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The Accessibility Paradox in Health Services: Global and Individual Costs
Prof. Luiz Antonio Titton, Universidade de São Paulo, Brasil
Prof. Julio Araujo Carneiro da Cunha, Universidade de São Paulo, Brasil
Prof. Dr. Marilson Alves Gonçalves, Universidade de São Paulo, Brasil
Prof. Dr. Hamilton Luiz Correa, Universidade de São Paulo, Brasil
The health organizations management has three important cornerstones that are
fundamental for organizational performance: quality; accessibility and costs (AL-ASSAF,
1997). They are, hence, fundamental for its evaluation, resulting in a perspective for
healthcare organizations more incisive based in performance (SHORTELL; KALUZNY,
2000). These issues related to healthcare organizations management are shown necessary
before the perception that great part of healthcare professionals point out that management
where they work is inefficient (VLASTARAKOS; NIKOLOPOULOS, 2007).
COSTS
The intense control over little resources on hospital-physician context demands an
adequate medical service that involves decision makings based on planning and resources
management (HARPER, 2002), Hospital financing limitations bring along the need to find
efficient ways to manage (utilize and allocate) lack of resources (AKTAS et al., 2007). This
consideration has direct effects on hospital management, since studies from several different
countries (developed nations and not-developed ones) have already denoted the challenge in
managing costs from lack of resources and contentions, e.g. United Kingdom
(FITZGERALD, 1994; FITZGERALD; DUFOUR, 1998), Sweden (QUAYE, 1997), Canada
(LOO, 1997; FITZGERALD; DUFOUR, 1998), Netherlands (SCHOLTEN; VAN DER
GRINTEN, 1998), United States (GOSS; VOZIKIS, 2002; SLOAN, 2007), Oman (ABRI et
al., 2006), Spain (SÁNCHEZ-MARTÍNEZ et al., 2006), France (BELLANGER; TARDIF,
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2006), Poland (KOZIERKIEWICZ et al., 2006), Turkey (AKTAS et al., 2007), Tanzand
(GILSON, 1995).
This worries with researches based on costs related to health also interferes on Brazil,
what is reflected when it’s perceived that 69% of researches from Economic Healthcare done
in the country involves in some way the analysis of costs from hospital management
(ANDRADE et al., 2007). In Brazil, according with Cherchiglia and Dallari (2006), these
pressures for higher efficient and effectiveness in organizational activities about lack of resources happened in 1990 decade, mainly when treating about public hospitals. The authors
allege that these lasts suffered with a State crisis that reduced the financial maintenance power
of the State with public organizations. This decade was marked by an increasing fiscal crisis,
protectionism exhaustion to national organizations and a bureaucratic and inefficient public
management.
Thus, it’s evidenced that one of the greatest issues of Brazilian hospitals relates to lack
of resources. In absolute aspects, in the year of 2004, the public spending with health had a
mean value of 99,89 euro per habitant (DATASUS, 2006). Adding to this, in the year of 2003,
5,32% of familiar earnings in Brazil was spent with health assistance (IBGE, 2004). So, it’s
justified why management costs is the greatest issue on national discussion in Healthcare
Management. In general aspects, managing lack of resources is still a challenge for Healthcare
Management.
It means that for some time, healthcare organizations from different countries are
facing similar problems (HUNTER, 1996), what brings the fact that no matter what culture
the nation has, similar issues are found in different healthcare organizations. In many
countries, the hospital costs make pressure over healthcare management, bringing along
reflections about how the resources are better destined and allocated in hospital management
(KEEN et al., 1993). According to Hunter (1996), these issues related to costs contention seek
for better services performance, in an effort to make hat services more sensitiveness to user
(patient) and to achieve higher value for hospital invested money.
Great part of these worries comes before a reality where there’s lack of financial
expertise for decision makings in medical management, what turns vulnerable the physicianmanagement (LLEWELLYN, 2001). Thus, it’s demanded a hospital management that has
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administrative and financial knowledge to deal with actual context given the essential of costs
management in healthcare organizations.
