s  specialty f a c i l i t i e s  and/or  personnel.  S p e c i a l p r o v i s i o n s h o u l d be made f o r t h e a d o l e s c e n t . Psychiatric  Services  T h e s e a r e an e s s e n t i a l p a r t o f t h e Community H o s p i t a l f a c i l i t i e s and  t h e y may  Physical  o r may n o t be i n a s e p a r a t e  area.  Medicine  May n o t be e s t a b l i s h e d as a s e p a r a t e m e d i c a l Laboratory General  department.  Services  laboratory services integrated with a regional laboratory  p r o g r a m s o t h a t new p r o c e d u r e s Nuclear  v r i l l be a v a i l a b l e .  Medicine  C e r t a i n b a s i c procedures  available  as p a r t o f g e n e r a l l a b o r a t o r y  service. Radiology General  X-ray procedures  t o meet t h e r e q u i r e m e n t s  of the c l i n i c a l  services. Direct  Patient Services  Post-operative recovery to  serve  room w i t h l i m i t e d  s u r g i c a l and o b s t e t r i c a l  specialized services  c a s e s ; I n t e n s i v e Care U n i t  appropriate t o the f u n c t i o n of the h o s p i t a l ; rehabilitation Supportive  a r e a ; adequate i s o l a t i o n  a c t i v a t i o n and .  facilities.  Services  P h y s i o - , o c c u p a t i o n a l and i n h a l a t i o n t h e r a p y meet l o c a l r e q u i r e m e n t s ;  and e d u c a t i o n t o  Volunteers.  Emergency An e s s e n t i a l i n t e g r a l d e p a r t m e n t o f t h e Community H o s p i t a l ; t h e  Table 6 (Continued) degree of development  and operation are dependent  on l o c a l  conditions. Out-Patlent  Ambulatory  Provision for diagnostic and treatment f a c i l i t i e s to accordance with health services programs, Day care, Surgery, Medicine, Psychiatry .  '  A breakdown of f a c i l i t i e s and services associated with other c l a s s i f i c a t i o n s of primary hospitals had not been performed at the  time at which the report ( 4 9 ) was prepared.  Source:  Patterns of Care, Greater Vancouver Regional Hospital D i s t r i c t , Advisory Committee, May, 1 9 6 9 .  2.  The Necessity and Urgency of H o s p i t a l i z a t i o n  Surgery, medical treatment, and diagnostic investigation comprise the reasons f o r the majority of patient h o s p i t a l i z a t i o n s . The degree of necessity and urgency d i f f e r s among these categories. Although h o s p i t a l i z a t i o n i s often necessary, a l l recommended admissions are not e s s e n t i a l . (50)  In a Massachussett's study  of h o s p i t a l admissions, i t was found that physicians f e l t  that 70 percent of the patient admissions which they recommended were "absolutely necessary" and that f o r another 20 percent of the cases the patient would be much better o f f i n the h o s p i t a l . Of the cases not judged as absolutely requiring h o s p i t a l i z a t i o n , the physicians f e l t that nearly 55 percent could have been treated at home, i n the physician's o f f i c e or on an out-patient basis.  The physicians indicated that approximately another 40  percent of these patients could not be treated unless they were i n the h o s p i t a l .  The study inferred that t h i s last group  probably was not i n need of urgent medical care. The physician's attitude toward the urgency of h o s p i t a l admission was also studied.  The surveyed physicians had advised  immediate admission f o r 70 percent of the patients, within a few weeks or months f o r 21 percent and eventually f o r another 6 percent. If the above figures are representative i t may be i n f e r r e d that a s i g n i f i c a n t m i s u t i l i z a t i o n of h o s p i t a l services occurs which warrants concern.  Various studies both i n Canada and the  United States support the contention that such m i s u t i l i z a t i o n does occur.  (See the Task Force Reports (69))  In order to understand the causes of m i s u t i l i z a t i o n we  55 must c o n s i d e r t h e b e h a v i o r a l a s p e c t s 3.  B e h a v i o r a l Aspects of H o s p i t a l  I n most n o n - p r i v a t e for  c a n be m e t .  incentives  Services  h o s p i t a l s there  administrators t o minimize  straints  of hospital services.  is little  incentive  c o s t s , s o l o n g as b u d g e t a r y  I n f a c t , there  con-  a r e o f t e n a number o f  f o r i n e f f i c i e n c y b o t h f o r p h y s i c i a n s and f o r a d m i n i -  strators. Administrative innovation t o minimize costs in  o p p o s i t i o n and c o n f l i c t  from m e d i c a l  can r e s u l t  s t a f f and v a r i o u s  h o s p i t a l employees.  I n t h e case o f p u b l i c h o s p i t a l s , the  administration gains  little  undertaking  b e n e f i t from cost  an i n c r e a s e d m a n a g e r i a l  savings  while  burden.  B o t h p h y s i c i a n s and a d m i n i s t r a t o r s a r e prone t o v i e w h o s p i t a l e x p a n s i o n and t h e a c q u i r e m e n t o f e x p e n s i v e facilities  f o r t h e i r p r e s t i g e value  than f o r t h e i r marginal  and complex  and s o p h i s t i c a t i o n r a t h e r  s o c i e t a l b e n e f i t weighed against  their  cost. (22) The sonnel  availability  o f f r e e d i a g n o s t i c and h o s p i t a l p e r -  services often afford a personal  physician.  time saving t o t h e  H o w e v e r , when i n d i v i d u a l p h y s i c i a n s  i n c r e a s i n g t h e i r own t h r o u g h p u t u n n e c e s s a r i l y these care  services the e f f i c i e n c y  with  oversubscribe  to  o f t h e h o s p i t a l and t h e h e a l t h  s y s t e m may be r e d u c e d . At t i m e s ,  when a l o w e r  a p h y s i c i a n may r e q u e s t  l e v e l o f care  patient  I s more a p p r o p r i a t e .  may o c c u r when a p a t i e n t i s c o v e r e d no  concerned  hospitalization This  situation  by h o s p i t a l i n s u r a n c e  coverage f o r l o w e r - l e v e l f a c i l i t e s .  but has  56 Inefficiency  due t o t h e s e c a u s e s a n d o t h e r s may  reduced through v a r i o u s o r g a n i z a t i o n a l c o n t r o l s  such as r e g i o n a l  p l a n n i n g and c o - o r d i n a t i n g a g e n c i e s w h i c h h a v e c o n t r o l certain activities centives  s u c h a s e x p a n s i o n and w h i c h  be  over  incorporate i n -  f o r cost reduction. The i n s t i t u t i o n  of successful organizational  controls  has b e e n i l l u s t r a t e d by t h e K a i s e r F o u n d a t i o n M e d i c a l C a r e I t was f o u n d t h a t t h e e x p e n d i t u r e p e r member vras 35-45  Program. percent  l e s s than the e x p e n d i t u r e of the average  no s i g n i f i c a n t  decrease i n the q u a l i t y  appeared  contributing to  t o be t h e " c o n t r o l  what m e d i c a l c a r e i s p r o v i d e d a n d w h e r e i t i s p r o v i d e d . s o u r c e o f economy  i s most a p p a r e n t  with  (56)  of care.  A l t h o u g h t h e r e w e r e a number o f f a c t o r s t h e l o w e r c o s t , t h e m a i n economy  Californian  over  This  i n h o s p i t a l c a r e , with the  a g e - a d j u s t e d d a y s o f h o s p i t a l c a r e p e r y e a r f o r K a i s e r members b e i n g o n l y 70 p e r c e n t o f t h e S t a t e ' s p e r c a p i t a a v e r a g e . " I t was s u g g e s t e d t h a t  i t i s the p r o f i t  s h a r i n g and t h e c o s t  consciousness of the i n d i v i d u a l p h y s i c i a n which t o the reduced  cost.  Although t h i s percentage  (56)  contributes  (56) type of p l a n i s l i k e l y  of the health  t o form o n l y a  implemented t o i n c r e a s e the e f f i c i e n c y Internal Structure  A w e l l managed unnecessary  and  of the health  be  system.  Control  a d m i s s i o n and d i s c h a r g e s y s t e m may  reduce  h o s p i t a l a d m i s s i o n s and i n c r e a s e t h e e f f i c i e n c y  resource u t i l i z a t i o n .  small  care systems i n N o r t h America, t h e r e  a r e o t h e r s t r u c t u r a l and o r g a n i z a t i o n a l c o n t r o l s w h i c h may  4.  most  The a d m i s s i o n p o l i c i e s  a r r a n g e m e n t s o f h o s p i t a l s may  and  of  organizational  s e r v e as t h e m o s t e f f e c t i v e  means  57  of c o n t r o l l i n g costly m i s u t i l i z a t i o n of h o s p i t a l f a c i l i t e s . Patient mix as well as occupancy rate are  determinants  of the u t i l i z a t i o n of various f a c i l i t i e s and services within the hospital. An imbalance i n patient mix may  result In. a less than  optimal use of resources, since some resources may while other resources are overtaxed. of some patient stays may patient may  be underutilized  As a consequence the length  be longer than necessary, since the  have to await the a v a i l a b i l i t y of overtaxed resources.  Any resultant Increases i n patient stay also increase the waiting time of patients scheduled f o r e l e c t i v e While patient mix may major variable which may  admission.  be controllable to an extent, the  be used to regulate f a c i l i t y  utilization  is the occupancy l e v e l of the h o s p i t a l . The occupancy l e v e l of a h o s p i t a l i s a balancing of the need for slack and of the need for the f u l l u t i l i z a t i o n of the facilities.  Between 1961 and 1968 the average occupancy l e v e l  of Canadian hospitals has been s l i g h t l y i n excess of 80%. (70) There are three major reasons for a less than 100 percent  occu-  pancy rate. (a)  F a c i l i t i e s have been b u i l t to meet projected demands for future years.  (b)  Randomness i n the discharge and admission  processes.  (c)  Intentional slack to allow for emergency admissions.  Most researchers believe that the extent of emergency slack and randomness of admission and discharge i s a function of hospital size.  From s t a t i s t i c a l considerations i t can be shown  that f o r an excess demand, hospitals with a greater number of beds  58 s h o u l d have smaller number  a higher  facilities  occupancy r a t e  serving  of beds, since  level will  be l e s s  wider range pancy r a t e depend  than  an i d e n t i c a l p o p u l a t i o n  the deviation  (see Berry  of services  about  (8)).  t h e mean  by l a r g e r h o s p i t a l s may  i n a greater  number o f with  occupancy  reduce  number o f d i s t i n c t i v e  In a d d i t i o n , h o s p i t a l s  i n t h e same r e g i o n  considered  as i n d e p e n d e n t  The o c c u p a n c y  h o s p i t a l may  depend  on t h e a v a i l a b i l i t y  will  capability  c a n n o t be  level  o f space  of a  the occu-  the t o t a l v a r i a b i l i t y  services.  units.  t h e same  However, t h e p r o v i s i o n  of larger hospitals, since  on v a r i a t i o n s  a greater  o f one  i n other  hospitals. Empirical certain To  distinctive  the extent  are  that  applicable,  effects  evidence patient Poisson  applicability  are admissions  be  on t h e b a s i s  describable  f o r which not  a Poisson  on s a m p l e d 5. (a)  and  policies.  o r may  not h o l d .  as e l e c t i v e s u r g e r y w h i c h  of patient  convenience,  distribution.  empirical  of Cost.  be d i v i d e d  are scheduled  a n d , t h u s , may n o t cases  d i s t r i b u t i o n s are s u c h as  d i s t r i b u t i o n s , may  of Hospital  on  Of p a r t i c u l a r  In studying  or other e a s i l y handled  The T h e o r y  s e r v i c e s may  be u s e d t o s t u d y t h e  other a n a l y t i c a l techniques  The C o s t  functions  of the Poisson d i s t r i b u t i o n r e s t s  by a P o i s s o n  appropriate,  based  or other e a s i l y dealt with  w h i c h may  such  t h e d a i l y census f o r  i s Poisson d i s t r i b u t e d .  s t a t i s t i c a l methods may  a number o f c o n d i t i o n s  partially  that  facilities  of a l t e r n a t i v e admission The  note  indicates  simulation,  be u s e f u l .  Services The c o s t s  i n t o two  of producing  categories.  goods  59 (i). (ii)  fixed costs which do not vary with output, and variable costs which depend on the amount of various services performed.  Economic theory makes use of three cost functions. 1.  T o t a l cost; the sum  of variable and fixed costs  T = F + VC where F = fixed cost VC = variable cost 2.  Average cost; the cost per unit of output AC =_T  =_F  q  + VC  q  q  where q i s the t o t a l units of homogeneous output. 3.  Marginal cost; the cost of producing one extra unit of output, MC =__  = 'B(VC)  5q  ^q Variable cost may  be written as  VC =2v (q,) ±  q  where v^ (q^) Is the unit cost of service i at the output l e v e l q^ In considering h o s p i t a l costs the often followed procedure is to assume a r e l a t i v e l y stable patient mix single appropriately weighted variable cost.  and, thus, to use a Thus:  T = F + V(q) q AC =_F  +  V(q)  q  MC = V(q) + q"3v(q)  3q where q i s a. proxy measure of t o t a l output  60 The depends the  on  short  division  run  and  these  costs  various  are may  production  units  fixed  capital  cost  functions  cost  time p e r i o d .  fixed. and  describe  levels  i n v e s t m e n t , whereas  In the  In of  long  run  physical plant  cost  the  costs  of i n d i v i d u a l  of p r o d u c t i o n  long  run  average  of p r o d u c t i o n  to believe  increased  that  of equipment  and  A decreasing or  for  at and  given marginal  varying  creasing  decrease  scale.  Beyond  complexity  production  unit  facilities  long  are  to scale  increased,  average  cost  produc-  facilities  are as  of p r o d u c t i o n ,  an  in-  a disproportionately  cost  of  output  increasing  i . e . a diseconomy  curve,  are  speciali-  i s referred to  lead to  VJith u n i t  to  increases  production  t h a t most p r o d u c t i o n  run  leading  skills  a certain level  in efficiency.  shaped  below.  as  o f managment may  It is believed  a U  cost  s e r v i c e s there  production  related labor  increasing returns  economy o f s c a l e .  figure  as  i n most p r o d u c t i o n  increased  have  the  costs  reduced.  for different  the  variable  physical depreciation  equipment  functions  describe  on  Prom e x p e r i e n c e  tivity.  as  or  and  investment.  reasons  large  hence  regarded  expanded  run  fixed  s u c h as  variable since be  Short  be  Into and  costs  e q u i p m e n t may  facilities  zation  costs  dynamic p r o c e s s e s  plant  capital  of  of  services, therefore, as  shown i n  the  61  COST  LRMC  LRAC  SIZE (Q) Figure 2 :  LRAC arid' LRMC as a Function  of Hospital Size  The minimum long run average cost (LRAC) i s given by 0 = 3(LRAC) = 2(F(Q) + V(Q)Q) c)  Q  3 Q  Q  = -F(Q) + 1 0>F(Q) + 9 v ( Q ) '  Q  2  Q  O'Q  The minimum LRAC occurs where LRAC=LRMC.  This can be  shown as follows: LRMC = V(Q)+Q3v(Q) +3 F(Q) 9  v  at the minimum of the LRAC curve,  Q  LRMC = V(Q)+QF(Q) = F(Q) + V(Q) = LRAC  Q  2  Q  I f the LRMC Is less than the LRAC then economics of scale e x i s t , since by increasing the scale* of plant and c a p i t a l equipment we can reduce the average cost of a unit of output.  62  (b)  Trends In Hospital Costs and Financing  The rapid r i s e i n the cost of h o s p i t a l services has been of concern and the subject of numerous studies.  Ingbar and  Taylor (38) note that the average per diem charge for non-federal short-term hospitals i n the U.S. had increased 185 percent between 1950 and 1965,  an average of approximately  4.2 percent yearly.  This increase was noted to be accelerating, as the yearly average increase between I960 and 1965 was increase was  8.3%.  6 . 5 percent and i n 1966 the  In Canada, expenditures on personal health  care rose from approximately  2.8 percent of a l l national expendi-  tures i n 1953 to 4.6 percent i n 1967.  At the same time the  proportion of expenditures f o r h o s p i t a l care rose from almost 59$ to over 63 percent.  (70)  Increases i n h o s p i t a l expenditures have been influenced both by increased u t i l i z a t i o n and increases i n the cost of providing services due to general i n f l a t i o n i n the economy and increased use of sophisticated equipment. Increased u t i l i z a t i o n (28 percent i n Canada and percent i n the U.S., between 1950  27  and 1967) has occurred  through  an increase i n both the admissions/1000 population (27 percent i n Canada and 24 percent i n the U.S. between 1950 the average length of stay and 1958  and 1967)  (A 6 percent decline between  and 1950  i n both countries followed by a 4 percent increase i n  Canada and 9 percent i n the U.S. between 1958 and 1967). (3) In Canada, the inauguration of universal h o s p i t a l i n surance arrangements has shifted f i n a n c i a l r e s p o n s i b i l i t y f o r h o s p i t a l payment from the Individual to governmental agencies. In B.C. h o s p i t a l patients pay $1 per day, plus additional  payments f o r s p e c i a l services, such as private or semi-private rooms, while the B r i t i s h Columbia Hospital Insurance  Service  (BCHIS) reimbruses i n d i v i d u a l hospitals at set per diem rates. These rates are set on an i n d i v i d u a l h o s p i t a l basis, taking into account the d i f f e r e n t services offered, research,  teaching,  past  f i n a n c i a l records, etc. The extent to which governments have assumed r e s p o n s i b i l i t y may  be i l l u s t r a t e d by the fact that the percentage of payments  of active treatment h o s p i t a l care made by governmental agencies i n Canada rose from 3 6 . 2 $ i n 1953 to 9 0 . 5 $ In 1 9 6 7 .  (70)  Hospital services are characterized by high c a p i t a l investment.  In 1 9 6 8 , B r i t i s h Columbia with a population  of  s l i g h t l y less than 2 m i l l i o n the t o t a l c a p i t a l investment i n over $170 m i l l i o n . (55)  hospitals was  Funds for c a p i t a l invest-  ment i n physical plant and major equipment are also largely derived  from public treasuries as may  be seen i n the  following  t ab l e . Table 7 :  Plant Fund - Source, 1968  B.C.H.I.S. Equipment Allowance 2  Interest Total  942,813 1,540  Federal Grants  Donations  1  $2,423,165  P r o v i n c i a l Grants  Grants  Hospitals )  T o t a l Public General Hospitals  Source  Municipal  (Public General  ,206  18,477,828  1,314,189 364,371  $25,062,572  I 2  Rehabilitation and extended care hospitals not Including regional h o s p i t a l d i s t r i c t grants  included  Table 7 (Continued) Source:  Report on Hospital S t a t i s t i c s and Adminstration  of the  Hospital Act, 1968 (55) (c)  An Empirical Look at Hospital Costs.  Tables 8 and  9 i l l u s t r a t e Canadian and B r i t i s h Columbian data on the major h o s p i t a l expenditure  categories and t h e i r r e l a t i v e importance.  From these tables i t may  be seen that wages and  are the largest component of expenditures, approximately 2/3 - 3/4 of the t o t a l . represent  accounting  In Canadian  This increase i s a result of increased paid hours of  work per patient day  (a 17$ Increase  in non-medical s t a f f hours  i n 1967 and a 22$  - from 11.9 i n 1961 to 13.9  hours per patient day - from 6. 3 to 7.7 increased average l e v e l of s k i l l and increase between 1961 and  increase i n nursing  i n the same period (70)),  increased wage levels (a 57%  1967 with preliminary indications of  an increase of 12% from 1967 Table 8:  for  Wages and s a l a r i e s also  one of the fastest growing expenditures  hospitals.  salaries  to  1968  (70)).  Operating Expenditures of Budget Review Hospitals $ Per Patient Day  (Excluding Newborn) Percent increase  1961  $14.84 Salaries & Wages Medical and Surgical Supplies 0.73 Drugs 0.99 Raw Food 1.46 Other Departmental 3.17 1.82 Other non-Departmental $23.01  Source:  % 64.5 3.2 4.3 6.3 13.8 7.9 100.0$  %  1961-1967  $27.10  66.8  83$  1.24 1.42  3.1 3.5 4.3 17.2 5.1  1967  1.75 6.96 2.06 $40.54  100.0%  Canadian Hospital Association Trends i n Health and Care Chart Book 1969, Vol. 1.  