Economic Model of Organizational Architecture* to Guide Design and Performance Evaluation in an Urban, Primary Care Telemedicine Network

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Economic Model of Organizational Architecture
to Guide Design and Performance Evaluation in
an Urban, Primary Care Telemedicine Network
Kenneth M. McConnochie, MD, MPH   Brickley
J, Smith C, Zimmerman J. The economics of
organizational architecture. J Applied Corp
Finance 19952019-31
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What makes this an economic model?

• Essence of economics
• theory of values
• how individuals make choices

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Whats this got to do with HIT?
Primary challenge organizational innovation
Adopting and integrating new technology
requires change in individual and organizational
roles and responsibilities
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Whats this got to do with evaluation?
Evaluation - an essential component of innovation
strategy Primary objective - to demonstrate
use of model to guide evaluation strategy
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Health-e-Access Health, Healthcare and Social
Problems Addressed

• Marked socioeconomic disparities in childhood
  morbidity burden.
•  
• More than half of US pre-school children spend
  time in child care.  
• Rates of common acute illness are increased in
  child care.  
• Illness in childcare accounts for 40 of work
  absence for parents using child care.  
• 20 - 70 of pediatric visits to the emergency
  department are for non-urgent problems.

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Short Story
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Organizational Problem

• Usual Healthcare
• Every child has a primary care medical home
• Physician(s) controls the organization directly
• versus
• Health-e-Access
• Many childcare sites
• Many different primary care offices
• No telemedicine utility service (yet)

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Conceptual framework the 3-legged stool
(1) Incentives   (2) Decision rights   (3)
Performance evaluation
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Health-e-Access Stakeholders

• Parent and Child
• Private Insurance Organizations
• State and County Government, Medicaid
• Industry
• Primary Care Physicians
• Childcare Programs

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Stakeholders and their Decision Rights

• Parent
• Use of telemedicine services vs. traditional
  alternatives
• Choice of insurance company and plan
• Industry
• Payment for telehealth services, if self-insured
• Qualify/cover telehealth services in dependent
  care or healthcare components of Flexible
  Spending Accounts
• Negotiate health insurance premiums, covered
  services
• Change health insurance company

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Decision Rights - continued

• Health Insurance organizations - Private
• Coverage of telemed services (yes/no)
• Type of coverage (e.g., fee-for-service,
  capitated)
• Reimbursement rates for telemed services
• Sponsorship of telemed
•   
• Health Insurance organizations, Public County
  State Government
• Licensing new types of healthcare workers
• Administrative approval of reimbursement for new
  services (i.e., Medicaid Managed Care)
• Support adoption of telehealth services (vs.
  ignore potential)
• Legislation that requires insurance reimbursement
  for telehealth
•  
• Primary Care Physician
• Provide/refuse telehealth services
• Promote/obstruct adoption of telehealth services,
  e.g., through participation on insurance
  organization committees that recommend coverage
  of new services

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Dominant Stakeholders

• Health Insurance Organizations
• Physicians

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Stakeholders and their Incentives

• Parent and child
• Improve child health and development
• Increase sense of security
• Increase access to healthcare
• Minimize symptom severity and duration in child
• Minimize disruption to usual activities/responsibi
  lities family from child illness
• Minimize out-of-pocket costs to family
• Improve financial status through steady
  employment and advancement
• Maintain a medical home

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Incentives - continued

• Industry
• Minimize work absence
• Maximize employee productivity - presenteeism
• Reduce healthcare costs

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Stakeholders and Performance Evaluation
Parents, Childcare Programs, Industry
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Absence Due to Illness Before and After
Health-e-Access
Net impact 63 reduction (Pediatrics May 2005)
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Parent Satisfaction
Based on interviews with parent after first use
of telemedicine. N 229.
ED
After hours
of families
Primary Care Physician
Yes
Yes
Allowed to stay at work
Saved parent trip to
Would choose child care with telemed over one
without
Estimated time saved 4.5 hours (SD 2.2) per
telemed visit
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Utilization Preliminary Data
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Utilization Predicted by TelemedBivariate
Analysis
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Utilization of Any Site for Illness Other
Determinants

• Sex
• Insurance type
• Child care site
• Primary care practice
• Childs age

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Logistic Regression Telemed Effects on
Utilization
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Expanded Program

• 22 child sites, 8500 total children eligible
• 7 current city child care programs
• 5 city elementary schools
• 5 suburban elementary schools
• 5 suburban child care programs (SE suburbs)
• 5 urban practices
• 6 suburban practices (SE suburbs)
• Insurance reimbursement for demonstration project
  telehealth visits