So, the financial management in hospitals can be defined as a set of specific
techniques that are fundamental, in order to the healthcare organizations management provide
entities perpetuation, reasonable remuneration to labor and capital factors and finally
excellence in medical services (OLIVEIRA; GIUSTI, 2006). A financial increment or an
additional rate charged to patient brings better quality in his attendance (LITVACK;BODART, 1993). It means that higher costs tend to involve greater financial quantities in
attendance, what favors the existence of a positive relation between cost and
quality .
It must be observed that this relation maintain in fixed costs as well as in variable
ones, once investments in equipments that provides better quality in diagnosis and treatment
demands higher costs. Also, there’s an increase in variable costs for better quality in
attendance.However, the adequate management of costs involves the precise diagnostic of
patient’s health problems and his real needs in terms of resources to be used (AKTAS et al.,
2007). It requires precise analysis that involves operational practices as well as practices
relate do managerial practices. It makes costs management related to others aspects of
healthcare organization, what is justified by the relation between costs to quality and
organization capacity to accessibility.
There’re, hence, pressures to costs reduction allied to hospital services quality
increasing, that comes from government, healthcare insurance plans, community and patients
(LI; BENTON, 1996).
However, it’s not possible due to the existence of a tradeoff between security and
costs, mainly what is referred to practices of material reutilization that should be used only
once (SLOAN, 2007), what is also common in Brazilian hospitals and directly affects services
quality i. e. it’s a practice that goes against security sanitary norms, but, that represents the
strategy usually used by physicians that struggle against lack of resources.
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QUALITY
Even before non-consensous and neither a research thought line common
between researchers in definition of hospital services quality, Chassin and Galvin (1998) had
already denoted the need to establish measurements over hospital quality with more scientific
precision and a more standardized definition between term researches.
Medical services quality have directly influence on patient’s quality of life(MIER et al., 2008). So, quality services have direct influence over healthcare organization
main function of population life quality improvement.
It brings along the so called evidence-based medicine (based com evidences
and proves) which determined hospitals and their respective physicians have greater prone to
develop scientific knowledge, offering healthcare services of higher quality and lesser costs
(BERRY et al., 2004). It’s based on the integration between clinical experience and expertise
of individual physician and from better external available evidences through systematic
researches done by physician (SACKETT et al., 1996). It’s perceived that a higher level of
quality, mainly when technology appears, can influence the costs reduction in a healthcare
organization. However, it’s defended the principle that quality increasing requires an
investment from health organization that is associated to a cost increasing. Adding to that,
Porter and Teisberg (2006) what is observed is a growing increase in hospital costs in an
alarming quality level. So, an increase in healthcare services quality can be linked also with a
posture and organizational culture change from hospitals (DAVIES et al., 2000).
From the moment that services quality and costs attentions have direct relation with
hospital management, we’re referring to a multidisciplinary attention that involves practical
clinical aspects as well as financial and quality management awareness. So, quality is related
with financial dimension of healthcare organizations when it’s recognized that quality
depends on management, no matter what name each one gives to it. Limits of what can be
done in an organization depend on it, as matter of investments (financial or not), that can be
done when expectations that will be lifted and ideally attended through quality (SCHIESARI;
MALIK, 2006 b).
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Quality in hospitals, according to Schiesari and Malik (2006 a), can be linked
with standard conformities, right using and client satisfaction. It’s considered here that quality
is related to standard conformity and to right using, in a services providence that can attend
the patient in a way that better satisfy him. However, it’s not considered as quality the
patient’s perception related to healthcare services, as considered in some researches (e.g.
ANDALEEB, 2001) or even the medical team perception of their offered job (e.g. ARNETZ,
1999).Quality is related to higher medical services practices. According to Campbell et al.
(2000), medical services quality is related to its efficiency and accessibility. The efficiency is
related to cliinical practices and inter-personal cares receipted.
Quality definition defended here is the same developed in the 1990 decade and
adopted by Institute of Medicine, in which quality is the level of healthcare service provided
to individuals and populations that increases the possibility in achieving expected results in a
consistent way with existent medical knowledge and practices. In this thought line, the
Institute of Medicine (2001) complements that hospital quality involves measures that
increases: patient’s security; service effectiveness according to available and existent medical
knowledge; patient centralization, guaranteeing a respectful and responsible attendance
according to his values and needs; wait reduction in attendance; efficiency in waste
avoidance, being them material, resources, ideas or energy; attendance equity, without
variations according to patients personal characteristics.