70 43 20 120 13 76%  Hospit  Table 9: Expenditures (Public G e n e r a l Hospitals ) i n B. C.  1964  Gross salariesand wages M i v ! i r n l nn<\ QiirgirM supplies  niri'.ry—fnnri Other  Sub-totals. Depreciation— Buildings and building-service equipment  $53,316,952 2,529,254 2,886,176 3,844,900 10,605,591  (72.8%) (3.5%) (3.9%) (5.3%) (14.5%)  $73,182,873 (100.0%)  $2,358,641 1,633,112  M a j oS ru b e- t qo t ua l is p m e n t . . , $3,991,753 $77,174,626 Total gross expenditure Average gross expenditure per patientd a y ( n e w b o r n d a y s I n c l u d e d a t 100 per cent) $25.S6 Average gross expenditure per patientd a y ( n e w b o r n d a y s i n c l u d e d a t 25 percent) . , 27.68  1966  1965  $58,960,066 2.786.0S4 3,139,972 4,060,728 11,745,180  ('.3.1%) i34%) (3.9%) (5.0%) (14.6%)  $80,692,030 (1(0.0%)  $67,284,459 3,241,747 3,594,893 4,423,947 13,859,558  1967  (72.8%) (3.5%) (3.9%) (4.8%) (15.0%)  $79,699,927 3,803,662 4,061,024 4,736,217 15,868,643  $92,404,604 (100.0%) $108,169,473  1968  (73.7%) $100,044,467 (3.5%) 4,629,812 (3.7%) 4,550,057 (4.4%) 5,274,827 (14.7%) 18,550,279  (100.0%) $133,049,442 (100.0%)  $2,988,832 1,562,555  $3,293,613  $3,459,556  1,793,940  2,008,751  2,309,864  $4,551,487  $5,087,553  $5,468,307  $6,212,590  $85,243,517  $97,492,157  $113,637,780  $139,262,032  $28.03  $31.14  $35.32  $41.38  29.84  33.01  37,41  43.78  1 Rehabilitation and extended-care hospitals not included.  Source: H o s p i t a l Statisitcs and A d m i n i s t r a t i o n of the H o s p i t a l A c t - 1968 (55)  (75.2%) (3.5%) (3.4%) (4.0%) (13.9%)  $3,902,726  66 Numerous factors complicate empirical studies of h o s p i t a l costs, e s p e c i a l l y those studies done on an i n t e r - h o s p i t a l comparative basis.  Comparability  of hospitals i s hampered by  differences i n s t a f f structures, wage and material operating  costs,  procedures, the range and quality of services, occupancy  l e v e l and the scope of teaching  and research programs.  Hospitals d i f f e r i n the q u a l i t y , number and mix of inpatient services and f a c i l i t i e s offered. considerable  v a r i a t i o n i n the extent of outpatient  education and research programs. appreciable  In addition, there i s treatment and  These differences may have an  e f f e c t of the costs incurred by the d i f f e r e n t hos-  pitals . As noted e a r l i e r , wages and s a l a r i e s account f o r approximately 2/3 - 3/4 of operating  expenditures.  In cross-sectional  studies, i t i s therefore e s s e n t i a l that wage differences be considered, e s p e c i a l l y i f appreciable hospitals.  wage differences exist among  I f aggregate wage costs are employed, i n analyzing  hospitals with d i f f e r e n t s t a f f structures, biases may be i n t r o duced i f an adjustment of wage rates does not take account of the differences i n the average l e v e l of s k i l l . Additional problems arise from the use of h o s p i t a l accounting data, which may be inappropriate  and may necessitate  the use of proxy measures, and from the use of time series analysis, which may be complicated by changes over time i n any of the factors influencing costs and may o f f e r only a limited range of output f o r study. Many studies have attempted to examine the r e l a t i o n s h i p between cost and s i z e , i n order to determine an optimal manner  67 of p r o v i d i n g care One  for a specified  of the major  a v e r a g e number o f p a t i e n t s .  difficulties  of studying h o s p i t a l costs  h a s b e e n t o s e l e c t a p p r o p r i a t e m e a s u r e s o f two variables; measuring would  size  The  most o b v i o u s a p p r o a c h  s i z e w o u l d be t o u s e b e d  Ignore the e f f e c t  e a r l i e r , may The to  and.output.  closely related  capacity.  of occupancy  T h i s , however,  l e v e l w h i c h , as  u s u a l manner i n w h i c h t h i s  daily  census  number o f p a t i e n t Adjusted tracting  discussed  be s i z e - d e p e n d e n t . difficulty  u s e m e a s u r e s r e l a t e d t o o u t p u t s u c h as a d j u s t e d  average  to  i s avoided bed  size  or e q u i v a l e n t l y t h e y e a r l y o r even  is and  monthly  days. bed  size  allows  f o r occupation  l e v e l by  sub-  t h e a v e r a g e number o f u n o c c u p i e d b e d s f r o m r e p o r t e d  capacity. ferences  T h i s method i s s u b j e c t i n the methods employed  t o e r r o r i n t r o d u c e d by  bed  dif-  b y h o s p i t a l s i n r e p o r t i n g bed  capacity. The  use o f average  m e a s u r e m e n t o f c o s t s due short-run  changes  production,  c e n s u s may  t o t h e use  with delayed  which average values In studying  create  e r r o r s i n the  of output measures  reflecting  adjustment of the f a c t o r s of  o r t o t h e use o f l o n g - r u n  not account f o r changes  is  daily  i n production  have been  measures of output which during  the time p e r i o d  The  results  t h e r e l a t i o n s h i p between c o s t s and s i z e , i t  t o t h e average measure o f  in  output.  o f some o f t h e m a j o r e m p i r i c a l s t u d i e s o f  h o s p i t a l c o s t s are summarized Feldstein  from  computed.  o f t e n assumed t h a t h o s p i t a l s c o m b i n e f a c t o r s o f p r o d u c t i o n  a manner a p p r o p r i a t e  do  i n Table  (26) e x a m i n e d  10.  the r e l a t i o n s h i p between the  cost  68 of various patient  factors  days  of production  i n a general,  and t h e m o n t h l y number o f  short-term, non-research  orientated  hospital. A month was it  i s sufficiently  in  c a p i t a l plant  variable  factors The  and in  costs  skilled  labor,  of p a t i e n t  short  complications  and e q u i p m e n t , w h i l e b e i n g of production of p l a n t ,  since  due t o c h a n g e s  long  t o be a d j u s t e d  enough f o r  t o output  equipment, a d m i n i s t r a t i v e  number o f p a t i e n t supplies,  levels.  services  food,  days, while  the costs  and d r u g s v a r i e d  with  o f un-  t h e number  days.  Departmental function  to avoid  f o r analysis,  p e r s o n n e l showed no v a r i a t i o n i n r e s p o n s e t o changes  the monthly  skilled  c h o s e n as t h e t i m e u n i t  costs  were a n a l y z e d  f o r the h o s p i t a l .  I t was  felt  to derive that  a total  cost  t h e use o f d e p a r t -  mental costs  would p r o v i d e  a more homogeneous m e a s u r e o f p r o d u c t  In  the i n f l u e n c e  of departmental  and  addition, also  the r e l a t i o n s h i p between output  department  could  The surgical of  OB d e l i v e r i e s ,  therapy  Operating  days  (p.d.),  and c o s t  number  patients,  o f EKG p a t i e n t s ,  number o f o p e r a t i o n s ,  time  states  that  number  supply  of p h y s i c a l  expenses  costs  f o r curvature,  t h e l i n e a r m o d e l was t h e most  Feldstein  number o f  i n the  i n the precedi  variable.  l i n e a r m o d e l was t e s t e d  that  each  o f o b s t e t r i c a l p . d . , number  room i n t h e p r e c e d i n g month, f o o d  The  within  cost  u s e d w e r e : number o f med-  number o f l a b o r a t o r y  month, and a c o n t i n u o u s  concluded  variables  p a t i e n t s , number  patients,  on t o t a l  derived.  independent  patient  radiology  be  costs  "a decreasing  and i t was  applicable. short-run  average  69 total  cost  excess less  curve, may be i n t e r p r e t e d  capacity  therefore  the  size  hospital  approximately explanation It might  increases  i n output  necessary  90 p e r c e n t  t o perform  returns  existed. The  a cross-sectional  i n order t o determine  ing  f o r the broader  was  inferred that The  by the  table.  square term capability and  Average  and  indicated  capacity  was n o t  cost. costs  therefore, of hospitals of increasing  a constant  are economies  LRMC w h i c h  of scale.  Account-  i n larger hospitals, i t  (10),the r e s u l t s  analysis.  slope.  e x p a n d e d and r e f i n e d  o f which  d a i l y c e n s u s was i n c l u d e d  of f a c i l i t i e s  c e n s u s , number o f o u t p a t i e n t of internship  affiliation,  t h e number The  l e v e l of  a r e shown i n  as a l i n e a r a n d  The measures  of service  a n d e d u c a t i o n p r o g r a m s u s e d w e r e : number o f f a c i l i t i e s  n u r s e s , number school  analysis  s t u d y was l a t e r  i n the regression  s e r v i c e s , number  daily  I t was,  t h e LRMC c u r v e h a s a downward  C a r r and F e l d s t e i n  exist,  increasing  r u n average  i f long-run  scope o f s e r v i c e s  cross-sectional  w o u l d be  returns  average  short  of hospital.  was b e l o w t h e LRAC, i . e . t h e r e  excess  short-run  decreasing  r e s u l t s o f t h e study  that  (26)  i n d i c a t i n g that  that  f o r any s i z e  sizes  increasing  s h o u l d be met by  f o r the decreasing  varying  plant  I n t h e s t u d y h a d an o c c u p a n c y  i s possible  exist  a smaller  long-run  of existing hospitals." The  an  e x i s t s , i n which.case  c o s t l y , and s e c o n d , t h a t  and  i n two ways: f i r s t ,  existence  of interns  and s e r v i c e s visits,  and r e s i d e n c y  times  number  of student  programs,  of a p r o f e s s i o n a l  average  medical  nursing  school,  and r e s i d e n t s .  use of average d a i l y  census  as a m e a s u r e o f s c a l e  70 and  average d a l l y census t i m e s the  facilities able  as  number o f  a measure o f s e r v i c e  r e s u l t s because of the  services  and  capability yields  question-  c o l l i n e a r i t y between these  two  measures. The  a u t h o r s d i d not  a n a l y s i s t o be variations  i n service  a n a l y s i s was capability excluding  conclusive  as  an  the  The  number o f s e r v i c e s  number o f f a c i l i t i e s  analysis  increased.  diseconomies of s c a l e o n l y  (38)  I n g b a r and  Taylor  regression  to derive  resultant  of s c a l e  e x i s t up  costs  increases  services  i n d i c a t e d economies of optimal  The  f o r the  and  study suggested  and  scale  size increasing  as  the  possible  largest h o s p i t a l s In  the  M a s s a c h u s s e t s community h o s p i t a l s ,  a non-linear  and  multiple  long-run average cost  U-shaped c u r v e s u g g e s t s t h a t  t o a c e r t a i n s i z e o f h o s p i t a l and e x i s t beyond t h i s .  increasing and  service  number o f s e r v i c e s  employed f a c t o r a n a l y s i s  inverted  economies of s c a l e with  and  the  c a p a b i l i t y group.  I n a s t u d y o f 72  The  first  Therefore,  hospitals into 5  independent v a r i a b l e the  offered.  service  r e s u l t s of the  c a p a b i l i t y were h a n d l e d .  over a wide range of o u t p u t , the  highest  the  because of the manner i n which  r e p e a t e d , grouping the  g r o u p s by  facilities  consider  non-linearly  as  This the  may  be  scope of  curve.  diseconomies that consistent services  economies of s c a l e p r e d o m i n a t i n g beyond a  certain  point. Berry  (8)  a t t e m p t e d t o overcome t h e p r o b l e m of  d i f f e r e n t i a t i o n by 28 the  services  and  g r o u p i n g h o s p i t a l s by  facilities.  On  the  this basis  p r o d u c t w i t h i n e a c h g r o u p w o u l d be  product  availability  I t was  reasonably  assumed  of that  homogeneous.  71 10 o r more  Analysis' of groups c o n t a i n i n g showed t h a t  36 o f t h e 40 g r o u p s h a d d e c r e a s i n g a v e r a g e  c u r v e s and t h a t the  e q u a t i o n s were s t a t i s t i c a l l y  Following  d a y s f o r 2 6 o f t h e 36 1  s i g n i f i c a n t but at a l e v e l of  .84.  confidence of less than  Berry's technique, Francisco  d a t a on 4 , 7 1 0 s h o r t - t e r m g e n e r a l h o s p i t a l s , 30 o r more  For  cost  the n e g a t i v e c o e f f i c i e n t o f c o r r e l a t i o n between  a v e r a g e c o s t c u r v e s and p a t i e n t s  containing  hospitals  (30) examined  s e l e c t i n g 25 g r o u p s  hospitals.  a linear regression  relating total  d a y s , 21 o f t h e 25 g r o u p s h a d p o s i t i v e d e c r e a s i n g average cost.  cost t o  intercepts,  However, o n l y  patient  indicating  a  4 of the p o s i t i v e  i n t e r c e p t s , were s i g n i f i c a n t l y d i f f e r e n t from z e r o a t a 5 p e r c e n t confidence  level.  In s t u d y i n g t h e r e l a t i o n s h i p between average cost p e r patient  day a n d o u t p u t  (patient  d a y s ) , 22 o f t h e 25 g r o u p s  f o r the large  hospitals  showed  the  a v e r a g e c o s t t o be l e s s  i n each  but  o n l y 7 o f t h e s e r e l a t i o n s h i p s w e r e s i g n i f i c a n t and 1 o f t h e  o t h e r 3 g r o u p s showed a s i g n i f i c a n t r e l a t i o n s h i p w i t h regression  coefficient.  A l l seven negative r e g r e s s i o n  a positive coeffi-  c i e n t s w h i c h were s i g n i f i c a n t w e r e f o r g r o u p s o f h o s p i t a l s 56  group,  with  beds o r l e s s . In a f u r t h e r  number o f s e r v i c e s  a n a l y s i s , grouping the hospitals  and f a c i l i t i e s , w i t h  combination of f a c i l i t i e s exhibited  and s e r v i c e s ,  a d e c r e a s i n g LRAC, b u t o n l y  significant  by t h e  no a c c o u n t made o f t h e 15 o f t h e 17. g r o u p s  8 relationships  and o f t h e s e 7 w e r e f o r g r o u p s w i t h  were  135 b e d s o r l e s s .  72  By grouping hospitals as small and large on the basis of the number of f a c i l i t i e s and services, i t was  Inferred from the  results that smaller hospitals (less than approximately 100 beds with limited f a c i l i t i e s and services) had Increasing returns to scale and large hospitals have either constant returns to scale or decreasing returns to scale, though not appreciable. Cohen (12 and 13), i n two related studies, employed a sample composed of short-term general h o s p i t a l s which were members of the United Hospital Fund of New York.  A l l hospitals used an  i d e n t i c a l accounting system, thus avoiding d i f f i c u l t i e s i n variations due to d i f f e r e n t accounting systems. Service output as defined by the i n d i v i d u a l outputs weighted by t h e i r r e l a t i v e costs was used as an explanatory variable.  The f i r s t study (12) used p h y s i c a l therapy treatments,  electrocardiograms, x-ray treatments, blood transfusions, electroencephalograms, weighted operations, d e l i v e r i e s , diagnostic x-rays, laboratory examinations, newborn days, outpatient v i s i t s , emergency room treatments and adult and p e d i a t r i c patient days as the component measures of output.  The second study also added  isotope treatments and ambulance t r i p s . The AC curve of the f i r s t study was U-shaped, with the minimum occurring.at 85,000-90,000 patient days or about 290-295 beds.  However, the manner i n which output was  converted to patient  days i s not clear. The second study attempted to p a r t i a l l y account for differences i n quality by employing ation with a medical school.  a dummy variable for a f f i l i -  Service output and patient days  were employed separately as explanatory v a r i a b l e s .  The minimum  AC occurred  f o r about 270,000 units of service and f o r 180,000  patient days, or approximately f o r a h o s p i t a l size of 540-555 beds (at s l i g h t l y more than 90 percent occupancy). Allowing  alternative weights f o r a f f i l i a t e d hospitals  by assuming that a teaching h o s p i t a l provides 10, 20, or 30 percent more service yielded a minimum average cost at approximately 640,700, 790 beds respectively. The  apparent inconsistencies i n these and other studies  are largely a r e s u l t of the differences i n the services offered, the groupings and measures of output employed, and the quality of services.  It would appear however that economies of scale  exist f o r small hospitals offering a limited range of f a c i l i t i e s and services and that within r e l a t i v e l y homogeneous groups of hospitals economies of scale also e x i s t .  Independent Dependent Variable Variables Administration costs Monthly number of Equipment costs adult patient days Skilled personnel costs Unskilled labour costs Supply costs Food costs Various monthly Drug costs departmental patient days and expenses Total operating expense Total operating expense Yearly number of excluding depreciation adult patient days Average daily census and 8measures of Total operating cost hospital service capabilityand educational programs Average cost per patient day  Patient days  Methodology  Sample  A general, short-term, Multiple regression, with non-research oriented hospital in Indiana account made of cost inflation, employee days off with pay, and changes in production  Multiple regression analysis  60 hospitals ranging in size from 48-453 beds 3,147 non-profit, general hospitals  Cost of dependent variable increased with increases in. patient days Feldstein Linear relationships between t o t a l e x p e n d i t u r e s a n d m e a s u r e s (26) of output (patient days) Constant LRMC with LRMC being less than LRAC Minimum LRAC (U-shaped cost curve) occurred for an Carr & average daily census of 190, Feldstein assuming amean number of (10 ) facilities and services  Linear regression analysis 5, 293 non-federal, shorto f h o s p i t a l s g r o u p e d b y t h e t e r m , g e n e r a l a n d o t h e r iD mo pw l ny wi an gr d e c so ln oo mp ii en s g A Co f c su c ra vl ee , availability of 28 services special hospitals and facilities  T a b l e 10: Selected E m p i r i c a l Hospital C o s t s Studies  Reference  No variation in response to changes in patient days  Scatter diagrams  Linear regression analysis  Result .  Berry (8 )  Dependent Variable  LRAC  Total and average cost LRAC  Total Cost  ti  Independent Variables  Methodology  Medical and surgical expense /p.d., weighted operations/p.d., Factor analysis and weighted outpatient r a d i o l o g i c a l f i l m s / p am. udnl .tai,lp l ye s rie sg r e,s s i o n private p. d. /p. d., occupancy rate, and number of beds Patient days Similar to Berry  Sample  Result  72 Massachusetts I n v e r t e dU - s h a p e d A C c u r v e , community hospitals, with am a x i m u m at 150 beds r a n g i n g i n s i z e f r o m 30 Ingbar St t o 300 b e d s (1958-59) , Taylor 67 of the above hospitals Similar shape curve, the (38* (1962-63) m a x i m u m occurring at190beds Weak indications of economies  o.f_ scale. American Hospital D e c number Grouping by number of A s s o c i a t i o n a n n u a l s u r v e y s m a rl el a hs oi sn pg i t a a v l e s r aa ng de cc oo sn ts t fa on rt services and facilities f o r 1966 returns to scale for large (less than 6 facilities and hospitals 6 facilities or greater) 23 member hospitals ofU-shaped LRAC curve with the Patient days and the United Hospital Fund minimum occurring in the various services Multiple regression o f N e w Y o r k C i t y r a n g e 85, 000-90,000 p . d . . weighted by their analysis ( a p p r o x i m a t e l y 290-295 relative average cost As above, but including 46 member hospitals of U-shaped LRAC curve, with a d u m m y variable to the above Fund (operating the minimum occurring at 11 account for affiliation a t s l i g h t l y m o r e t h a n 9 0 % 540-555 b e d s with amedical school occupancy)  Patient days and of facilities  Table 10: -- Continued  Reference  i  Francisco (30)  Cohen b e (tz) ds) Cohen (13)  G.  Conclusions' W i t h i n most  large  organizations  are involved  the  of health  of  provision these  there and  agencies  c o m m u n i t i e s , numerous i n d i v i d u a l s and i n the p r o v i s i o n  and h e a l t h  related services.  act l a r g e l y independently  a r e s i g n i f i c a n t , though n o t always  i n t e r d e p e n d e n c i e s b e t w e e n them. i n which a p h y s i c i a n  a patient  i n a h o s p i t a l or i n a private  admission  and a l a c k  plexity  care d e l i v e r y  of health  o f i n t e r e s t which  g r o u p s , as i n t h e c a s e of  nursing  services  home.  i s often  o r as i n t h e c a s e  insurers  of physicians  t h e com-  increased  sometimes a r i s e b e t w e e n party  can g a i n  In addition to  of o v e r a l l coordination,  of t h i r d  placing  i s insured f o r  home c a r e .  