Utilization of VA and Medicare Services by Medicare-Eligible Veterans: The Impact of Additional Access Points in a Rural Setting, William Brinson Weeks, Peter J. Mahar, and Steven M. Wright
The Veterans Health Administration (VA), the nation’s largest healthcare system, has recently established community-based outpatient clinics (CBOCs) in an effort to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare-eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolled in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine health services utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded through Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural northern New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted from the organizational perspective, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.
First Principles: Substantive Ethics for Healthcare Organizations, Eva C. Winkler and Russell L. Gruen
Healthcare organizations (HCOs) often face ethical dilemmas, but ethical principles analogous to those of clinical ethics have not been established to guide resolution of such dilemmas. To date, most progress in business and organizational ethics has been made in developing processes that promote responsible behavior in complex organizations.
In this article we offer a normative framework to guide value-laden decision making of HCOs. We propose four substantive principles—provide c are with compassion, treat employees with respect, act in public spirit, and spend resources reasonably—that are derived from the roles that HCOs are expected to play as caregivers, employers, citizens, and managers, respectively. We anticipate that these principles can clarify and resolve tensions between different spheres of HCOs’ responsibility, help to promote organizational values and trust in HCOs, and aid the discussion about the appropriate roles of HCOs in our society.
Contemporary Challenges and Opportunities and Academic Health Centers, Sheldon M. Retchin, and Ron R. Clark III
Academic health centers (AHCs) have struggled in recent years to redefine their special position in healthcare delivery. This article presents a description of structural and process features at AHCs to serve as a framework for redesigning healthcare delivery at AHCs. The authors review and synthesize the literature regarding health system performance. In addition, they address attributes of healthcare delivery that represent both challenges and opportunities for AHCs, including costs of care; comprehensiveness and capacity of care; coverage; continuity, communication, and coordination of care; consistency of practice; and consolidation. Recommendations on priorities for AHCs are given, and specific features of desirable academic delivery systems for the future are described.