This quality vision is linked with costs and it’s seen on studies that allege that patient
can pay for a better performance (e.g. TERRIS; LIKATER, 2008; ROSE, 2008), gaining more
qualified professionals and better structure and materials, as well as medications availability.
It indicates that quality in services is financial linked with what can be done in a medical
service.
To Chassin and Galvin (1998), healthcare services quality depends also on medical
team training, as well as other hospital functionaries, and on services and medical processes
organization.
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These elements indicate that healthcare services quality depends on investments and
on higher operational cost level that makes believe that quality is positively related to hospital
costs .
ACCESSIBILITY
Healthcare services quality, as mentioned, are related to accessibility capacity that
service offers to its users (CAMPBELL et al., 2000). From the three cornerstones of hospital
management, accessibility is the more related one to social objectives of healthcare
organizations. Socially, a hospital has the function to attend the higher number of individuals
as possible, in order to provide higher welfare to population. In fact, healthcare organizations
can promote elements that facilitate individual’s accessibility to its dependencies
(DONABEDIAN, 1973).However, accessibility, as social objective, must be done under equity between
individuals (SILVA; FORMIGLI, 1994), what doesn’t happen when talking about private
healthcare organization, given that corporative earnings are over this social function.
Accessibility can be seen through the focus on patient’s satisfaction according to his
accessibility opportunities.
Accessibility can be also related to healthcare organization geographical issues,
mainly when the hospital localization doesn’t favors attendance maximization. So, it’s
recognized that healthcare services localization interferes also on accessibility rate
(UNGLERT et al., 1987). This discussion gains more relevancy when treating about patients
from rural area (e.g. FORTNEY et al., 1999).
This fact guides to other reflections, that industrialized regions, that have
higher socio-economic levels than rural areas, hence, have higher accessibility to health
(ADLER et al., 2008). It means that proximity is not just an explicative factor to healthcare
services accessibility, but also, financial issues affect its access.
The focus utilized here is related to internal and structural capacity that
healthcare organization has to attend a specific quantity of patients. i.e. it’s a vision related to
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resources availability (inputs) and price formation from these organizations to potentially
attend their patients.
ACCESSIBILITY, QUALITY AND COSTS
Researches in healthcare must contain information about medical dimension that canbe related and correlated to social information (ROOS et al., 2008). It must keep sociological
character when medicine is seen through sociological medicine scope (SETTLETON, 2007),
this one that better justifies itself when it’s observed a healthcare organization through
Organization Theory focus. So, understand the social reality as well as environmental and
population concepts attended by hospital is fundamental to make conclusions about
qualitative information lifted on research.
Accessibility and quality dimensions have lot of adherence between each other
because is desirable the accessibility increase with quality maintenance and vice-versa.
When accessibility increase is chased, not only social issues are important. Costs
reduction, especially through fixed costs dilution, is desired. It happens because in direct
relation between accessibility and quality, investments in material resources also happen to
quality increase, resulting in fixed costs.
A healthcare organization performance boundary is the lack of financial resources
available that is opposing (inverse related) to the objective of quality and accessibility
maximization. The costs minimization is the main manner available to keep conditions for
organization work under available resources.
Performance = f(Max Q + Max A + Min C)
When seeking for quality maximization, the consequences are the cost increase and
accessibility reduction, resulting the reduction of financial resources availability.
The cost increase happens through necessary investments in resources that possiblybetter diagnosis and treatments. These equipments, besides better performance and
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productivity, maintain significant values in immobilization. As result, it’s necessary the cost
re-pass to user (patient), that when treating about private health, absorb it in order to gain
better service perception.
When observed the health public service, this cost can’t be re-passed to user. In the
specific case of Brazil, there’re public hospitals that receive investments (very little), that
usually end up being used to equipment maintenance, many of them already obsoletes, but
that are absolutely necessary to hospitals (peccary) function. All citizens have the right topublic assistance, without distinction, and their search for a better attendance is justified by
the existence of private healthcare insurance plans.