systems  by  The f i n a l  by w h e t h e r o r n o t t h e p a t i e n t  but not f o rnursing  while  may be e x e m p l i f i e d  may have t o c h o o s e b e t w e e n  interdependencies  conflicts  o f one a n o t h e r  t o a h o s p i t a l o r whether the p a t i e n t  hospitalization  Various  direct, interactions  This  instances  d e c i s i o n may be i n f l u e n c e d  and i n s u r a n c e f o r  by  various  and t h e s u p p l i e r s  and h o s p i t a l  admini-  strators . Effective of h e a l t h  care  planning  delivery  a n o t h e r , as t h e d e g r e e organizational determinants services,  requires  s h o u l d be s t u d i e d  of substitutability,  of the cost  Although planning  over which v a r i o u s  planning  relative  s h o u l d be made o f t h e i n t e r a c t i o n s jurisdiction.  costs,  and e f f e c t i v e n e s s are o f t h e component  and e f f e c t i v e n e s s i s confined  b o d i e s have  services  i n r e l a t i o n t o one  o f t h e mix and r e l a t i v e u t i l i z a t i o n  and t h e r e f o r e  their  t h e component  arrangements, a v a i l a b i l i t y  care p r o v i s i o n .  outside  that  of health  t o those  areas  r e s p o n s i b i l i t y , account  and e f f e c t s  of other  activities  CHAPTER IV. THE RESOLUTION OF SUPPLY AND DEMAND A.  Introduction The manner i n which supply and demand are resolved and  the extent to which the delivery of health care services i s e f f e c t i v e depend on the features p a r t i c u l a r to any given medical services market.  V/hile a varied number of health care service  market structures e x i s t , t h i s discussion w i l l be primarily confined to f i n a n c i a l and organizational c h a r a c t e r i s t i c s p a r t i c u l a r to markets i n Canada. B.  Distinguishing Features of the Health Services Market In t r a d i t i o n a l economic theory, p r o f i t maximization i s  assumed on the part of the suppliers and the resolution of supply and demand occurs through the p r i c i n g mechanism of the market. The health services market d i f f e r s substantially i n these aspects from the markets normally dealt with i n t r a d i t i o n a l economic analysis.  The major c h a r a c t e r i s t i c s of the health services market  are b r i e f l y summarized below. 1.  Monopoly Aspects:  There i s r e s t r i c t e d entry to the  medical profession and overt price competition  i s not practiced.  The physician often performs services demanding l i t t l e of h i s medical knowledge and s k i l l , many of which could e a s i l y be provided by lesser trained personnel.  However, substitutes, except  those permitted to a s s i s t and a i d physicians, are excluded, by law, from engaging i n the provision of medical practice services. 2.  Product Uncertainty  and Competition:  Knowledge,  78 either  as p h y s i c i a n  advice  of p e d i c a l s e r v i c e s . there  able  product.  In the  form  charged given  The  general  such  judge  g o v e r n m e n t a l and 4.  Profit  of h e a l t h concern  c o n t r o l and  Motive:  services. f o r the  The The  profit  overtly  conof  compete are  the  within  next, except  fees a  for  contributes.to i n p r o d u c t , as  e s p e c i a l l y In research,  welfare  have  i s subdued  i s supposedly  of h i s p a t i e n t s  f o r only  1962,  p r o p r i e t a r y h o s p i t a l s accounted  a small  motive  physician  account  the between  such led  to  Hospitals U.S.,  are  rather  in  governed than  largely non-profit  proprietary hospitals  proportion  of h o s p i t a l s .  f o r only  the  5%  exist.  (In  o f h o s p i t a l beds  (36))  Market  Resolution  1•  Financial  As  previously  important  provided.  of the  interventions.  These  supplied,  This  Externalities,  i n the  an  services,  specialist.  although,  C.  part  component  q u a l i t y or b e n e f i t  t o the  institutions,  U.S.  and  or q u a l i t y , nor  wealth.  the  the  does n o t  maximizing h i s personal  in  on  the  surgery.  disease  other  products  differentiation  Externalities:  communicable  i s a major  substantially different  physician  limited  p r a c t i t i o n e r and  as  his  one  as p l a s t i c  image o f  3. cases  other  medical profession  s p e c i a l t y , from  care  knowledge  to adequately  for similar services  public's  by  most  of a d v e r t i s i n g of p r i c e s  specialties  area  Unlike  skilled  is usually insufficient  sumer t o be the  or  Considerations discussed,  r o l e i n determining  and One  t h e - e f f i c i e n c y with of the  most  financial manifest  considerations demand, t h e  which h e a l t h  important  aspects  care  o f the  play  services  services health  are  services  79  market i s the increasing role of governments and t h i r d party payment arrangements which often void p r i c e as a market rationing mechanism. In the United States, proprietary h o s p i t a l s , s l i d i n g scale fees, and a coverage of only a part of the population by various • medical care insurance programs complicates an economic discussion -  of the medical services market.  Since we are primarily concerned  with the Canadian market, i n which u n i v e r s a l coverage e x i s t s , and since the trend i n many other countries, including the U.S., i s towards increased governmental intervention and other t h i r d party payments, the current discussion of market r e s o l u t i o n w i l l be confined to a market i n which price does not serve as a market rationing mechanism. In a s o c i a l context, and i n the absence of price rationing, the concept of shortages may be introduced.  These shortages may  consist not only of services which are sought and not obtained, but also of delays In obtaining the sought a f t e r services. D.  A Surplus of Medical Services? In a number of health service markets, including those i n  Canada and the United States, there are two unajor arguments which may be presented against the occurrence of a manifest surplus of medical services.  The f i r s t argument i s that the medical pro-  fession exercises influence over the number of physicians  trained  and the granting of practice licenses and h o s p i t a l p r i v i l e g e s . The  second argument i s that physicians, e i t h e r f o r economic  reasons or high r i s k avoidance preferences,  may increase the demand  f o r available medical services by p r e s c r i b i n g a d d i t i o n a l services f o r t h e i r patients.  80 While the second argument may  be applicable when physicians  are paid on a fee f o r service b a s i s , other payment arrangements o f f e r inducement to maintain the amount of physician services at a l e v e l at which they are required. Time, e f f o r t , and income are the three basic physician resource variables which may  influence the manner i n which the  physician combines his own and other resources.  The  combina-  t i o n a l processes which determine the ease with which the resources may  be varied and the resultant marginal u t i l i t y to the physician.  Each physician w i l l , of course, have varying preferences i n the trade o f f between income, and time and e f f o r t . "So long as physicians are independent entrepreneurs paid on a fee f o r service b a s i s , the incentives to expand the demands f o r medical services, expand the supply of (free) complementary factors of production, and to r e s t r a i n the entry of substitute health care suppliers w i l l p e r s i s t .  The industry cannot be made  more e f f i c i e n t unless control over the supply of new entrants to medical care supply i s taken away from p r o f e s s i o n a l groups and returned to the public and at the same time competitive forms of service supply are permitted and encouraged." (22) While other forms of reimbursement such as on a capit a t i o n , or s a l a r i e d basis may physicians who  eliminate abuse by  unscrupulous  overprescribe t h e i r services, the incentives to  over u t i l i z e complementary factors of production s t i l l remain. "The choice of factor combinations  i n health service supply i s  too important to be l e f t to one group of suppliers who  have no  t r a i n i n g i n management and worse, every incentive to choose i n e f f i c i e n t forms of supply." (22)  It i s only under such o v e r a l l  81 p r o f i t sharing arrangements as the Kaiser Plan that  physicians  are motivated to balance complementary service costs. such arrangements presently account f o r a very small  However, proportion  of the t o t a l health care arrangements i n North America. E.  Interaction Between Suppliers The  organizational arrangements between the  various  components of medical services, notably the system of r e f e r r a l s and h o s p i t a l admissions, may  vary between countries and even be-  tween regions within a given country. schematically  represent  Figures  3a, 3b, and  3c  three i d e a l i z e d systems from the spectrum  of systems which have emerged. Hospital  Patients  etc. Filter I * Physician refers to any h o s p i t a l (no hospital privileges)  etc.  F i l t e r II * Hospital adminis t r a t i v e control according to ( i ) resources available and ( i i ) h o s p i t a l p o l i c i e s and constraints .  F i l t e r III Individual admission screening by f u l l time h o s p i t a l specialists. Also policy screening.  * These two f i l t e r s are strongly coupled. Extended matching c a p a b i l i t y but with corresponding high search cost.  Accentuated random fluctuations i n referred patient flow to each h o s p i t a l .  3a.  Centralized  System  al.  (46)  System Characteristics  Figure  Source  Milsum et  Admission  82 Figure as  instituted  Israel.  to  the  government  system the  of  event  patient  specialists  specialists  and  and  resident  that  the the  physicians  Sick  patient  such  Funds  t r e a t e d by  general  i s screened  subsequently  Physician  the  i s normally  hospitalization is required,  staff  a c e n t r a l i z e d system  i n Sweden and  patient  In the  h o s p i t a l where t h e  hospital tal  i s representative  practitioner.  that  any  by  In t h i s  general feels  3a  a  practitioner is referred  f o r admission  treated  in  by  by  the' h o s p i -  i f admitted.  Hospital  Patients  etc. Filter I Referring  F i l t e r II F i l t e r III (I) C e n t r a l admission I n d i v i d u a l adbureau matches p a t i e n t s ' m i s s i o n screening needs w i t h h o s p i t a l r e - by f u l l - t i m e sources a v a i l a b l e , ( i i ) h o s p i t a l s p e c i a l ists. Also Some f u r t h e r f i l t e r i n g policy screening* by a s s i g n e d h o s p i t a l as i n S y s t e m A.  physician  System C h a r a c t e r i s t i c s Optimal matching c a p a b i l i t y with minimal search cost to referring physician. Economy o f sfcale a c c r u i n g i n c e n t r a l i z e d search and c o n t r o l system. Figure Source:  etc.  3b.  F l o w f l u c t u a t i o n s smoothed c e n t r a l l i m i t theorem. Flow r e s p o n s i v e state.  Central  Milsum et a l . (46).  t o each  R e f e r r a l System  by  hospital's  83 The  city-wide c e n t r a l r e f e r r a l system (Figure 3b) i s  representative of an experimental  program i n Rotterdam, Holland.  In t h i s system, physicians with patients requiring h o s p i t a l i z a t i o n r e f e r to a central agency which then screens patient needs and attempts to match patient needs to available h o s p i t a l resources. Once a patient i s referred by the physician to a h o s p i t a l there is a further screening by h o s p i t a l s t a f f s p e c i a l i s t s . Figure 3c i s representative of the majority of situations i n Canada and the United States.  In t h i s system a s p e c i a l i s t or  general p r a c t i t i o n e r with h o s p i t a l p r i v i l e g e s may  recommend the  admission of a patient to a h o s p i t a l where he has been granted privileges.  Although the private p r a c t i t i o n e r i s not an employee  of the h o s p i t a l , he may and personnel  make extensive use of h o s p i t a l f a c i l i t i e s  i n the treatment of his p a t i e n t s .  The number of  hospitals at which a physician has p r i v i l e g e s , the number of beds which he can u t i l i z e i n a h o s p i t a l , and the p r i o r i t y given his patients by the h o s p i t a l may  d i f f e r considerably between physi-  cians. The physician's recommendation f o r h o s p i t a l i z a t i o n i s not s u f f i c i e n t to gain admission f o r his patient.  The  admission  p o l i c y of the h o s p i t a l , i t s census state, the physicians status f o r having patients admitted, and the waiting l i s t also determine when and i f a patient gains admission.  84  Physician  Hospital  Patients  etc,  etc.  Filter I Physician with hosp i t a l privileges selects h o s p i t a l i n predictable ways  F i l t e r II Hospital administrat i o n control according to ( i ) resources available and ( i i ) hospital policies and constraints.  F i l t e r III Hospital medical utilization committee screening (policy rather than i n d i v i d u a l screening).  System Characteristics  Limited search range by each physician but correspondingly low matching capability.  Relatively uniform flow pattern over time of r e f e r r a l to each h o s p i t a l by each physician.  Figure 3c. Source:  Milsum et a l  System t y p i c a l of North America  (46)  As indicated in the above discussion, the relationships between s p e c i a l i s t s , general p r a c t i t i o n e r s , and hospitals vary considerably.  General p r a c t i t i o n e r s may  to s p e c i a l i s t s or the patient may ist directly.  may  r e f e r t h e i r patients  seek the services of a s p e c i a l -  However, under various  insurance plans, there  may  be a f i n a n c i a l penalty to the patient, i f he seeks s p e c i a l i s t services without being referred by a general p r a c t i t i o n e r . penalty  This  often constitutes payment of the difference between the  general p r a c t i t i o n e r ' s fee and the s p e c i a l i s t ' s fee, as i s the case under the B r i t i s h Columbia Medical Services  Plan.  In some systems, patients admitted to a h o s p i t a l are treated by h o s p i t a l s t a f f s p e c i a l i s t s and resident  physicians.  85 In other systems., such as that t y p i c a l of Canada and the United States, continuity of patient care i s maintained by the patient's regular physician or s p e c i a l i s t to which he has been referred . It should be noted that s u r g i c a l procedures are often performed only by surgeons, that i s , patients are referred to a surgeon (a physician specialty) f o r s u r g i c a l treatment. In the event that a patient i s placed on a waiting  list  or i s not granted admission to a h o s p i t a l , the physician may prescribe an alternative pattern of treatment, or attempt to have the patient admitted to another h o s p i t a l . Within any h o s p i t a l , services are generally segmented along service c a p a b i l i t y l i n e s , such that the i n d i v i d u a l segments are r e s t r i c t e d to supplying  l i m i t e d patient services.  An im-  balance i n patient mix may thus r e s u l t i n a shortage of some services and a surplus of others, at any given time.  Short run  fluctuations i n various demand categories may r e s u l t In patients of low medical need receiving treatment before  cases of greater  medical need, because of variations i n the a v a i l a b i l i t y of r e quired services. The  c e n t r a l r e f e r r a l system offers the greatest p o t e n t i a l  for c o n t r o l l i n g and regulating patient mix, occupancy levels and the s t a b i l i t y of patient demands on i n d i v i d u a l h o s p i t a l s .  This  system also provides the greatest f l e x i b i l i t y i n matching patient needs to available resources. Of the three systems, the centralized admission system presents  the greatest uncertainty i n predicting demands on  i n d i v i d u a l h o s p i t a l s ' services.  While eliminating the constraint  of h o s p i t a l p r i v i l e g e s , i t may require the greatest amount of  86 search e f f o r t on the part of the physician and the patient i n obtaining h o s p i t a l admission f o r the patient. In the system t y p i c a l of Canada and the U.S., the search e f f o r t to f i n d available h o s p i t a l services i s limited to hospit a l s at which the physician has p r i v i l e g e s and of which he i s more aware of the p o s s i b i l i t y of having the patient admitted. This system also affords less p o s s i b i l i t y of duplicating diagnost i c services than the other two systems. It should be emphasized that these are only three i d e a l i z e d systems from the spectrum of e x i s t i n g systems and that there may be several d i f f e r e n t systems operative i n any given region. P.  The Effect of Supply on Demand Of p a r t i c u l a r note, i n the discussion of the resolution  of the demand and supply of medical s e r v i c e s , i s the e f f e c t of supply on demand.  I t i s commonly believed that the supply of  h o s p i t a l beds influences the demand f o r them. In a study of an upstate New York county, Roemer (57) found that following a sudden increase i n bed supply, a s t a t i s t i c a l l y s i g n i f i c a n t increase i n u t i l i z a t i o n occurred.  This  increase was evident both i n the number of admissions and the average length of stay. Durban and Antelman (19) used multiple regression analysis to study u t i l i z a t i o n i n 48 continental states.  I t was concluded  that admission rates and average length of stay increase with bed supply.  In the same study, the number of physicians per 100,000  population was also found, to affect h o s p i t a l u t i l i z a t i o n , admission rates decreasing  and average length of stay Increasing as the  87  physician/population r a t i o increased.  I t was postulated that as  the r a t i o of physicians/population Increases, a greater percentage of patients are treated without h o s p i t a l i z a t i o n , thus making greater use of available physician time.  The average length of  stay increases since the patients treated without h o s p i t a l i z a t i o n are l i k e l y t o be primarily "short stay" patients. 5.  Short Run Resolution In the absence of price r a t i o n i n g , i t i s r e l a t i v e  attractiveness i n terms of a v a i l a b i l i t y , waitng time, costs both to the physician and patient, and certain p r i o r i t i e s within the system that, i n the short run, determine which demands are met, which demands are s a t i s f i e d by alternative services, which demands are met with delay, and which demands go unmet.' Relative a t t r a c tiveness of physician alternatives i s dependent both on the method of payment and  the time and e f f o r t required of the physician  under different system structures. H.  Long Run Resolution In the long run, the resolution of supply and demand i s  influenced by past r e s o l u t i o n .  A manifest  shortage of physician  oi* h o s p i t a l services may serve as an impetus f o r a future increase in  supply. It. should be noted that f i n a n c i a l and p o l i t i c a l constraints  may play a large role In determining  long run r e s o l u t i o n .  Since a s i g n i f i c a n t lag i s l i k e l y to occur between the time an impending or overt shortage of physician or h o s p i t a l services i s recognized  and the time additional physicians are trained c r  attracted to the region and h o s p i t a l f a c i l i t i e s b u i l t , i t i s necessary to project demands and to plan f o r the provision of adequate health services on a long range b a s i s . I.  