Regional Healthcare Service Systems: A Conceptualization of the Meso-Level of Healthcare

摘要

Service operations are categorized into preparations (back-office) and delivery (front-office). In healthcare most service require that patients meet a prepared provider in person, therefore services are time/location constrained and regional. Services can be made available through various channels, and can thus be analyzed as distribution systems. This paper provides a conceptualization of regional health service systems and an empirical illustration. Health service systems strive to optimize equity and efficiency. In publicly financed care the major equity issue is time/location access. To this end the configuration of a regional service system is crucial. A regional health service supply system consists of resource units (RU), service provision points (SPP), and contact points (CP) that can overlap in various ways. From a distribution perspective demand can be classified into three categories: (1) Cases that can be treated with one or a few preplanned visits to one SPP. Such services can be modeled based on locations, distances and travel time. (2) Cases requiring several visits to several specialists, where the process can't be planned and scheduled in advance. The distribution system needs to link several SPPs. (3) Cases requiring continuous care and a facilitated network of providers and peer support. From a supply perspective a SPP can offer (1) a variety of different services (non-substitutes) for different needs, and (2) various levels of specialization (substitutes) for different severity and complexity of needs. Specialization typically require high asset specificity from which follows high costs unless capacity utilization is sufficient and economies of scale can be exploited. The volume of demand from a region decreases with increasing specialization. Thus maintaining sufficient capacity utilization requires concentration, which in turn hampers time/location access. The equity-efficiency dilemma can be elaborated into two trilemmas: (1) the equity opti- - mization of time/location access, variety, and specialization, and (2) the efficiency optimization of scale, scope, and capacity utilization. In the literature regional health service systems have been studied as reengineering issues ignoring sunken costs and legacies. In this paper, we apply the above outlined conceptual construct to a real world case. A region in Northern Europe with a population of 180 000 is studied to find out how the distribution system, and solutions to the equity-efficiency dilemma have emerged in a specific regional and historical context. The findings suggest the need for better theory. It is apparent that the effects of specialization and centralization to the efficiency of single procedures are well known, while their impact on access is unclear, and the mechanisms of scale and scope are not well understood. To this end it is essential to develop conceptualizations about the units of analysis to which scale and scope may apply, i.e. the operationally and economically smallest and largest viable SPPs. From a service distribution perspective a hospital is not necessarily a relevant unit of analysis, but needs to be decomposed into a set of RUs, SPPs, and CPs that can be configured in various ways.