On its turn, private healthcare insurance plans attend through an agreement network
within private hospitals. However, the biggest client of private hospitals is the State. Public
sector contracts remunered services based on charts that pay values much lower than that
practiced value on private sector. e.g. the laboratorial exam chart is not readjusted for 13
years, even with an 4% per year inflation, and the sector survives due to the investments is
equipment and higher productivity.
To compensate for this, the output is to maximize the free resources generation, which
is the difference between inflows and costs. Tickets are scarce and therefore the action of
management focuses on reducing costs, which is one of the pillars of management.
When you reduce costs is the result of the increased accessibility, however is not
desirable deterioration in the quality of service. Thus, quality acts as limiting the reduction of
both costs and increased access.
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Maximising the accessibility, which is access to services of health organizations, is a
social objective. When you increase the capacity of numerical care, the quality serves as a
limiting factor, for example, when there is considerable influx of patients in clinics to free
vaccination against tropical fevers in Brazil, the level of quality of care is very disadvantaged,
both in the health point of view about the perception of quality perceived by the user. A
medical consultation in situations like this takes on average ten minutes, which is well below
the estimated time only for a standard history (the time pattern of consultations for the SUS,Brazilian public health system, thirty minutes for the first consultation and fifteen minutes in
returns). The time of doctors is a scarce resource, as far as beds, and very poorly paid, and any
increase in access to care leads in crisis throughout the country.
The goal of maximizing accessibility affects the cost of two ways, within an
organizational and another in the level of each transaction.
Under the terms of organization, the increase in the level of accessibility as a result
brings the increase in total expenditures, since they are necessary investments and the level of
operating costs in a higher level. This increase in costs may reflect a greater or lesser amount
of free resources, depending on the level of revenue from this increase in accessibility. This
dependence is linked to the ability to sum of these costs to the user, and if this is a user comes
from the public system, there's no way to pass the short and medium term.
Thus, while maximizing access, there is a drop in costs accompanied by a decrease in
funds free. These conditions are real in both the fixed costs (which are better diluted) and the
variable costs (which can be shared). For free resources, increased accessibility creates a
demand for working capital finance the service, because both the public and the private sector
service providers of pay periods with more than 30 days and is common in the public sector,
in default of law, delays of up to one year, and these resources should be allocated for the
financial management of the hospital.
The generation of free resources for the organisation of health can only be obtained in
two ways:
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1) increasing the spin, the quantitative increase in attendance and gain in scale, or,
2) gain in margin from the reduction of unit cost of transaction.
What is presented as paradox is that the limited resources leads the administrator to
decisions based on two factors: one wishes that the organization reduce their individual costs
of transaction, and secondly that there is a greater training Free Resources total.
The first parameter decision leads to a desired result antagonistic to the second:
When you aim Minimize Cost, you get greater accessibility, which will generate the
detention of the capital of spin, reducing the accessibility and in turn generating costs, is to
finance the shortfall of cash, is to maintain accessibility.
The solution found in one of the cases was investigated pass the lack of resources freeto start the operation through a constant negotiation with suppliers, increasing deadlines so
that the cycle of receipts could offset the financial commitments. In the case studied, suppliers
are not prepared to accept the negotiation have been replaced.
The equation suggests that it cancels a course in search of a static equilibrium, which
is not necessarily the result of cost reduction. In this case, there is still the limiting factor is
that the quality is not negatively elastic.
Final
The prospect of consequences of reducing costs is the generation of increasing the
availability Appeal Free generated per transaction, which will finance other activities that
consume resources of the organization. These other activities can consume resources by
increasing the cost (aiming to increase quality, for example), or the decrease of free generated
result (when there is a need to fit working capital).
This sets a paradox regarding the maximization of accessibility within the overall
context of individual and organizational processes. A hospital, seek to increase the
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accessibility of its health service in its social role to seek meet as many of the people, reduce
the scarce resources if it is a balance favourable to enable it to pass its cash needs for
investment.
The need to allocate resources for turning in medium and long term is not consistent
with the increase of resources generated by trade, leaving the hospital management with an
unresolved paradox in relation to planning goals, achievement of objectives and strategic
alignment of the organization, it does not admit fall of quality.The study was conducted in a scenario with specific characteristics of developing
countries, and new comparative studies would be needed to form a picture of how this
happens in other scenarios, even if it is a paradox inherent in the stage of development.
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