Conclusion A r a t i o n a l approach to the provision of health care  services necessitates many changes i n the present system, both i n f i n a n c i a l arrangements and i n the organizational arrangements between the various The  components of health care services.  present system i n North America, which i s largely  based on a fee f o r service payment to physicians, not only to provide motivation  fails  to balance complementary health care  service costs, but often motivates physicians to m i s u t i l i z e complementary services i n order to increase t h e i r own throughput. The e f f i c i e n t u t i l i z a t i o n of health care resources requires that incentives be i n s t i t u t e d which motivate suppliers of health care services to balance complementary service costs and to provide only those services which are required. The present Canadian system of admissions and r e f e r r a l s could be considerably The  improved i n areas with several h o s p i t a l s .  i n s t i t u t i o n of some form of centralized coordination such as  a centralized admission or r e f e r r a l bureau could better match patient needs with available resources and provide better control of the occupancy l e v e l s , and the mix and s t a b i l i t y of patient flows i n i n d i v i d u a l h o s p i t a l s .  CHAPTER V. A.  RATIONAL PLANNING FOR HEALTH CARE SERVICES  A Framework f o r Planning Public Law  In the United States, views com-  89-749,  prehensive health planning as " a process that w i l l enable r a t i o n a l decision making about the use of private and public resources to meet health needs. I t s concern encompasses p h y s i c a l , mental, and environmental health: the f a c i l i t i e s , service and manpower required to meet a l l health needs: and the development and coordination of p u b l i c , voluntary and private resources to meet these needs." ( 3 7 ) Health planning i s based on c u l t u r a l values which vary among cultures and which vary over time within a given culture. The problem of defining and assigning r e l a t i v e weightings to various aspects of c u l t u r a l values r e l a t i n g to health and the quality of l i f e Is a d i f f i c u l t  one. The methodologies and  resultant quantified values are not absolute; however, they do provide a r a t i o n a l approach .to a subjective evaluation process (see Chapter I ) . A;.-set of r e l a t i v e value weightings may be applied to the projected shortcomings  of the future health care system.  value weighted shortcomings based on r e l a t i v e  The  may then serve to provide an ordering  importance.  An analysis of these problem areas i n terms of t h e i r r e l a t i v e importance,  the extent to which medical science and  technology may be e f f e c t i v e i n reducing the problems and p r e l i m i nary estimates of the costs involved may then serve to establish p r i o r i t i e s for planning.  This preliminary cost-benefit or cost-  effectiveness analysis should recognize Individual and s o c i e t a l  90  costs.  The  s o c i e t a l costs involved are not only the d i r e c t  c a p i t a l and operating costs for maintaining system, but also the opportunity goods which may  the health  care  costs of alternative public  have been foregone and of losses i n productivity  and well-being because of i l l n e s s and F i n a n c i a l and other resource the -number of p r i o r i t i e s which may  disability. constraints set l i m i t s on  be resolved.  Given the con-  s t r a i n t s , i t i s necessary to choose subsets of p r i o r i t i e s which may  be dealt with i n d i f f e r e n t , although often overlapping, time  periods.  The  chosen p r i o r i t y subsets may  to define planning  then serve as a basis  objectives.  Care must be exercised i n the choice and d e f i n i t i o n of objectives.  Operational objectives cannot be vaguely defined such  as improving the l e v e l of population health.  A measure of health  must be defined and the objective stated i n terms of t h i s measure. We may  define such objectives as reducing  infant mortality or of  providing the same l e v e l of service, but at a lower cost. v a l i d and operational, the objective must be well defined possess a basis for r e l i a b l e measurement and  To be and  evaluation.  Having defined a set of objectives, a l t e r n a t i v e s t r a t e gies which may  achieve the objectives should be enumerated.  These strategies must then be evaluated  by cost-benefit or cost  effectiveness and a course of action defined. Once a decision has been made on an appropriate  course  of action, resources must be allocated and the chosen strategies implemented. The evaluate  f i n a l step of a p a r t i c u l a r planning  a c t i v i t y i s to  the extent to which the implemented strategies have  91 been e f f e c t i v e i n attaining the desire objectives. It should be emphasized that planning Is a continuous evaluation and decision making process, necessitated by the extent of success  of implemented strategies and by changing  value systems, needs, demands, medical technology, resource a v a i l a b i l i t i e s , etc. This chapter w i l l attempt to discuss some of the major problems encountered i n planning, various techniques  employed  to forecast needs and demands, and f r u i t f u l areas i n which to search for possible alternatives i n the delivery of health care services. B.  Problems Encountered i n Planning Rational planning presupposes some knowledge of causal  relationships.  Planning  for health care provision i s hampered  by a fragmentary and imprecise knowledge of the Influences of s o c i a l , c u l t u r a l , and environmental factors on s o c i e t a l and i n d i v i d u a l health status.  Furthermore, numerous causal and  causal i n d i c a t o r variables are often d i f f i c u l t to quantify may  be interdependent.  Causal variables such as pollutant levels  and indcator variables such as age and sex c l a s s i f i e d incidence rates may  such as measures of health status may  l e v e l are The  disease  be q u a n t i f i a b l e ; however, the exact nature of  the causal relationships are not always known.  normative terms.  and  Other variables  have meaning only i n  Various variables such as income and  educational  interdependent. above-mentioned problems, as well as the  complexity  of system i n t e r a c t i o n s , the involvement of various groups and agencies that often act independently  of one another, and  the  92  sampling requirements for meaningful s t a t i s t i c s have been major d i f f i c u l t i e s i n studying health care systems and have resulted i n a lack of much needed data f o r r a t i o n a l planning. C.  Techniques Employed i n Predicting Future Requirements f o r H e a l t h Care Delivery Knowledge gained  from studies of the e f f e c t s of selected  variables on u t i l i z a t i o n of health care delivery services t o gether with a knowledge of the functioning of the health care delivery system and an adeauate data base can serve i n planning for future health care d e l i v e r y . This section w i l l attempt to review and discuss some of the shortcomings of the major approaches to forecasting health care needs and demands and t h e i r applications to planning. 1.  Utilization  Models  Methods based on u t i l i z a t i o n vary i n s o p h i s t i c a t i o n from simple bed/population  and physician/population r a t i o s to models  which project u t i l i z a t i o n through an analysis of demand, (a)  Planning by comparison  I f the 'status quo' performance of health care delivery i s deemed, by those responsible for planning, to be adequate, then current u t i l i z a t i o n appears to be an appropriate basis on which to plan f o r future service. I f an improvement of regional health care delivery i s desired, another region may be found which w i l l serve as a standard.  This approach i s subject to the precarious  assumption that the needs and demands of the two regions are comparable.  I t i s , however, possible to subjectively  adjust current u t i l i z a t i o n rates f o r the region concerned  and to employ these estimates In planning. The simplest form of planning on the basis of u t i l i z a t i o n rates i s to compute such figures as bed/ population and physician/population r a t i o s . the underlying assumption that constant  This has  utilization  for a given size population w i l l hold i n the future. A more sophisticated v a r i a t i o n  3  which has been  employed, i s to compute ratios of the u t i l i z a t i o n of selected health resources/demographleally population.  categorized  Projections of population growth by  demographic c l a s s i f i c a t i o n future resource  may then be used to predict  requirements.  In these and other methods, the v a l i d i t y  of pre-  dicted requirements depends to a great extent on the reliability (h)  of population projections.  Planning on the Basis of E x i s t i n g Demand  Planning based on demand considers not only actual u t i l i z a t i o n , but also u t i l i z a t i o n which would occur i f known unmet demands were s a t i s f i e d . A method which has been employed i n England i s based on Bailey's (6) concept of a " c r i t i c a l number of beds'.  This number represents the number of h o s p i t a l  beds which would s a t i s f y current levels of known demand, and i s determined as follows: "In any year the number of patients recommended f o r admission m u l t i p l i e d by the average duration of stay of the patients died and d i s charged gives the number of bed-days which would have been spent i n h o s p i t a l had a l l patients recommended been  admitted." (6) The number of patients recommended f o r admission i s calculated as in-patient deaths and d i s charges plus or minus the change i n w a i t i n g - l i s t s . Prediction of bed requirements on the basis of t h i s model f a i l s to take account of changes i n population age and sex composition, which a f f e c t both the demand for admissions and the average length of stay. of other variables i s also ignored. the e f f e c t of supply on demand.  The e f f e c t  Of s p e c i a l note i s  Should the c r i t i c a l  number of beds be supplied and other factors having no influence, one might f i n d unmet demand^ as r e f l e c t e d by waiting lists^would s t i l l e x i s t . (c)  Planning  Based on Analysis of Demand  Predicting demand on the basis of an analysis of contributing factors offers a more a t t r a c t i v e and sophist i c a t e d approach than the above methods. Barr (7) i n a study of the Reading County Borough derived sex-age-specific discharge, rates of new admissions, staying f o r one night or more, f o r d i f f e r e n t h o s p i t a l departments i n d i f f e r e n t districts  ( c l a s s i f i e d as county borough, municipal boroughs, urban  d i s t r i c t s and r u r a l d i s t r i c t s ) . This method may be u t i l i z e d as a basis not only to plan for the number of beds required, but also f o r t h e i r d i s t r i b u t i o n . Using multiple regression analysis, Brooks, et a_l (9) have described a model to predict future demand i n each of the categories l i s t e d below.  95 1. 2. 3. 4. 5. 6. 7. 8. 9.  A number of factors,  analysis.  10. 11. 12. 13. 14. 15. 16. 17.  Ob.stetrJ.es (O.B.) Newborn Medicine Cardiology Communicable Dermatology Neurology Psychiatry Surgery  Ear-Nose-Throat (ENT) Gynaecology Neuro-surgery Ophthalmology Orthopaedics Proctology Urology Paediatrics (children under 14 years)  117 i n a l l , were selected f o r the  "From two to f i v e factors were f i n a l l y established  as being predictors f o r the cases considered." (9) Rosenthal (58) has presented a u t i l i z a t i o n model with socio-demographic  and economic variables.  The model i s a least  squares linear multiple regression employing the following variables selected on the basis of t h e i r popularity i n the l i t e r a ture . 1. 2. 3,  4. 5. 6. 7.  % % % % % %  over age 64 under age 15 of females married male urban over 12 years educa^ tion % non white  8.  9. 10. 11. 12.  population per dwelling unit charges f o r 2 - bedroom % over $5995 income % under $2000 income % h o s p i t a l coverage  The alternate variables used to measure u t i l i z a t i o n i n short-term general and s p e c i a l nonfederal hospitals i n the United States were 1. 2.  patient days/1000 population admissions/1000 population  3.  average length of stay per admission The analysis was performed f o r two years, 1950 and I960.  In both years the c o e f f i c i e n t of multiple c o r r e l a t i o n was greater for length of stay than for admissions. To take account of trends, the t o t a l observations f o r both years were pooled and a dummy time variable added.  The results  indicated that the relationships f o r patient days and  admissions  96 displayed a s i g n i f i c a n t time dependence. aspect  "The most i n t e r e s t i n g  of these relationships i s the negative  the time period.  coefficient for  This means that, f o r any given set of charac-  t e r i s t i c s , there would have been lesser u t i l i z a t i o n i n i960 than 1950.  It follows, therefore, that the increases i n u t i l i z a t i o n  noted over the 10-year period resulted from changes In o v e r a l l s o c i a l , demographic, and economic c h a r a c t e r i s t i c s i n the United States, rather than from an increasing propensity  to consume hos-  p i t a l services at a given l e v e l of these v a r i a b l e s . " To test the a p p l i c a b i l i t y of a l i n e a r model, a c u r v i l i n e a r model was employed, but l i t t l e s i g n i f i c a n t difference was found. Peldstein and German (27) have presented an evaluation of three approaches to predicting h o s p i t a l u t i l i z a t i o n .  State  data on short-term general and s p e c i a l nonfederal hospitals was employed to evaluate the predictive value of the following three approaches: 1.  Trend l i n e extrapolation  2.  Bed supply extrapolation  3.  Demand analysis  The r e s u l t s of the study are summarized i n Table  11.  VARIABLE  OPERATIONAL DEFINITION  METHODOLOGY OF ASSESSMENT  SHORTCOMINGS A N D / O R  patient days/1000 pop. in non-federal, shortt e r m , general hospitals  Trendline-Multiple regression (going back 1 year in time for each year projecting into the future) a) 5 year trend of absolute p. d. /population b) 5 year average of p . d . /population c) 5 year trend in changes in p . d . /population d) 5 year average in annual change in p. d. /pop.  Beds  number of non-federal, s h o r t - t e r m , general and other special hospital beds/1000 population in each state  A s above, except using bed/population ratios  Income  median family income  Hospital Insurance  proportion of population covered  Demand analysis - Multiple r e g r e s s i o n Determination of the dependence of patient days/1000 population on socio-economic variables and changes in these variables  Patient days (P. d.)  Cost of Hospital Care  2-bed room rate  Age  proportion of population over 55 years of age  Urbanization  proportion of population living in r u r a l areas  Race  proportion on non-whites living in the state  VALIDATION:  ADVANTAGES  a) m u l t i c o l l i n e a r i t y between independent variables may cause problems b) avoids multicollinearity, however assumes equal weights for a l l / e a r s c) avoids multicollinearit / and the use of equal weights d) i m p l i e s equal weights for a l l / e a r s  Makes explicit account of variables influencing utilization  7.  H i s t o r i c a l data is used to test ; coefficients, standard e r r o r of estimation, standard e r r o r of the net r e g r e s s i o n coefficient  coeficient of multiple c o r r e l a t i o n and  Table 11: Evaluation of Three Approaches of Predicting Resource Requirements  98  It was 1000  found that trends i n patient days/1000 and beds/  population  were s i m i l a r and much more r e l i a b l e than the  use  of the selected socio-economic variables in predicting patientday /population The  ratios.  authors also incorporated  a trend variable into the  demand model which resulted i n a lower standard error than any of the trend models. "further research  However, the authors cautiously state that  i s s t i l l required to determine more accurate  measures for the demand variables so as not to misinterpret e f f e c t s , and also to develop an appropriate Multiple regression account for i n t e r a c t i o n s .  analysis may  their  trend variable."  (27)  f a i l to s a t i s f a c t o r i l y  Analysis of variance may  be used to  handle i n t e r a c t i o n s , however, uneven d i s t r i b u t i o n s of observations among c e l l s lead to orthogonality  problems.  reasons that Reinke and Baker (5*0  It i s for these  have employed the  multi-sort  technique, which i s an approximation procedure following of variance regression  p r i n c i p l e s but simplifying computations. analysis was  been i d e n t i f i e d .  The  analysis  Multiple  performed after the key variables  had  authors, by a comparison of results using  the multi-sort technique and of those from certain multiple regression  and analysis of variance  re-  procedures conclude that  "the  multi-sort technique offers more promise i n the evaluation  of  demographic data than previous applications of analysis of  variance  would indicate".  (54)  2.  Methods Based on Mortality  The  a v a i l a b i l i t y and r e l i a b i l i t y of mortality data has  previously  attracted some e f f o r t to u t i l i z e this information  estimating  required health resources.  for  Some measures based on m o r t a l i t y which have been employed are: 1.  L i f e expectancy by age and sex  2.  Survival rate  3.  Selected  at v a r i o u s ages  death r a t e s  such as  (a)  infant  (b)  maternal m o r t a l i t y  (c)  mortality  still-births  (d)  mortality  (e)  post-neonatal  (f)  major i n f e c t i o u s  among c h i l d r e n ages  known as the bed-death  disease (35)  r a t i o which c o n s i d e r s  deaths and an estimate  deaths that w i l l occur i n the h o s p i t a l . employed i n a number of s t a t e s , P l a n n i n g on the b a s i s  socio-economic incidence.  ratios  d e r i v e d a technique the  relationship  of the p r o p o r t i o n of  T h i s technique has been  of m o r t a l i t y data assumes As p r o v i o u s l y  ignores the e f f e c t s  and other f a c t o r s  of changing  which i n f l u e n c e  for health  care d e l i v e r y  a  static  discussed,  the  demographi  u t i l i z a t i o n and  As p o i n t e d out i n Chapter I , m o r t a l i t y  appropriate basis 3.  mortality  I n c l u d i n g New York and M i c h i g a n .  r a t i o of u t i l i z a t i o n t o m o r t a l i t y . use of constant  1-4  mortality  The Commission on H o s p i t a l Care  between p r e d i c t a b l e  grouping  i s not an  planning.  Approaches Based on M o r b i d i t y  M o r b i d i t y i s the u n d e r l y i n g f a c t o r which i n i t i a t e s of the processes  l e a d i n g t o demand.  c h a r a c t e r i z e d by a s i n g l e i n d u r a t i o n and s e v e r i t y  U n l i k e d e a t h , which  s t a t e , morbidity i s  many  is  a continuum v a r y i n g  and having a number of p o s s i b l e  The problems of o b t a i n i n g r e l i a b l e m o r b i d i t y data and of  outcomes trans-  100 l a t i n g morbidity incidence into u t i l i z a t i o n have limited a p p l i cation of approaches based on morbidity.  In addition,this  approach i s based on subjective 'expert' opinion of the .needed health care resources and there i s nothing to ensure that the needs w i l l become translated Into demands. Surveys of morbidity such as those of Lee and Jones  (43)  and Kalimo and Slevers (39) have attempted to calculate needed health care resources to cope with existent levels of morbidity.  determined  However, surveys of t h i s nature are few i n number  and are often dated. D.  The Need for Alternatives i n Health Care Planning Most of the techniques discussed above are employed to  forecast requirements  on the basis of past c h a r a c t e r i s t i c s of the  population at r i s k and the e x i s t i n g patterns of health care delivery. Advances i n technology and new treatment  drugs and approaches to  have been evidenced which have had appreciable impacts  on disease incidence and medical p r a c t i c e , sometimes r e s u l t i n g i n the obsolescence  of service f a c i l i t i e s , as i n the case of  active tuberculosis treatment. A r a t i o n a l approach to planning requires that such p o s s i b i l i t i e s be considered and that the design of various f a c i l i t i e s be such as to be functionally f l e x i b l e within the constraint of economic considerations. VJhile various advances i n medical science may  offer  improvements i n the quality and effectiveness of health care d e l i v e r y , great p o t e n t i a l l i e s i n research e f f o r t s directed t o -  101 wards s t u d y i n g  a l t e r n a t e modes o f p r o v i d i n g h e a l t h c a r e  Little strategies  effort  has been devoted t o s e e k i n g a l t e r n a t i v e  f o rdelivering health  care  attempts a t h e a l t h s e r v i c e s planning than e f f o r t s  to collect  aggregatae data are  services.  census d a t a , v i t a l  on u t i l i z a t i o n  of various  further  s t a t i s t i c s , and h e a l t h s e r v i c e s which aggregate c h a r a c t e r i s -  of the target population" (4). With the p r e v a i l i n g high  care  "To d a t e most  have gone l i t t l e  t h e n u s e d i n summary f o r m t o d e s c r i b e  tics  services.  expenditures,  patterns  l e v e l s and s p i r a l i n g  we c a n no l o n g e r  of health  care  a f f o r d t o accept  and r e s e a r c h  patterns  of health  of p r o v i d i n g h e a l t h delivery  a valid  are i n c r e a s i n g l y being  care care  existing  d e l i v e r y w h i c h have h i s t o r i c a l l y  o f t e n i n a p i e c e m e a l f a s h i o n and w i t h o u t Interest  of health  d e l i v e r y i n search services.  developed,  assessment.  focussed  on a l t e r n a t e  o f more e f f e c t i v e means  Such approaches t o h e a l t h  a r e a l m o s t c e r t a i n t o be s y s t e m  oriented.  1.  Systems A n a l y s i s  The  systems a n a l y s i s approach attempts t o e v a l u a t e  Approach  measure o f performance o f the h e a l t h subsystem t h e r e o f .  This  care  care  some  d e l i v e r y s y s t e m o r some  approach n e c e s s i t a t e s  identifying  inputs  t o t h e s y s t e m , i n t e r a c t i o n s w i t h i n t h e s y s t e m , and t h e o u t p u t o f the  system.  Evaluation  between i n p u t on  i s defined  i n terms o f a r e l a t i o n s h i p  and output o f t h e s y s t e m , o f t e n w i t h  a restriction  some o f t h e i n t e r a c t i o n s w i t h i n t h e s y s t e m . Most o f t e n , t h e s e a p p r o a c h e s have d e a l t w i t h  such as a ward  subsystems,  ( F e t t e r and Thompson ( 2 8 ) , G u r f i e l d a n d  Clayton  (33)), a n d t h e e v a l u a t i o n h a s b e e n a m e a s u r e o f p r o d u c t i v i t y . The  shift  from acute t o c h r o n i c  care, shorter  lengths  102 of s t a y f o r a g i v e n d i a g n o s i s , and ambulatory care have made i t necessary  t o view the t o t a l care system r a t h e r than j u s t h o s p i t a l  beds, s i n c e the l a r g e s t percentage of h e a l t h care i s p r o v i d e d o u t s i d e the domain o f the h o s p i t a l . A recent  approach along these  by Navarro. ( 4 7 )  l i n e s has been d e s c r i b e d  The model employs a Markov chain t o d e s c r i b e  the s t o c h a s t i c i n t e r a c t i o n s of t h e component p a r t s of the h e a l t h service  system. The  subsystems are grouped by type  l a t i o n not under c a r e , primary m e d i c a l  o f care i . e . popu-  care, consultant  medical  c a r e , n u r s i n g home c a r e , h o s p i t a l care and d o m i c i l a r y care.  The  input t o each subsystem i s the number o f e n t r i e s , as d e r i v e d from demand d a t a , during a s e l e c t e d u n i t o f time. subsystem i s the number o f d i s c h a r g e s model allows  p e r u n i t o f time.  of each The  f o r t r a n s f e r s and r e f e r r a l s w i t h i n the system, with  the throughput being periences  The output  d e f i n e d as "the t o t a l i t y  of u t i l i z a t i o n ex-  f o r a l l patient^'. ( 4 7 )  Underlying its applicability  the model are two assumptions which weaken i n i t s present  form.  These a r e :  (a) . The t r a n s i t i o n a l p r o b a b i l i t i e s between s t a t e s o r subsystems are independent o f t h e p r e v i o u s  states,  i . e . the past h i s t o r y of the p a t i e n t s i n the system. (b)  The t r a n s i t i o n a l p r o b a b i l i t i e s are time i n v a r i a n t - i . e . the model does not account f o r changes i n u t i l i z a t i o n p a t t e r n s due t o s h i f t s i n p o p u l a t i o n age  and sex s t r u c t u r e e t c .  Navarro has d i s c u s s e d three a p p l i c a t i o n s f o r which the  103 model may be used. (a)  Prediction:  to predict required resources i n future  time periods on the basis of the productivity of various health care resources and current u t i l i z a t i o n patterns. (b)  Parametric study: to predict required resources i f various changes occur i n u t i l i z a t i o n , productivity or r e f e r r a l patterns.  (c)  Goal seeking: to calculate the r e f e r r a l pattern which " w i l l minimize an objective function such as cost or change i n current resources In such a manner as to reach, i n a given time period, s p e c i f i e d u t i l i z a t i o n patterns  or to require a specified  amount of resources." (47) An extension of t h i s model to include changes i n popul a t i o n size and age structure, and d i f f e r e n t u t i l i z a t i o n by d i f f e r e n t age groups has been described by Navarro, Parker, and White. (48) E•  Changing Patterns of Health Care Delivery The systems approach provides a framework with which to  analyze various aspects of alternative patterns of health care delivery.  In some cases the parametric values of personnel  requirements, etc. to be employed i n the system simulation must be derived through subsystem models. While there are many possible areas for research i n health care subsystems, t h i s section w i l l discuss three aspects of health care delivery which are l i k e l y to have important implications  104 throughout  t h e whole  system o f f u t u r e h e a l t h care  delivery,  namely; (a)  Ambulatory  care  (b)  Geographical facilities  (c) (a)  Ambulatory i n v a r i o u s areas and  are  likely  benefits  basis,  cost  than  to find  has  been e s t i m a t e d  are  from  1/3  to  and  care  are both  can be  that the  cared  accrue  are  significantly The  s i n c e the  than  surgery  impact  o f day  care.  mately  one-quarter  regional hospital  o f day  o f one  care  ambulalower  In  of a l l admissions can  be  states that " I t hospital  controlled  care  In  economic b e n e f i t s beds  beds.  illustrates  area of  ambula-  the p o s s i b l e  b e e n shown t h a t  to children's units  cared  a  care p s y c h i a t r y f o r  particular  " I n V a n c o u v e r i t has  Subsequently,  an  hospitalization".  f o r acute  for children,  district  The  c o s t s of p r o v i d i n g ambulatory  f o l l o w i n g example  c a r e , day  future.  treatment.  o p e r a t i n g c o s t s o f day  capital  less  f o r on  J . S. T y h u r s t  of t h a t of f u l l  care  at a s i g n i f i c a n t l y  in-patient  H o s p i t a l (71),  i n the  health  e c o n o m i c and t h e r a p e u t i c .  provided  institution  acceptance  psychiatric  t o o p e r a t i n g cost s a v i n g s , long run  may  units.  surgical  g r e a t e r implementation  the  1/2  of  personnel  s e r v i c e s have a l r e a d y g a i n e d  conventional hospital  recommending  addition  of a u x i l a r y medical  of m e d i c a l ,  Vancouver General  tory  care  treatment  distribution  personnel  c a s e s where p a t i e n t s can be  tory  report  institutional  Care  of ambulatory In  and  G r e a t e r use Ambulatory  and  f o r i n ambulatory  studies of medical  approxii n the surgical  complications  105 and p a r e n t a l a t t i t u d e s towards s u r g i c a l day which demonstrated that day  surgery was  care were undertaken,  a s a f e and  a l t e r n a t i v e t o c o n v e n t i o n a l h o s p i t a l i z a t i o n and was to  parents and p r o f e s s i o n a l s a l i k e "  f a c i l i t a t e e a r l i e r treatment a n x i e t i e s concerning  acceptable  (/5).  P a t i e n t s r e c e i v i n g ambulatory care m a i n t a i n i n the f a m i l y and the community.  economical  social  contact  In a d d i t i o n , ambulatory care  i n some cases where p a t i e n t s  h o s p i t a l i z a t i o n and who  may  possess  might normally  delay  treatment. Intermediate  or s e l f help wards f o r p a t i e n t s , not r e -  q u i r i n g f u l l n u r s i n g and housekeeping s e r v i c e s , a l s o h o l d promise of  p r o v i d i n g h e a l t h care s e r v i c e s at lower c o s t s than  f u l l hospitalization. motivated  conventional,  L i k e ambulatory c a r e , p a t i e n t s may  be  t o be more s e l f dependent, r a t h e r than becoming con-  d i t i o n e d to i n v a l i d r o l e s as sometimes occurs when treatment provided  i n the c o n v e n t i o n a l manner.  been i n s t i t u t e d i n Veterans'  is  Such wards have r e c e n t l y  A d m i n i s t r a t i o n h o s p i t a l s i n the  U n i t e d S t a t e s , with some p r i v a t e h o s p i t a l s now  beginning  t o adopt  t h i s method of care as w e l l . What i s b e l i e v e d t o be the f i r s t i n North America which i s p h y s i c a l l y is  scheduled  t o open i n Toronto  s a t e l l i t e health centre  separated  i n 1972.  The  from a h o s p i t a l centre i s to o f f e r  a wide range of d i a g n o s t i c s e r v i c e s and emergency c a r e .  The  i n s t i t u t i o n of such c e n t r e s holds promise of b r i n g i n g h e a l t h s e r v i c e s t o w i t h i n s h o r t e r d i s t a n c e s of more members of the community and  of r e l i e v i n g unnecessary p r e s s u r e  on c o s t l y  hospital  facilities. (b)  Geographical facilities  and  and  Institutional distribution  personnel  of  106 The service and  geographical  facilities  also i n determining  visitors,  ambulances  t o be p l a c e d services,  c e n t r e s may  health  care  tions,  an i m p o r t a n t  role  travelling  context  among  importance.  the i n d i v i d u a l  will  be d e p e n d e n t  or f a i l u r e  delivery  o f community  distribution  and p e r s o n n e l  institutions  a particular  with  service unit  there  U n i v e r s i t y ' s School  v a r i o u s mixes  resulting  f r o m more e f f i c i e n t  a cardiac unit  should  of  and C l a y t o n ' s  are l i k e l y  be  facilities.  are allowable Such  studies  of Medicine  and s y s t e m s f o r p r o v i d i n g  and G u r f i e l d  institu-  t h e m i x and d i s t r i b u t i o n o f  i n t h e mix and number o f p e r s o n n e l .  of the Stanford  of  i s of considerable  on t h e d i s t r i b u t i o n  services,  in  of h e a l t h care  influence future patterns of  facilities  To a l a r g e e x t e n t ,  However, w i t h i n  dealing  aspects  delivery.  distributed  those  f o rpatients,  More a t t e n t i o n i s l i k e l y  a d d i t i o n t o the g e o g r a p h i c a l  variations  other  i n i n f l u e n c i n g demand  and c o s t s  the success  significantly  t h e manner i n w h i c h  personnel  time  and p h y s i c i a n s .  and i n t h i s  In  o f h o s p i t a l s and  on t h e d i s t r i b u t i o n a l  health  as  plays  distribution  (33) s t u d y  allocations to find  (11)  nursing  of cost  of capital  savings  and  more a p p l i c a t i o n  staff  i n the  future. An ties  a n a l y s i s of the d i s t r i b u t i o n  should  buting  consider  to accessibility,  possible  economies  t o balance  development  and  the factors  of specialized  of s c a l e , i n c r e a s e d problems  i n f o r m a t i o n exchange cation  and a t t e m p t  of personnel  contri-  skills,  of decentralized  and c o o r d i n a t i o n , and u n n e c e s s a r y  and u n d e r u t i l i z a t l o n  facili-  rdupli-  of various s e r v i c e s .  (c)  Greater  use o f p a r a m e d i c a l  Many  routine  clinical  personnel  c r minor p r o c e d u r a l  d u t i e s are  107  performed by doctors and nurses which do not require much of t h e i r medical s k i l l or knowledge and could e a s i l y be performed by lesser trained personnel.  In some areas of health  care,  such as p e d i a t r i c s i n the U.S., auxilary medical personnel have been successful i n r e l i e v i n g the physician of many routine duties (72).  A willingness of B. C. physicians to accept auxilary personnel i s indicated by the Medical Manpower Survey ( 6 l ) . The following r e s u l t s show the reaction of the surveyed physicians to the question  "Do you think that a medical auxilary of some  kind could be trained to r e l i e v e you of part of the medical professional work load i n your practice?"  Yes  No  Undecided  No Answered or not applicable  Specialist  H5%  31%  9%  9%  GP  53%  27%  18%  2%  The  survey also reported that Hospital Directors of  Nursing f e l t that nurses could be given s p e c i a l t r a i n i n g to perform additional i n - h o s p i t a l tasks such as Intravenous therapy, blood transfusion, vaginal examination during labor, care of i n c i s i o n s , and changing or removing complicated The  dressings.  success of greater use of auxilary personnel rests  largely on acceptance by the medical profession and t h e i r patients. It should be noted that i n the above situations the physician's p o s i t i o n i s not threatened, and, i n f a c t , h i s earnings may be Increased.  Under such circumstances, i t i s not surprising that  physicians are w i l l i n g to accept the performance of various by auxilary medical  personnel.  tasks  108 P.  Conclusion G r e a t e r emphasis i s needed on r a t i o n a l p l a n n i n g of h e a l t h  care systems, e s p e c i a l l y w i t h regard t o seeking a l t e r n a t i v e modes of p r o v i d i n g h e a l t h care s e r v i c e s . on expected  Such p l a n n i n g should be based  demands under a l t e r n a t i v e p a t t e r n s of h e a l t h care  d e l i v e r y and should be viewed i n terms o f a system, r a t h e r than a subsystem, such as one  or two  hospitals.  In a d d i t i o n , h e a l t h care should be viewed not only w i t h i n the context of what i s t r a d i t i o n a l l y regarded system, but w i t h i n the broader have an a p p r e c i a b l e impact t h i s end,  one  such  Systems Group and  as the h e a l t h care  p e r s p e c t i v e of those systems which  on h e a l t h and the q u a l i t y of l i f e .  system model has been developed i s presented  i n the next  chapter.  i n the UBC  To Health  CHAPTER VI. A.  REGIONAL HEALTH PLANNING MODEL  Objectives The regional health planning model i s a p r e s c r i p t i v e  model and i s intended to serve as an aid i n p o l i c y formulation and resource a l l o c a t i o n i n the Greater Vancouver region.  The  model i s intended to provide estimates f o r future time periods of resource requirements and the effectiveness and e f f i c i e n c y of organizational structures and p o l i c i e s which determine the operat i o n a l mechanism of the health care d e l i v e r y system. Although the model has been designed f o r the Greater Vancouver region, i t i s general enough In design that i t may  be  readily modified and adapted f o r other regions, providing an adequate data base i s available. The health planning model i s designed in such a manner that i t can be interfaced with various other submodels to take into account the modifying and contributing e f f e c t s of environmental and l i f e style factors.  This leads t o the p o s s i b i l i t y of  evaluating d i f f e r e n t alternative strategies and resource a l l o cations, not just within what i s t r a d i t i o n a l l y regarded as the health care system but also including those systems having an appreciable impact on health and the q u a l i t y of l i f e .  Although  t h i s does not permit a complete evaluation of the various opportunity costs, i t does open the way  to a more meaningful  social  evaluation analysis. In  i t s present state of development  a  the model u t i l i z e s ,  110 U . S . data where Canadian data were not available and various aggregations of data which sometimes have had to be subjectively adjusted.  It, i s intended, at present, to show the operational  f e a s i b i l i t y and a p p l i c a b i l i t y of the model, and to pursue r e f i n e ments at a l a t e r time when the conceptual framework has been more f u l l y developed and the appropriate data obtained. B.  I n t e r - I n s t l t u t l o n a l Policy Simulation The regional health planning model Is one submodel of a  larger simulation project.  The o v e r a l l project, the Inter-  I n s t i t u t i o n a l Policy Simulator (HPS) i s a large scale simulation of the Greater Vancouver region which i s intended to simulate various aspects of a c t i v i t y and development i n the region. V/ithin the HPS  project are ten subgroups which are  described below, together with t h e i r e x i s t i n g and proposed links to the health planning model. 1.  Population arid Demographic Submodel.  This model Incorporates both natural population growth and migration.  The migration model i s to be interfaced with the  economic and the environmental quality submodels to account f o r r e l a t i v e regional attractiveness compared to other regions. This model now serves as a basic input to the health planning model. 2.  Economic Submodel  The economic submodel u t i l i z e s an input-output framework with shift-share analysis to predict f i n a l demands i n the region. The role of l o c a l governments i n economic conditions and regional development i s currently being studied. It i s proposed that t h i s model be u t i l i z e d i n c a p i t a l  Ill budgeting decisions f o r the health care system and other submodels influencing the q u a l i t y of l i f e In the region. 3.  Transportation Submode1  The transportation model Is based on the behavioral assumption underlying the well-known gravity or p o t e n t i a l model, i.e.  persons are most drawn to locations of closest proximity,  possessing the highest levels of a c t i v i t y .  Distance i s measured  i n terms of t r a v e l time along the most convenient  a r t e r i a l route.  The model should be able to provide data on t r a f f i c accidents and medical distance as input to the health planning model. 4.  Land U t i l i z a t i o n Submodel  The purpose of t h i s model i s to a l l o c a t e subareas by a c t i v i t i e s such as a g r i c u l t u r e , f o r e s t r y , mining, recreation, employment and  housing.  This model may  provide useful demographic data f o r the  health planning model. 5.  Health Systems Submodel  This model w i l l be discussed i n d e t a i l In a subsequent section. 6.  P o l l u t i o n Submodel  The p o l l u t i o n submodel considers a i r , water, s o l i d waste, and noise p o l l u t i o n and t h e i r e c o l o g i c a l impact. The  levels of the various p o l l u t i o n types can be used as  input to the health planning model as factors modifying incidence rates.  Together with the economic submodel a wider  perspective of q u a l i t y of l i f e and a l t e r n a t i v e costs may sidered.  various  be con-  112  7.  Human Ecology •Group  This subgroup i s concerned with human behavior and the e f f e c t s of changes i n the variables of the various submodels on human behavior. The aspects of human behavior may form an important input to the evaluation of the consequences of alternative p o l i c i e s within the region. 8.  Land C l a s s i f i c a t i o n Group  The  land c l a s s i f i c a t i o n subgroup provides data input f o r  the land u t i l i z a t i o n model, c l a s s i f i e d by land use, s o i l type and other physical attributes of the land. 9.  Data Management Group  The data management subgroup i s responsible f o r the management and r e t r i e v a l of data and f o r the development of computer graphic 10.  techniques.  Resources arid Public Services Group  This subgroup Is responsible f o r providing projections of the cost of s i t e services such as s t r e e t s , sidewalks, sewer and water, gas and e l e c t r i c i t y , and telephone.  In addition, i t  w i l l a i d In forecasting energy requirements f o r the region. C.  System P r i o r i t i e s and Evaluation As previously discussed, there i s , as yet, no s a t i s f a c t o r y  quantifiable objective function f o r the macro evaluation of a health care system. In an attempt to give one measure of psychological and physical well being, as influenced by the health care system, system shortages have been employed as a measure of performance. This would appear to be the only appropriate macro evaluative  113 measure which can presently be employed. Recent work along the lines followed by Holmes and h i s colleagues (76) offers a quantifiable measurement of the above and appears to possess a v a l i d b a s i s . Holmes et. a l . have derived o r d i n a l and cardinal rankings of the seriousness of 126 of the most common and representative illnesses.  The Seriousness of I l l n e s s Rating Scale (SIRS) i s  based on i n d i v i d u a l perceptions of the seriousness of various i l l n e s s e s i n r e l a t i o n to a normalizing value of 500 for peptic ulcer.  This scale has been shown to have a high degree of con-  cordance between the ranking by medical and non-medical people (76) and to be s a t i s f a c t o r i l y reproducible. (77) A system p r i o r i t y matrix having 6 p r i o r i t y classes (highest p r i o r i t y = l ) was the medical rating scale.  derived for each morbidity category from As the morbidity categories used i n  the model were aggregations, a weighted index was basis of the component conditions.  Because of the  computed on the aggregations  and varying severity within morbidity categories, these p r i o r i t i e s were adjusted by professional judgement to r e f l e c t varying p r i o r i t i e s within each category.  The r e s u l t i n g p r i o r i t y matrix  represents the proportion of cases of each category belonging to a p a r t i c u l a r p r i o r i t y class.  Thus, for example, heart disease  and hypertension i s represented by a discrete p r o b a b i l i t y d i s t r i b u t i o n , with 50 percent of the cases belonging to p r i o r i t y class 1, 20 percent to each of p r i o r i t y classes 2 and 3 , and 10 percent to p r i o r i t y class 4. In a few cases a rating was not given f o r a p a r t i c u l a r i l l n e s s and not at a l l for services such as prophylactic innoculation.  In these instances i t was  necessary to subjectively  114 extrapolate values. The performance evaluation i s based on an index employing the non-medical seriousness scale values as weightings f o r unmet demands.  The evaluation i s thus a measure of the s o c i a l  impact  of the performance of the health care system, with larger values of the index of untreated cases s i g n i f y i n g a poorer performance of the system. D.  Delegation Assumptions At present there are 11 resource categories employed i n  the model; 9 physician s p e c i a l t i e s , beds, and nurses. The model i s p r e s c r i p t i v e i n nature and therefore allows substitutions of various resources which might not f u l l y conform to a descriptive model of the health care system.  The p r e s c r i p t i v e  orientation of the model i s an attempt to evaluate the system at i t s greatest c a p a b i l i t y f o r given work loads, h o s p i t a l occupancy l e v e l s , and standards of care, when there i s greatest f l e x i b i l i t y in substituting physician resources. A number of physician categories often treat cases i n the same demand category, for example upper respiratory conditions may normally be treated by a general p r a c t i t i o n e r , a p e d i a t r i c i a n or a s p e c i a l i s t i n i n t e r n a l medicine.  I f the available amount of any  one of the physician resources which normally are employed to meet the demand i n a given category i s i n s u f f i c i e n t to treat the normal proportion of these cases, delegation i s allowed.  The model  prescribes that, i f at a l l p o s s i b l e , other physicians normally treating these cases are u t i l i z e d i n the order of the specialty normally treating the greatest proportion of these cases.  The  underlying assumption i s that t h i s physician specialty w i l l be  115 the most p r o f i c i e n t resource to u t i l i z e . I f a l l appropriate physician resources have been depleted, other physicians are allowed to substitute, in the order of the greatest percentage  of resources remaining  available.  In allowing substitutions between physicians, exchange rates based on specialty work loads have been employed to r e f l e c t d i f f e r i n g amounts of time required to treat a given case. makes the s i m p l i f i e d assumption  This  that there i s a constant trade-off  r a t i o between physician s p e c i a l t i e s . Additional physician v i s i t s are allowed to compensate i n the event of a bed shortage.  In the present model, a bed case  shortage i s compensatable by an additional number of physician cases (at present t h i s number i s 1)  and t h i s number has been  assumed to be equal f o r a l l categories. E.  Data Base The data base used i n the i n i t i a l runs of the model was  derived from several d i f f e r e n t sources.  I t was  necessary to  process the data as described below. 1.  Incidence Data  Categorized yearly incidence and prevalence rates/100 population i n the U.S. (1,  c l a s s i f i e d by age, sex, and diagnosis  1%) were adjusted when appropriate to r e f l e c t l o c a l conditions. In order that the various data be compatible, i t was  necessary to aggregate into broad diagnostic categories. 2.  Demands on Physician Resources  Of the data pertaining to 16 s p e c i a l t i e s categorized i n Specialty P r o f i l e ( 6'6) (accounting f o r approximately 90% of r  physicians with a private practice;), a l l but that r e l a t i v e to the  -  116  Psychiatrist/Neurologist was used. It was f e l t that, at t h i s time, the project would not concern i t s e l f with p s y c h i a t r i c and neurological conditions. In order to be compatible with available data on medical manpower i n the lower mainland and greater Vancouver regions of B r i t i s h Columbia, i t was necessary to aggregate various s p e c i a l t i e s as shown below: (a)  General p r a c t i t i o n e r includes  a l l e r g i s t , and osteopathic (b)  dermatologist,  physician.  Internal medicine includes gastroenterologist,  proctologist and c a r d i o l o g i s t . The  relevant data given f o r each specialty was the number  of s p e c i a l i s t s , reason f o r v i s i t , and number of v i s i t s f o r a s p e c i f i e d reason. Multiplying the number of v i s i t s by the number of physicians active i n a specialty gave the number of v i s i t s by specialty f o r a s p e c i f i e d reason.  This figure was then converted  to v i s i t s / 1 0 0 population.  From the data on incidence and v i s i t s , i t was then possible to compute the number of v i s i t s / i n c i d e n c e by diagnosis and s p e c i a l t y . (Appendix D) The number of v i s i t s available per year f o r each specialty at the work load l e v e l of the survey summarized i n Specialty P r o f i l e was calculated as follows: daily patient load* x number of s p e c i a l i s t s * * x 2 2 0  *  Based on a five-day week.  ** In the lower mainland and greater Vancouver regions ( 6 1 )  117  This was  then adjusted  for the physician work loads i n the  relevant regional areas on the basis of figures of sampled physician work loads published by the B. C. Health Resources Council ( 6 l ) .  It was  representative of the 3.  assumed that these values would then be region.  Bed Requirements  From the rate of h o s p i t a l i z a t i o n / 1 0 0 , 0 0 0 population ( 6 7 ) , average length of stay C6y),  and the incidence r a t e / 1 0 0  (U.S. data), the number of bed days/incident  f o r the  population  various  aggregated categories of diagnosis were derived. (Appendix C). The number of bed days available/year was  calculated by  multiplying the rated bed capacity of hospitals i n the lower mainland and greater Vancouver region (^5) year. was  by the number of days/  For the purposes of the model an 85 percent  occupancy rate  assumed on the basis of data i n d i c a t i n g an 8l-85# occupancy  rate i n B. 4.  C. Graduate Nurses  From the Report on Hospital S t a t i s t i c s (55),  the number  of f u l l - t i m e equivalent graduate nurses working i n the hospitals i n the above region was  derived.  Using t h i s f i g u r e , the number  of graduate nurses/bed days as well as the yearly available graduate nurses/bed day was 5.  Other  Various  calculated.  (Appendix B).  Considerations  service v i s i t s to physicians, i . e . checkups,  innoculations, etc. and several diagnoses f o r which incidence data was  not available were handled In a s l i g h t l y d i f f e r e n t manner. In order to u t i l i z e the simulation program and data  relevant to the above cases the i n c i d e n c e / 1 0 0 population replaced by v i s i t s / 1 0 0 populations  was  and v i s i t s / i n c i d e n c e was  set  118 equal to the f r a c t i o n of v i s i t s seen by a s p e c i a l t y . P. . Model Logic 1.  Overview of the Model  The model generates demands, allocates selected health care resources, on a p r i o r i t y b a s i s , feeds back and evaluates system shortages. Various interventions and p o l i c y alternatives are allowable f o r any year of the simulation. requirements  U t i l i z a t i o n , resource  f o r demand categories, exogeneous variable impact  (dominating f a c t o r s ) , and available annual resources may I n d i v i dually be allowed to Increase or decrease  l i n e a r l y or compoundly  and these rates may be changed f o r any simulated year. The yearly output i s a l i s t i n g of the t o t a l population, number of incidences In each demand category, available resources, resource surpluses or deficits i f demands and resources are matched without delegation, the number of treated and untreated cases, the actual resource surpluses or d e f i c i t s , and the value of the S o c i a l Impact Index. While the output i s currently available only In tabular form, a command language Is being developed to provide on-line graphical displays of a l l HPS submodel outputs as well as f o r the t o t a l regional simulation.  H E A L T H  P L A N N I N G  ^  119  M O D E L  START >J;  \ READ ALL DATA (INCLUDING INPUT / \ FROM POPULATION MODEL) /  ^  :  b  CALCULATE RESOURCES AT BEGINNING OF PERIOD \fc  INCIDENCE  SUBROUTINE  RESOURCE ALLOCATION SUBROUTINE (CALLS DELEGATION SUBROUTINE IF NECESSARY) I  *  1  | FATE SUBROUTINE | r  CALCULATE  —  INDEX  CALCULATE VARIOUS GROWTH FACTORS JK  r  PRINT RESULTS | \ i INCREMENT TIME  PERIOD  NO  -3>  UPDATE POPULATION MODEL  120  2.  Description (a)  of Subroutines  Incidence Subroutine ( i ) • Variable  Definitions  AGEP(K)  =  number of females i n age class K  AGEM(K)  =  number of males i n age class K  PDISM(K,I)  =  p r o b a b i l i t y of category I incidence i n males of age class K  PDISF(K,I)  =  p r o b a b i l i t y of category I incidence i n females of age class K  DOM(J)  =  value of J t h dominating factor  UTIL(I)  =  u t i l i z a t i o n factor f o r category I  CAT(I)  =  number of new cases i n category I  NNBRC  =  number of non b i r t h related categories  LDOM  =  the maximum number of dominating factors per category (presently  JD0M(L,I)  =  this i s 2 )  the number of the Lth dominating  factor  relevant  to disease I . I f there are fewer than L factors r e l a t i n g to category I,  121  JDOM(L,I) = 0. (II)  Program Logic The population submodel provides  the incidence subroutine  input to  i n the form of age and sex  c l a s s i f i e d yearly population projections. The number of incidences  or cases r e -  quiring services i n each category are calculated from population data and age and sex c l a s s i f i e d morbidity  incidence and service rates. Exogenous data from other submodels or  parametric estimates are used t o a l t e r "natural" prevalence rates of various morbidity  categories.  The exogenous variables influencing incidence  rates  have been termed dominating factors and are expressed as c o e f f i c i e n t s , which when m u l t i p l i e d by the natural prevalence rates y i e l d modified  rates r e f l e c t i n g the  e f f e c t of the exogenous v a r i a b l e s . The extent to which demand i s manifest depends on a number of factors previously  discussed  and Is subject to change as these factors change. It was, therefore, decided to Incorporate factors f o r each category.  utilization  Although In the program  these factors modify incidence and service rates, a given percentage change i n these rates w i l l result i n the same percentage change i n demand. Various  services such as prenatal care  etc., are related to the number of c h i l d d e l i v e r i e s . Required services related to b i r t h s , are calculated from population model data by multiplying the number  of d e l i v e r i e s , account being made f o r m u l t i p l e b i r t h s , by the s p e c i f i c requirements per (Appendlcies  C and  D)  dellve  123 I N C I D E N C E  ^  S U B R O U T I N E  START^  I = 1,NBRC CALCULATE THE NUMBER OF CASES IN CATEGORY I WORK = E{AGEM(K)*PDISM(K,I) + AGEF(K)*PDISF(K,I)} K  ;L = l,LDOM  J = JDOM(L,I)  NO  WORK = WORK*DOM(J)  CALCULATE MODIFIED DEMAND DUE TO ALTERED UTILIZATION CAT(I) = WORK*UTIL(I)  CALCULATE REQUIRED SERVICES '•. RELATED TO BIRTHS ;  t  ^  END  ^  124  (b)  P r i o r i t y Streaming (i)  Subroutine  Variable Definitions LPRI(I) = the highest p r i o r i t y to which cases i n category I may r i s e . STPRI(I,J) = the proportion of new cases i n category I waiting f o r treatment at p r i o r i t y l e v e l J , including new cases plus cases carried forward from the previous year.  The value  i n the f i r s t time period i s read i n , so that h i s t o r i c a l back logs may be accounted f o r . NCAT = number of morbidity and service categories (ii)  Program logic This subroutine allows f o r p r i o r i t i e s i n  providing service to the various demands.  Each  category i s described by the proportion of cases i n various p r i o r i t y classes, with 1 being the highest priority. Patients who f a i l * t o receive treatment i n one time period may move up one p r i o r i t y class i n the succeeding time period, with the l i m i t a t i o n that the highest p r i o r i t y to which a patient i n category I may r i s e i s LPRI(I). The subroutine calculates CAPRI(I,J) from the number of ne\i cases plus those returning from the previous year which have moved up one p r i o r i t y class where permitted.  P R I O R I T Y  S U B R O U T I N E  S T R E A M I N G  CAPRI ( I , J) = CAPRI ( I , J) + CAT(I)*STPRI ( I , J )  CALCULATE THE NUMBER OF CASES IN CATEGORY I AND PRIORITY CLASS J CAPRI (I,J) = CAPRI ( I , J)+CAPRI (I,JH) +CAT(I) *STPRI (I, J)  j = j +l  YES  NO  CAPRI ( I , J) = CAPRI(I,J+1) +CAT.(I) *STPRI ( I , J)  ^CONTINUS^-  ^  END  •> CAPRI ( I , J ) = CAT (I) *STPRI ( I , J)  125  126  (c)  Resource A l l o c a t i o n (1)  Subroutine  Variable Definitions UNTRE(I) = the number of untreated cases of category I. TRE(I) = the number of treated cases of category I. NPRI = the number of p r i o r i t y classes RES(K) = amount of resource K currently a v a i l able.  At present resources 1 - 9  are  physician s p e c i a l i t y resources, 1 0 i s beds and resources, 1 1 i s nurses. REQU(K, I) = the amount of resource K required per case i n category I. CAP - the number of untreated cases, ( i i ) Program Logic This subroutine allocates resources i n order of p r i o r i t y class.  Note that since the cases of  equal p r i o r i t y are treated sequentially by category number, there i s an i m p l i c i t secondary p r i o r i t y . This i s not intended to have any s i g n i f i c a n t  inter-  pretation and i s merely a r e s u l t of programming constraints. Appropriate resources are decremented on a p r i o r i t y basis to meet the requirements p r i o r i t y and category block, ( I , J ) .  for each  I f at any  time,  i t i s detected that the a l l o c a t i o n of resources to a p r i o r i t y and category block ( I , J) drives one or more resources negative, the delegation subroutine is c a l l e d .  Delegation i s then attempted before the  R  E  S  O  U  R  C  E  A  L  L  O  C  A  T  I  (" START  O  N  S  U  B  R  O  U  T  I  N  127  E  ~)  SET NUMBER OF TREATED (TRE) AND UNTREATED (UNTRE) CASES IN ALL CATEGORIES EQUAL TO 0 J = 1,NPRI I =  l NCAT f  END ^  YES IDEL = 2  K = 1.11  H O  YES DECREMENT RESOURCE K BY REQUIREMENTS RES (K) = RES (K) -REQU(K,I) * CAPRI (I, Jl  NO  YES IDEL = 1  CALL DELEGATION SUBROUTINE £ CALCULATE NUMBER OF TREATED CASES IN CATEGORY I TRE (I) = TRE (D+CAPRI (I ,J) -CAP CALCULATE NUMBER OF UNTREATED CASES IN CATEGORY I UNTR(I) - UNTR(I) -hCAP  <^I^L^>-  CALCULATE NUMBER OF TREATED OASES IN CATEGORY I TRECI) = TRE(I)+CAPRI) I, J)  next sequence ( I , J) Is processed.  The number of  cases which are not treated each time the delegation 'subroutine i s c a l l e d i s calculated by the delegation subroutine and returned i n storage area CAP. The number of treated and untreated cases f o r each time period i s calculated f o r a l l categories and stored i n TRE(I) and UNTRE(I). (d)  Delegation Subroutine (i)  Variable Definitions CAP = the equivalent number of untreated cases ALPA = the additional number of GP equivalent cases required to compensate f o r a f a i l u r e to provide a h o s p i t a l bed f o r a case. RES(l) = G.P. resources  (visits)  EXCHA(K,1) = the exchange rate when using G.P. resources to substitute f o r physician resource K. RESI(K) = amount of resource K at the beginning of the time period, (il)  Program Logic The flow chart Is self-explanatory f o r the  most part, except f o r the c a l c u l a t i o n of the equivalent number of untreated cases when a bed shortage exists f o r which physician resources cannot  fully  compensate, (see Section D) Each case requirement  i s assumed to be  represented by one GP equivalent case requirement the GP equivalent of the case bed requirement., or  plus  129 D E L E G A T I O N  [ C A P = 0  S U B R O U T I N E  PHYS* = 0  j  REQ = 0  )L  CONVERT A L LPHYSICIAN RESOURCES T O GP RESOURCE EQUIVALENTS AND A L LPHYSICIAN REQUIREMENTS TO G P R E S O U R C E E Q U I V A L E N T R E Q U I R E M E N T S 9  P H Y S =Z  RES(K)* EXCHA(K,1)  K  9  R E Q = ^ E R E Q U ( K , I ) * E X C H A ( K , 1) )k CALCULATE GP EQUIVALENT CASE SURPLUS (DEFICIT) PHYS = PHYS/REQ i  NO  CAP ...  =  -PHYS V  PHYS = 0  :  ;  & RESTORE BED AND NURSING SERVICES WHICH WERE ALLOCATED B U T F O R WHICH TREATMENT IS NOT GIVEN BECAUSE OF PHYSICIAN SHORTAGE RES(10) = R E S ( 1 0 ) + R E Q U ( 1 0 , I ) * C A P R E S (11) = R E S ( 1 1 ) + R E Q U ( 1 1 , I ) * C A P  NO  \  YES  CALCULATE B E D CASE SHORTAGE (SURPLUS) BEDS = RES(10)/REQU(10,I)  NO  YES  •M  l  RES(10) = 0  :  :  ±  RESTORE NURSING SERVICES WHICH WE'RE ALLOCATED BUT NOT UTILIZED BECAUSE OF BED SHORTAGE R E S ( l l ) = RES(11)-REQU(11,I) *BEDS CALCULATE EQUIVALENT GP CASES WHICH COULD COMPENSATE FOR BED SHORTAGE BEDS = BEDS*ALPHA  WORK  _  = PHYS+BEDS  WORK  >  :  DECREMENT ALL APPROPRIATE PHYSICIAN RESOURCES  0  . . e . , CAN PHYSICIANS COMPLETELY COMPENSATE . F O R ' B E D SHORTAGE. ?  YES  *  E5ES(K)  CALCULATE EQUIVALENT NUMBER OF UNTREATED CASES • CAP = CAP-WORK/ (1+ALPHA) 5  \k  S E T ALL PHYSICIAN RESOURCES TO 0  ^ E N D  NO  =  RES ( K ) +  REQU(K,I)*BEDS  131  .CANNOT SUBSTITUTE WITH THIS PHYSICIAN RESOURCE SUB(K) = 0  | BIG  =  00001  C H O O S E i n E AVAILAcLci S f ^ C X A L T ' I W h i c t i NORMALLY TREATS THE GREATEST NUMBER OF CASES I N CATEGORY I OR WITH THE GREATEST PERCENTAGE OF RESOURCES REMAINING WHEN ALL PHYSICIAN RESOURCES NORMALLY ALLOCATED TO CATEGORY I ARE DEPLETED BIG = S U B ( K ) KSUB = K  NO XL  CALCULATE THE RATIO OF REMAINING RESOURCES TO INITIAL RESOURCES FOR EACH CATEGORY SUB(K) = RES(K)/RESI(K)  132  © K = 1.9  YES  SUBSTITUTE DECREMENT R E S ( K ) .-  FOR  THIS  RESOURCE  SUBSTITUTED  AND  RESOURCE  RES(KSUB)+RES(K)*EXCHA(K,KSUB)  (1 + ALPHA)GP equivalent cases.  The number of d e f i c i t  equivalent cases i s given by WORK = PHYS + BEDS. Therefore the number of untreated cases i s given by CAP - WORK 1 + ALPHA )  Subroutine Fate (i)  Variable Definitions HAPT(I,K) = the number of treated cases of category I r e s u l t i n g i n outcome K. HAPU(I,K) = the number of untreated cases i n category I r e s u l t i n g i n outcome K. PHAPT(I,K) = the p r o b a b i l i t y of outcome K f o r treated cases i n category I PHAPU(I,K) = the p r o b a b i l i t y of outcome K f o r untreated cases i n category I. NHAP = the number of d i f f e r e n t possible outcomes.  ( i i ) Program Logic The subroutine calculates the various outcomes for a l l categories and the number of cases by category and p r i o r i t y to be carried over to the succeeding year. At present only one possible outcome i s considered (K = 2) f o r which treated and untreated cases return i n the subsequent year f o r treatment. PHAPT(I, 2) has been set equal to 0 and PHAPU(I, 2) has been set equal t o 1.  F A T E  ( I =  134  S U B R O U T I N E  START  }  l.NCAT K =  1,NHAP HAPT(I,K)  =  HAPU(I,K)  =  TR(T)*PHAPT(I,K) \^ UNT(I)*PHAPT(I,K)  NO  TR(I)  = T R ( I ) -WORK  YES C A P R I (I,J)  ±  =  WORK*PU  C A P R I (I, J ) =  C  END  3  (WORK+TR(I) ) *PT-TR(I)*PU  CHAPTER VII.  EXPERIMENTS"  This chapter w i l l present the r e s u l t s o f several p i l o t 1  experiments  which have been chosen to demonstrate some of the  c a p a b i l i t i e s of the regional planning model.  The experiments  are designed to show the possible impacts of various resource growth rates.and environmental factors.  The impact i s measured  i n terms of the s o c i a l impact index and shortages or surpluses of resources. Experiment  1  The model was run f o r a 25 year simulated time period, with projected regional population growth and constant resource growth rates of 1, 2, 3, 4, and 5%. Various resources, even i n the i n i t i a l year of the simul a t i o n , were i n excess of forecasted regional requirements, whereas others were i n shortage.  For i l l u s t r a t i v e  purposes,  obstetrician/  gynecologist (OG) and urologist (UROL) resource surpluses ( d e f i c i t s ) for a 4$ constant resource growth rate are presented i n Table 12. .Year 0 5 10 15 20 25  Table 12.  OBG visits  UROL visits  -22,230 -16,773 -54,340 -116,947 -190,184 -265,135  15,026 14,202 8,657 -3,150 -22,434 -49,464  Obstetrician/Gynecologist and Urologist Resource Surpluses f o r a 4% Constant" Resource Growth Policy  136 Since the model allows f o r s u b s t i t u t i o n of v a r i o u s r e s o u r c e s , the s u r p l u s r e s o u r c e s  compensating f o r d e f i c i t r e -  s o u r c e s , an o v e r a l l r e s o u r c e shortage, as r e f l e c t e d by a nonzero v a l u e of the s o c i a l Impact index, i s not evidenced years  until  4 , 6 , 8 , 1 2 , and 1 7 f o r the r e s p e c t i v e growth r a t e s  ( F i g u r e U).  The s u b s t i t u t i o n process  allowed In the model i s  p a r a l l e l e d i n r e a l i t y , s i n c e many s p e c i a l i s t s p r o v i d e f o r c o n d i t i o n s which are not s t r i c t l y i n t h e i r f i e l d zation.  treatment of s p e c i a l i -  T h i s s i t u a t i o n occurs f r e q u e n t l y , as a number of  s p e c i a l i s t s are a l s o engaged, p a r t - t i m e , i n g e n e r a l p r a c t i c e .  137  YEARS  Figure 4:  The Effect of Various Linear Growth Rates(for A l l Resources) on the Social Impact Index  138 For a l l f i v e growth rates, the s o c i a l impact index grows i n an exponential or compound manner.  This behaviour of the  index i s to be expected, since; (a) requirements  the population and also the i n d i v i d u a l resource increase at compound rates of approximately  4 - 5%  (Table 13). As demand increases at a f a s t e r rate than supply, the shortages grow at an increasing rate. (b)  as the resource shortages increase, the untreated  cases are of progressively higher p r i o r i t y classes.  While a l l  SIRS values within a given p r i o r i t y class are not greater than a l l SIRS values i n lower p r i o r i t y classes, the average SIRS value Increases as the p r i o r i t y class increases.  The untreated cases  are, therefore, generally weighted with increasing SIRS values, as the resource shortages increase. (c)  the present version of the model allows only one  possible outcome, each, f o r treated and untreated cases. A l l untreated cases are returned f o r treatment with a p r o b a b i l i t y of 1 and a l l treated cases are regarded as being completely r e covered and are returned f o r treatment with a p r o b a b i l i t y of 0. As resource shortages continue to increase, the cummulative effects of the demand carry-over increases the index at an accelerated rate. While the untreated demands may properly be regarded as contributing to the s o c i a l Impact Index i n the year i n which they are i n i t i a l l y not met, i t i s not v a l i d to assume that a l l such cases w i l l be manifest as demands carried over into the subsequent year.  Other outcomes such as death, p a r t i a l recovery of treated  and untreated cases, and the relapse of treated cases w i l l ,  t h e r e f o r e , be added t o l a t e r v e r s i o n s of the model. Experiment 2 The above experiment was repeated f o r compound r e s o u r c e growth r a t e s .  The f i r s t year In which o v e r a l l system shortages  were evidenced f o r growth r a t e s of 1, 2, 3, and *\% were 4, 6, 9 and 22 ( F i g u r e 5) .  No o v e r a l l shortage;was e v i d e n c e d f o r a 5%  compound r e s o u r c e growth rate.,.  120-1  Y E A R S  F i g u r e 5: The E f f e c t of V a r i o u s Compound Growth Rates (for A l l R e s o u r c e s ) o n the Social Impact Index  141 In experiments 1 and 2, the s o c i a l impact index has a value of 0 i n the e a r l i e r years of the simulation, indicating that, o v e r a l l , resources are i n i t i a l l y requirements.  i n excess of regional  This apparent surplus i s l a r g e l y due to the export  of services to other regions, i . e . services u t i l i z e d by patients referred to the Greater Vancouver region f o r treatment.  Since  the export of services has not been accounted f o r i n the present version of the model, the results must be Interpreted as the a b i l i t y of regional resources to cope only with regional demands. To bbtain an impression of the manner i n which regional resource requirements behave over time, the annual increases i n resource requirements, f o r the projected population growth, are presented i n Table 13.  The more or less constant yearly increase  in resource requirements i s a result of a population growth rate which i s approximately compounded at 4 - 5%, with very l i t t l e change occurring i n the age and sex structure. In comparison, Table 14 i l l u s t r a t e s the percentage change i n resource requirements (for five year i n t e r v a l s ) under conditions approximating zero population growth (no migration and births limited to 2 per susceptable women). The following are some of the more important aspects observed i n Table 14. (a)  As a r e s u l t of a decrease i n the b i r t h rate,  obstetrician/gynecologist resource requirements  significantly  decrease by 16.78$ during the f i r s t f i v e year period of the simulation.  A decrease i s again evidenced i n the last f i v e year  period of the simulation, years 20-25.  This decrease of 5.66$  in the last f i v e year period r e f l e c t s the maturing of women who were born subsequent to the zero population growth intervention.  Table 13: Percentage Increases i n Population and R e s o u r c e R e q u i r e m e n t s * for P r o j e c t e d Population Growth  SURG visits  ORS visits  PED visits  UROL visits  Beddays  IM visits  4.58  4.55  4.56  4.38  4.48  4.45  4. 5 7  4. 6 4  4. 9 6  4.66  4. 38  2 - 3  4. 5 8  4. 55  4. 5 6  4. 3 8  4. 4 8  4. 4 7  4. 5 8  4. 6 4  4. 9 7  4. 6 7  4 36  3-4  4. 5 9  4. 5 6  4. 5 6  4. 4 0  4. 50  4.45  4. 5 9  4.63  4.95  4.67  4. 38  4-5  4.60  4. 60  4.59  4.43  4. 51  4. 5 5  4. 6 0  4. 6 8  5.12  4. 6 8  4. 4 9  5 -6  4.62  4. 6 3  4.59  4. 4 8  4. 5 5  4. 6 2  4. 6 2  4.40  5.12  4 69  4. 53  6 - 7  4.63  4. 68  4.62  4. 5 6  4.60  4. 7 3  4.63  4. 70  5.19  4. 7 0  4.68  7 -8  4. 6 5  4. 70  4. 6 4  4. 5 7  4.61  4. 7 4  4.65  4. 71  5.24  4. 71  4. 6 9  8 - 9  4.66  4.72  4.65  4. 5 5  4. 58  4. 7 5  4.66  4. 7 2  5.31  4. 7 3  4. 6 7  9-10  4.68  4. 74  4.68  4.57  4. 5 9  4.80  4.68  4.76  5. 38  4.75  4. 7 2  1 0 - 11  4. 71  4. 79  4. 70  4. 6 3  4. 6 5  4.86  4. 71  4. 7 8  5.41  4. 7 7  4.80  11- 12  4. 7 2  4.82  4.73  4.65  4.66  4.91  4. 7 2  4.81  5. 3 5  4. 7 8  4 83  12 - 13  4. 7 4  4.83  4. 75  4. 6 5  4.66  4.93  4. 7 4  4.83  5 33  4 80  4 82  Population  1-2  * The key to p h y s i c i a n abbreviations i s given in appendix B  OTO visits  OBG OPH 'v i s i t s visits  GP visits  Vears  T a b l e 13; -- Continued  > OPH visits  OBH visits  UROL visits  4.90  4.85  5. 2 8  4.81  4 88  4.96  4. 7 7  4.89  5.18  4.82  4.82  4.69  4.97  4. 7 7  4.87  5.01  4.82  4. 7 8  4.69  4.69  4. 9 6  4. 7 7  4.89  4. 7 9  4.81  4. 74  4.77  4.65  4.65  4. 9 3  4. 7 5  4.87  4. 58  4 80  4 65  4. 7 9  4.75  4. 6 5  4.65  4. 91  4. 73  4 85  4. 35  4. 78  4. 5 9  4. 70  4.75  4.72  4.60  4.60  4.86  4. 70  4.82  4.15  4. 7 5  4 49  20 - 21  4.67  4. 71  4.68  4.58  4. 58  4.83  4.67  4. 78  4.00  4. 71  4 43  21- 22  4.63  4.66  4.64  4. 5 3  4.53  4. 7 8  4.63  4. 7 4  3.85  4. 6 7  4 36  22 - 23  4. 58  4. 61  4. 5 9  4.49  4. 4 9  4. 7 3  4. 5 8  4. 6 9  3. 71  4 63  4 28  23 - 24  4.54  4. 5 7  4. 5 5  4.46  4.47  4. 6 9  4. 5 4  4. 6 4  3. 6 4  4 58  4 25  24-- 25  4.50  4. 52  4.50  4. 3 9  4.40  4. 6 2  4. 5 0  4. 6 0  3. 5 6  4 54  4 18  SURG visits  ORS visits  4. 7 7  4.71  4.71  4.97  4.86  4. 79  4.68  4.68  4. 7 7  4.86  4. 78  4.69  16 - 17  4. 7 7  4.84  4. 7 9  17 - 18  4. 75  4.82  18 - 19  4.73  19 - 20  GP visits  Years  Population  13 - 14  4.76  4.86  >'14 - 1 5  4. 7 7  15 - 16  IM visits  PED visits  OTO visits  Feddays  -Cr  Table 14: Percentage Increases i n Population and Resource R e q u i r e m e n t s for Z e r o Population Growth  Years  Population  GP visits  ORS visits  PED visits  .14  ,.53  .72  2.07  1.89  1. 46  1. 46  1.95  1.92  1.73  1.99  1.86  1.96  1.38  1. 34  1. 85  2. 04  .77  -.34  .02  . 04  .27  .77  1.24  1.13  10 - 15  1.96  15-20  5  -r81  .29  . 66  . 56  . 55  OPH visits  1.06  5-10  5  -1.35  OTO visits  - . 20  •  25  SURG visits -.77  0 - 5  20 -  IM visits  1.41  . 37  OBG visits -16.78  UROL visits .95  Bedda  /B  -5.93  7.11-  I. 53  1. 23  6. 66  2. 25  2. 42  I. 84  . 53  2. 24  .94  . 53  - 5 . 66  1.00  - 1 . 34  The cohort of women with the highest f e r t i l i t y rates comprise a smaller proportion of the t o t a l population i n t h i s time period than i n previous periods of the simulation. (b)  a s i m i l a r result i s evidenced  for p e d i a t r i c i a n s .  i n the requirement  The requirements decrease by 1.35% i n the  f i r s t 5 year period and the rate of increase has declined from l.&5%  i n years 15-20  significantly  to 0.27? i n years 20-25.  Experiment 3 As discussed i n Chapter V, the use of constant may  ratios  not be an appropriate basis to plan f o r future health care  delivery services.  In order to determine t o what extent t h i s  applies i n the present case, bed day requirements/total regional population r a t i o s were calculated.  Table 15 shows these r a t i o s  for projected regional population growth over a 25 year period. Year  Ratio  Year  Ratio  Year  Ratio  1 2 3 4 5 6 7 8  1.011 1.008 1.006 1.004 1.002 1.001 1.001 1.001  10 11 12 13 14 15 16 17  1.001 1.002 1.002 1.003 1.004 1.004 1.003 1.003  18 19 20 21 22 23 2^4 25  1.001 1.000 .997 .995 .992 .988 .985 .982  Table 15.  Bed day requirements/total- population f o r projected r e g i o n a l population.  As can be seen, the use of a constant value of approximately 1 bed day per person per year could adequately determine regional bed requirements.  serve to  However, i n instances i n  which the underlying demographic variables undergo more r a d i c a l changes, t h i s may  not be a very appropriate method.  The actual d i s t r i b u t i o n of beds along f u n c t i o n a l lines  such as maternity, s u r g i c a l and chronic care i s not indicated at t h i s l e v e l of g r a n u l a r i t y .  Changes i n population age and  sex  structure are l i k e l y to produce s h i f t s i n the demands f o r s p e c i f i c bed categories.  Later more refined versions of the model w i l l ,  therefore, c l a s s i f y beds and demands for beds by functional use. Experiment 4 L i t t l e i s known about the r e l a t i o n s h i p between a i r p o l l u t i o n and morbidity.  We may,  however, parametrically  examine the possible impact of a i r p o l l u t i o n on the performance of the health care system. Lave and Seskin (42) suggest that a 50 percent i n a i r p o l l u t i o n i n the major urban areas of the United  reduction States  could r e s u l t i n a 25 percent reduction i n morbidity and mortality due to a l l respiratory diseases.  It was,  therefore, f e l t that  compound growth rates of up to 2% i n the incidence of morbidity suspected  of being related to a i r p o l l u t i o n would not be unreason-  able to assume f o r the Greater Vancouver region, which currently experiences  r e l a t i v e l y low a i r p o l l u t i o n l e v e l s .  Dominating  factors 2 (gaseous a i r p o l l u t i o n ) and 7 (particulate a i r p o l l u t i o n ) were, therefore, allowed to Increase model, at compound rates of 1 and 2%.  i n two separate  runs of the  (Figure 6).  While the e f f e c t s of these exogeneous variables on the s o c i a l impact index do not appear to be s i g n i f i c a n t , i t should be noted that some degree of caution must be exercised i n i n t e r p r e t i n g the r e s u l t s .  Changes i n the s o c i a l impact index provide a measure  only of the a b i l i t y of the health care system, with i t s predeter- : mined p r i o r i t i e s , to cope with any increases i n demands as a result of the influences of the exogeneous v a r i a b l e s .  In many cases.  gure 6: S o c i a l Impact Index f o r 1 a n d 2% Compound Growth i n A i r P o l l u t i o n R e l a t e d Morbidity-  demands of lower p r i o r i t y may be displaced i n order that resources may be allocated, i n the model, to provide treatment f o r i n creased incidences of higher p r i o r i t y .  In such cases, the index  r e f l e c t s the impact of the variables only i n terms of an increase in untreated demands of lower p r i o r i t y .  I f the increased i n -  cidences receive treatment, no account i s made of the discomfort, loss of s o c i a l function, etc. experienced by these i n d i v i d u a l s . Ohly i n the event that resources are i n s u f f i c i e n t to meet these increased demands, does the s o c i a l impact index r e f l e c t more f u l l y the seriousness of the increases i n incidence. The SIRS values which have been employed to derive the s o c i a l impact index are measures of the public's perception of the seriousness of having s p e c i f i c conditions. not d i f f e r e n t i a t e  These values do  between having a condition for which treatment  Is received and having a condition for which treatment i s not received.  In many cases, i t i s l i k e l y that the perceived  seriousness of having s p e c i f i c conditions Is influenced by perceptions of the effectiveness with which these conditions may be treated and the consequences of not receiving treatment. For these two circumstances the perceptions may be almost  identical,  i n cases f o r which treatment i s not perceived as being.effective or may d i f f e r s u b s t a n t i a l l y , i n cases f o r which the outcome may be dependent on whether or not treatment i s received. The above shortcomings of the s o c i a l impact index necessitates  a more refined approach.  A methodology similar t o that  used i n deriving the SIRS values should be employed to obtain values f o r (a)  the seriousness of having conditions f o r which treatment i s received.  (b)  149  the seriousness of having conditions f o r which treatment i s not received.  Such measures would provide an improved weighting system for evaluating the s o c i a l impact i n terms of the a b i l i t y of health care resources to meet demands.  In addition, such measures would  provide a means to measure the Impact of exogeneous variables not only i n terms of those who seek treatment, but also i n terms of that segment of the population which are affected but which do not seek professional medical services.  1 Some of the results are also discussed i n E c o l o g i c a l Planning of Health Care, I. Ventinsky and G. Povey, Unpublished Working paper of U.B.C. Health System Group.  CHAPTER VIII. A.  FUTURE IMPROVEMENTS AND EXPERIMENTS  Extensions and Refinements While, i n i t s present stage of development, the described  planning model can be u t i l i z e d f o r demonstration purposes, further extensions and refinements are necessary before i t can be operationally employed f o r r e a l planning purposes i n B r i t i s h Columbia.  In addition to the extensions and refinements proposed  i n Chapter VII, t h i s section w i l l discuss other major improvements to the model. (1)  The present version of the model employs 27 aggregate  demand categories. The weighting values used i n deriving the s o c i a l impact index are a composite  of SIRS values.  These com-  posite values were arrived at on the basis of the r e l a t i v e comp o s i t i o n of the aggregate demand categories i n 1968, the base year of the simulation. The s o c i a l Impact index i s , thus, i n sensitive to changes which may occur i n the r e l a t i v e composition within the demand categories.  In addition, resources are  allocated on the basis of requirements f o r the aggregate demand categories.  A change i n the r e l a t i v e composition of a demand  category may, i n r e a l i t y , require that the mix of required resources also change.  I t i s , therefore, anticipated that a f i n e r  classifi-  cation of the demand categories w i l l be provided when compatible data become a v a i l a b l e . (2)  The simulation model employs v i s i t s as a measure of  physician time u t i l i z a t i o n .  The t o t a l number of available v i s i t s /  year within each physician specialty i s s p e c i f i e d as the product  of the average number of v i s i t s / y e a r / f u l l time equivalent s p e c i a l i s t and the number of f u l l time equivalent p r a c t i c i n g i n the s p e c i a l t y .  physicians  Since the average time required per  v i s i t i s not the same f o r a l l demand categories, v i s i t s may be an inappropriate measure of physician resource a v a i l a b i l i t y and u t i l i z a t i o n , e s p e c i a l l y i f the composition  of demand changes.  Later versions of the model may, therefore, employ measures which better r e f l e c t physician time u t i l i z a t i o n . (3)  The logic of the current version of the model assumes  that physicians may substitute f o r bed shortages.  The r a t i o of  s u b s t i t u t i o n , ALPHA, i s the same f o r a l l demand categories r e quiring h o s p i t a l beds.  For conditions requiring a major s u r g i c a l  procedure, physician time cannot substitute f o r the required hospital f a c i l i t i e s .  In other cases, the s u b s t i t u t i o n which can  be made d i f f e r s between demand categories. tuting physician resources  The r a t i o of s u b s t i -  f o r h o s p i t a l beds should be r e f l e c t i v e  of the actual s u b s t i t u t i o n which can be made i n each demand category  and i n cases where s u b s t i t u t i o n cannot be made, the  demand should be regarded as being unmet.  Future versions of the  model w i l l , therefore, attempt to correct t h i s shortcoming. (4)  I t i s planned to expand the resource  include e s s e n t i a l support  categories to  services such as radiology, anaesthesi-  ology, operating f a c i l i t i e s , etc.  This extension may also include  alternative f a c i l i t i e s and services such as private hospitals and chiropractor services. (5)  To provide a basis f o r cost-benefit or cost-effec-  tiveness analysis, cost functions, both operating and c a p i t a l , w i l l be added to l a t e r versions of the model. (6)  I f the s o c i a l impact index i s to r e f l e c t a s o c i a l  evaluation of the a b i l i t y of the health care system to meet demands, the shortcomings of the system should be examined i n r e l a t i o n to the t o t a l demands placed on i t .  A normalized s o c i a l  impact index (SII) having the following form i s proposed. SII = S S I R ( i ) u n t ( i ) ^SIRU)dem(i) where:  SIR(i) = the perceived seriousness of not receiving treatment f o r a condition i n demand category i u n t ( i ) = the number of untreated cases i n demand category i f o r which  treat-  ment i s sought dem(i) = the number of cases i n demand category 1 f o r which treatment i s sought. By redefining the s o c i a l impact index i n this manner, a r e l a t i v e measure of system performance i s obtained.  The develop-  ment of this index w i l l necessitate obtaining data r e l a t i n g the number of v i s i t s / t r e a t e d case or the number of incident cases f o r which treatment i s sought/the t o t a l number of incident cases i n each demand category.  Further research w i l l be required to define  levels of system performance and to e s t a b l i s h a correspondence between these levels and values of the s o c i a l impact index. B.  Future Experiments Some of the model's c a p a b i l i t i e s were demonstrated by the  experiments presented i n Chapter VII.  These are but a few of the  possible experiments which can be performed employing the model. This section w i l l discuss two experiments which are now being planned.  153  (1)  To date, only one p r i o r i t y system and one  routine have been employed In the model. alternatives which may  be studied.  Impact index and resource shortages  delegation  There are numerous  The s e n s i t i v i t y of the s o c i a l to p r i o r i t i e s and delegation  should be examined. One  aspect of medical care which i s l i k e l y to be impor-  tant In the future i s the increased use of auxilary medical personnel.  It Is e s s e n t i a l that the implications of an increased  role for auxilary medical personnel be investigated. The model offers one possible means of examining the economic implications as well as the maximum a b i l i t y of given levels of physician resources to cope with demands when various delegations are allowed. may  The parameters to be used i n the model  be a combination of data from empirical studies such as that  of Uyeno (72) (2)  and subjectively extrapolated The present  estimates.  logic of the model assumes that current  treatment patterns w i l l p e r s i s t i n the future.  Alternative  patterns of treatment such as day care and s a t e l l i t e health centre services may  have appreciable implications f o r future modes: of  health care d e l i v e r y . The model, with appropriate cost functions and of the human and physical resource requirements/case, alternative health care delivery patterns, may  estimates under  serve as a frame-  work to study alternative c a p i t a l and operating costs. 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V o l . 113, No. 5 (Nov. 1970T  60.  Sanders, B.S. Vol.  "Measuring Community Health Levels" 54  A.J.P.H.  (1964).  61.  Scarrow, H. Medical Manpower Survey I968-I969. B. C. Health Resources Council, Technical Report M-l ( 1 9 6 9 ) .  62.  Shannon, G.W., et a l . "The Concept of Distance As A Factor In A c c e s s i b i l i t y and U t i l i z a t i o n of Health Care" Medical Care Review. V o l . 26 (February 1 9 6 9 ) .  63.  Shapiro, Sam. "End Result Measurements of Quality of Medical Care" The Milbank Memorial Fund Quarterly Vol. 45, No. 2 ( A p r i l 1 9 6 7 ) .  64.  Sheps, Mendel C. "Approaches to the Quality of Hospital Care" Public Health Reports. V o l / 70, No. 9 (Sept. 1 9 5 5 ) . :  65.  Sokolow, J . and E.J. Taylor. "A Method f o r Functional D i s a b i l i t y Evaluation" Journal of Chronic Disease. Vol.  20  (1967).  66.  Specialty P r o f i l e - National Disease and Therapeutic Index. Lea, Incorporated, Ambler, Pennsylvania ( 1 9 6 9 ) .  67.  S t a t i s t i c s of Hospital Cases Discharged. Department of Health Services and Hospital Insurance, V i c t o r i a , B r i t i s h Columbia ( 1 9 6 9 ) .  68.  S u l l i v a n , D.F. Conceptual Problems in Developing arid Index of Health. Office of Health S t a t i s t i c s Analysis, National Center for Health S t a t i s t i c s , Series 2, No.  17  (1966).  69.  Task Force Reports on the Cost of Health Services i n Canada. Ottawa, The Queen's Printer f o r the Department of Health and Welfare, No. 1969.  70.  Trends In Health and Hospital Care Chart Book 1969. Vol. 1. Canadian Hospital Association and The Dominion Bureau of S t a t i s t i c s , ( 1 9 6 9 ) .  71.  Tyhurst, J.S. "A Plan For Day Hospital Care of Psychiatric Patients At The Vancouver General Hospital " Jan. 14, 1965.  72.  Uyeno, Dean. Health Manpower Systems. Unpublished PhD. d i s s e r t a t i o n , North Western U n i v e r s i t y , ,Evenston, I l l i n o i s , June 1971.  160  73.  V e r t i n s k y , I . " L i f e S t y l e s , E n v i r o n m e n t , And H e a l t h P r o b l e m s : A n . E c o l o g i c a l P e r s p e c t i v e Of H e a l t h C a r e " I n Human B i o l o g y and Human E c o l o g y . H. E. K a s i n s k y and S. K o r t ( e d . ) ( i n p r e s s ), ;  74.  W e i s s , J . E . and M.R. G r e e n l i c k . "Determinants o f Medical C a r e U t i l i z a t i o n : The E f f e c t o f S o c i a l C l a s s and. D i s t a n c e on C o n t a c t s w i t h t h e M e d i c a l C a r e S y s t e m " M e d i c a l Care. V o l . V I I I , No. 6 (Nov.-Dec. 1 9 7 0 ) .  75.  W i n k e l s t e i n , W. J r . and F . E . F r e n c h . "The R o l e i n t h e D e s i g n o f a H e a l t h Care System" Medicine.  V o l . 1 1 3 , No.  5  (Nov.  of Ecology California  1970).  76.  W y l e r , A.P.., M. Masuda, and T.H. H o l m e s . "Seriousness of I l l n e s s Rating Scale" J o u r n a l o f Psychosomatic R e s e a r c h . V o l . 1 1 (196871  77.  W y l e r , A.R., M. Masuda, and T.H. H o l m e s , " S e r i o u s n e s s o f I l l n e s s Rating Scale P e p r o c u c i b i l i t y " . Journal o f P s y c h o s o m a t i c R e s e a r c h . V o l . 14 ( 1 9 7 0 7 7 " ^  APPENDIX A - Major (a)  Pollutants  Particulate  Air Pollution  L i t t l e study has been made on the e f f e c t specific particulate  air pollution.  Some s t u d i e s have i n d i c a t e d that strongly that  on h e a l t h of  carbonaceous  a s s o c i a t e d with the i n c i d e n c e of g a s t r i c  -asbestos p a r t i c l e s  asbestos lung (b)  soot  is  cancer and  are c o r r e l a t e d w i t h a s b e s t o s i s  and  cancer. Carbon Monoxide  Carbon monoxide  (CO), produced l a r g e l y  combustion of motor v e h i c l e any of the major gaseous  f u e l , has the h i g h e s t  lncomplet  c o n c e n t r a t i o n of  pollutants.  In low c o n c e n t r a t i o n s s p e c i f i c In high c o n c e n t r a t i o n s  from the  it  symptoms are not  can produce headache,  evident.  vertigo,  mental  c o n f u s i o n , unconsciousness and d e a t h . It  i s b e l i e v e d the CO may have an e f f e c t  on some people  w i t h p r e - e x i s t i n g m e d i c a l c o n d i t i o n s such as emphysema and coronary v a s c u l a r d i s e a s e .  The e v i d e n c e ,  however,  i s not c o n -  clusive . (c)  S u l f u r Dioxide A i r P o l l u t i o n  Sulfur dioxide  ( S O 2 ) , an i n d u s t r i a l p o l l u t a n t ,  is  the  major component of smog t y p i c a l of Londoi^New York and Tokyo. S u l f u r d i o x i d e causes can adversely diseases  affect  i n c r e a s e d airway r e s i s t a n c e  persons s u f f e r i n g  and  from such r e s p i r a t o r y  as c h r o n i c b r o n c h i t i s , asthma, and emphysema.  It  has  been c o r r e l a t e d t o c h r o n i c b r o n c h i t i s deaths when p a r t i c u l a t e , a i r pollutants (d)  are  present.  Photochemical A i r P o l l u t i o n  Energy from s u n l i g h t t r i g g e r s  chemical r e a c t i o n s  of  7 h y d r o c a r b o n v a p o r s and n i t r i c ozone, n i t r o g e n d i o x i d e  162  oxide i n the atmosphere t o produce  and o t h e r p h o t o c h e m l c a l s .  T h i s form o f p o l l u t i o n i s c h a r a c t e r i s t i c California  of Southern  smog.  Ozone i s h i g h l y t o x i c  even  i n s m a l l c o n c e n t r a t i o n s and  has been f o u n d t o a c c e l e r a t e b a c t e r i a l i n f e c t i o n s  a t low tempera-  tures . Other p h o t o c h e m l c a l s can produce irritation  and o t h e r e f f e c t s  e y e and r e s p i r a t o r y  on t h e r e s p i r a t o r y  a g g r a v a t i n g asthma and c h r o n i c b r o n c h i t i s . t h a t t h e y may h a v e an e f f e c t (e)  s y s t e m , s u c h as  I t i s also  on t h e c a r d i o v a s c u l a r  believed  system.  Sewage  Sewage t r e a t m e n t h a s l a r g e l y b e e n c o n c e r n e d w i t h r e d u c i n g the  t r a n s m i s s i o n o f c o m m u n i c a b l e d i s e a s e s s u c h as t y p h o i d f e v e r ,  c h o l e r a and d y s e n t r y . P r i m a r y and s e c o n d a r y i n removing  sewage t r e a t m e n t i s n o t e f f e c t i v e  t o x i c heavy m e t a l s , d e t e r g e n t s and n u t r i e n t s .  N u t r i e n t s , d i s c h a r g e d i n t o t h e waterways cause a l g a e and o t h e r oxygen d e p l e t i n g p l a n t g r o w t h . instances this  I n a number o f  e x c e s s i v e p l a n t grox^th and o r g a n i c p o l l u t i o n  r e s u l t e d i n t h e d e a t h o f numerous (f)  increased  have  fish.  Mercury  Many o r g a n i c m e r c u r y  compounds f r o m i n d u s t r i a l and  a g r i c u l t u r a l s o u r c e s and i n o r g a n i c m e r c u r y may be c o n v e r t e d t o m e t h y l m e r c u r y t h e y have been d i s c h a r g e d i n t o t h e M e t h y l mercury  Organic mercury  by n a t u r a l p r o c e s s e s  sources  after  waterways.  i s both highly t o x i c  concentrated In b i o l o g i c a l  from i n d u s t r i a l  and s t a b l e and c a n be  tissues.  has been w i d e l y r e p o r t e d i n f i s h  and b i r d s  and i n i s o l a t e d cases has resulted  i n human deaths from the con-  sumption of food containing i t i n excess l e v e l s , (g)  DDT  DDT and other insecticides are carried great distances from t h e i r o r i g i n a l sources by a i r and water with the r e s u l t that organochlorine residues are widely d i s t r i b u t e d over the earth. These residues are concentrated through the food chain, DDT occurring with an average of 12 ppm i n human fat i n the United States. DDT i s suspected to be correlated with l i v e r cancer and deaths due to hypertension and leukemia.  A P P E N D I X B - A v a i l a b l e R e s o u r c e s i n the F i r s t Y e a r  Resource  Visits/year  1.  G e n e r a l P r a c t i t i o n e r (GP)  3,922,424  2.  Internal Medicine (IM)  438, 504  3.  Surgeon (SURG)  411,136  4.  Orthopedic Surgeon (ORS)  142,956  5.  Pediatrician (PED)  318,384  6.  Otolaryngologist  286, 286  7.  Ophthamologist (OPH)  8.  Obstetrician/Gynecologist  9.  Urologist (UROL)  (OTO)  202,048 (OBG)  T o t a l graduate nurse bed days A v a i l a b l e b e d days (at 100% occupancy)  218,240 83,160  399,483 2, 000, 930  Demand Category  infective and Parasitic Diseases Common Cold  Hospital Bed Days /Incidence .203 0  Influenza  .024  Bronchitis  .325  Other Respiratory Conditions  .041  Digestive System Disorders (Acute)  2.785  Injuries and Adverse Effects  1. 272  Diseases of the Ear  .60 7  Genitourinary Disorders  7.883  Diseases of the Skin  1.780  Diseases of the Musculo-skeletal System  5. 725  Heart Conditions and Hypertension  8.682  Arthritus and Rheumatism  1.030  TMale 1 Incidence/100 Population „ * FemaleJ Under 6 6-16 17 - 44 45 & Over 14.6 7. 3 50,9 37.9 20.1 33.8 46.9 9.9 51.0 55.9 34.8 29. 2 40. 7 24. 2 37. 7 39.6 24. 6 41.9 2.4 13. 5 3.8 2.5 9.0 3.2 3.3 2.5 81.2 47. 7 151.4 35.6 198. 2 132.2 106. 2 67. 7 14.8 8.7 7.0 7.0 13.1 9.6 9.1 6.0 37.4 43. 7 38.2 22.0 32.3 24.5 21.0 21.9 4.9 4.6 0.8 5.4 2.2 3.0 .1.6 2. 7 Under 45 65 and Over 45 - 64 1.6 12.5 39.5 2. 2 17.4 1.0 1.4 25. 3 2.1  A P P E N D I X C - Incidence Rates and H o s p i t a l B e d R e q u i r e m e n t s  20.8  39. 3  Demand Category-  Hospital Bed Days/Incidence  Digestive Conditions (Chronic)  2.467  Visual Impairments  1.395  ., ., „ „ _ ... Incidence / 100 Population r  Under 45 3.9 3.0 1.1 1.4  45 - 64 13. 7 11.6 3.9 4.1  Visits/100 Population Medical and Surgical After Care  46.1  Medical or Special Examination  200.0  Prophylactic Innoculation  35.0  Non-Endocrine Obesity  8.4  Diabetic Mellitus  .460  11.6  Neoplasms  . 260  11. 7  Well Baby and Child Care  35.0  Other Visits to Opthamologist  11.0 5.4  Other Visits to Otolaryngologist  Visits /Delivery 1.27  Post -partum Observation  3.90  Prenatal Care Deliveries and Disorders of the Puerperium  A P P E N D I X C - Continued  5.9  Male „ |FemaleJ 65 and Over 22.4 20.0 12.8 16.2  Visits/Incidence Demand  GP  Category  IM  o r P r o p o r t i o n of V i s i t s Seen by Specialty  SURG  ORS  PED  Infective and P a r a s i t i c D i s e a s e s  . 018  . 072  Bronchitis  -901  .430  Influenza  . 085  Other R e s p i r a t o r y Conditions  .247  Digestive System D i s o r d e r s (Acute ) . 260 Injuries and A d v e r s e  Effects  .017  OBG  UROL  . 028  1. 333  1. 236  .110 . 476 . 260  . 175  . 115 . 261  of the E a r  Genitourinary Disorders D e l i v e r i e s and D i s o r d e r s of the P u e r p e r i u m D i s e a s e s of the Skin D i s e a s e s of the M u s c u l o s k e l a t a l System Heart Conditions and H y p e r t e n s i o n APPENDIX D  OPH  . 010  Common Cold  Diseases  OTO  -  . 209 1. 901  . 847  . 117  1. 426  . 193 2. 697 2.813 4. 763  . 015  . 071  6. 668  Physician Resource Requirements  V i s i t s / I n c i d e n c e or P r o p o r t i o n of V i s i t s Seen by Specialty Demand Arthritis  Categoryand R h e u m a t i s m  Digestive  Conditions  GP  IM  . 252  . 343  (Chronic)  . 276 . 36  . 18  . 12  M e d i c a l o r Special E x a m i n a t i o n  . 75  . 20  Prophylactic  . 50  ORS  PEE  OTO  OPH  OBG  UROL  . 02  . 05  . 06  . 09  . 05  . 03  . 01  . 083  . 145  M e d i c a l and S u r g i c a l (Aftercare)  Innoculation  SURC  . 08  . 01 . 50  . 68  . 32  P r e n a t a l Care W e l l Baby and Child  Care  . 31  . 69 6. 223  V i s u a l Impairments . 70  . 22  Diabetic M e l l i t u s  . 50  .49  Neoplasms  . 35  . 36  P o s t p a r t u m Observation  . 30  Non-endocrine  Obesity  Other V i s i t s to Otolaryngologist Other V i s i t s to Ophthamologist  . 08 . 01 . 12  . 03  . 02  . 12 . 70  3 1  A P P E N D I X D - Continued CO  169  APPENDIX E - Priority Matrix  Demand Category Infective and Parasitic  Diseases  Priority 1 2  3  .2  .6  .2  .1  .1  Bronchitis Common Cold  .1  Influenza Other Respiratory Conditions Digestive System Disorders (Acute) Injuries and Adverse Diseases of the  Effects  .4  Ear  Genitourinary Disorders Deliveries and Disorders Puerperium Diseases  of the Skin  Diseases System  of the  .8  5  .2  .6  .1  .2  .2  .7  .2  .6 .2  .1  .2  .5  .3  .2  .1  .2  .3  .3  .2  .2  .3  .3  .2  .1  .2  .7  6  .7 .2  .2 1  Musculoskeletal  Heart Conditions and Arthritus and  of the  4  H y p e r t e n s i o n .5  Rheumatism  .2  .3  .3  .2  .2  .2  .1  .1  .3  .3  .2  .1  (Chronic)  .1  .1  .3  .3  .2  Medical and Surgical Aftercare  .1  .2  .3  .3  .1  Medical or Special Examination  .1  .1  .8  Prophylactic  .1  .1  .8  .2  .6  .1  .1  .1  .8  .2  .2  .4  .2  .8  .2  .4  .1  .9  Digestive Conditions  Innoculation  Prenatal Care  .1  Well Baby and Child Care Visual Impairments Non-endocrine  .2  Obesitv  Diabetic Mellitus  .3  .4  Neoplasms  .8  .2  Post partum Observation  .3  .4  .3  .1  .1  Other Visits to Otola rynpoloci st Other Visits to  Ophthamolopst  .3  .2  170  APPENDIX F The  -  Substitution Exchange Ratios  rate of exchange between physician visits i to j (the amount  of physician visits i needed to substitute for 1 visit of physician j) is calculated on the bases of work load ie E X C H A ( i , j) = work load(daily visits) of physician i work load(daily visits) of physician j The  exchange ratios are given in the table below.  EXCHA(I, J) 1 1  1  2  3  4  5  6  7  8  9  1. 40  1. 66  1. 24  1. 06  1. 25  1. 29  1. 37  1. 51  1  1. 18  . 88  . 75  . 89  . 92  . 97  1. 08  1  . 75  . 64  .76  . 78  . 83  . 91  . 85  1. 01  1. 04  1. 10  1. 22  1. 19  1. 23  1. 30  1. 44  1  1. 03  1. 09  1. 21  1  1. 06  1. 17  1.  1. 11  2  . 71  3  . 60  . 85  4  . 81  1. 73  1. 34  1  5  . 95  1. 33  1. 57  1. 18  6  . 80  1. 12  1. 32  .99  . 84  7  . 77  1. 09  1. 28  .96  . 82  .97  8  . 73  1. 03  1. 21  .91  . 77  .92  . 95  9  . 66  . 93  1. 09  . 82  . 70  . 83  . 85  N. B.  1  . 90  Physician specialty numbers are the same as given in Appendix B  1  APPENDIX Demand  G  -  Seriousness  of Illness  Rating Index Rating  Category-  Infective and P a r a s i t i c  Diseases  Bronchitis  190 270  Common Cold  67  Influenza  230  Other R e s p i r a t o r y Conditions  250  Digestive System D i s o r d e r s Injuries and A d v e r s e Diseases  (Acute)  Effects  160 450 204  of the E a r  Genitourinary Disorders  506  D e l i v e r i e s and D i s o r d e r s of the P u e r p e r i u m  550 55  Diseases  of the Skin  Diseases  of the M u s c u l o s k e l e t a l System  400  Heart Condition and Hypertension  650  A r t h r i t u s and R h e u m a t i s m  444  Digestive  (Chronic)  550  M e d i c a l and S u r g i c a l A f t e r c a r e  350  Medical or Special Examination  59  P r o p h y l a c t i c Innoculation  59  Conditions  P r e n a t a l Care  150  W e l l Baby and Child  Care  150  V i s u a l Impairments  350  Non-endocrine  267  Obesity  Diabetic M e l l i t u s  570  Neoplasms  650  Postpartum Observation  550  Other V i s i t s to Otolaryngologist  230  Other V i s i t s to Ophthamologist  230  A P P E N D I X H - Dominating F a c t o r s  Demand  Dominating F a c t o r  Category  Infective and P a r a s i t i c D i s e a s e s  1  Bronchitis  2  Influenza  1  Other R e s p i r a t o r y Conditions  2, 7  D i g e s t i v e S y s t e m Conditions (Acute)  3  Injuries and A d v e r s e E f f e c t s  4  D i s e a s e s of the E a r  5  H e a r t Conditions and H y p e r t e n s i o n  6  V i s u a l Impairments  7  Non-endocrine O b e s i t y  6  Key 1  Crowding  2  A i r P o l l u t i o n (gaseous)  3  Water Q u a l i t y  4  Traffic Accidents  5  Noise  6  Nutrition  7  A i r P o l l u t i o n (particulate)  

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