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This chapter integrates organization design and sustainability concepts to describe an accelerated transformational change at the Fairview Medical Group (United States).

A case study of the transformation at Fairview Medical Group’s primary care clinics was developed from interviews and first-person accounts of the change. Objective data regarding outcomes was used to evaluate the effectiveness of the redesign process.

The Fairview Medical Group developed an innovation and change capability to transform 35 primary care clinics in six months. All of the clinics were certified by the state of Minnesota as complying with their healthcare standards. Clinical outcomes, costs, and employee and physician engagement also increased. All of the improved measures are sustained.

Healthcare reform in the United States struggles because the organization design challenges are great and the change difficulties even greater. Fairview’s experience provides important evidence and lessons that can help advance our understanding of effective healthcare and create more sustainable healthcare systems. This chapter provides healthcare system administrators evidence and alternatives in the pursuit of implementation.

Employer-provided benefits are a large and growing share of compensation costs. In this paper, I consider three factors that can affect the value created by employer-sponsored benefits. First, firms have a comparative advantage (e.g., due to scale economies or tax treatment) in purchasing relative to employees. This advantage can vary across firms based on size and other differences in cost structure. Second, employees differ in their valuations of benefits and it is costly for workers to match with firms that offer the benefits they value. Finally, some benefits can reduce the marginal cost to an employee of extra working time. I develop a simple model that integrates these factors. I then generate empirical implications of the model and use data from the National Longitudinal Survey of Youth to test these implications. I examine access to employer-provided meals, child care, dental insurance, and health insurance. I also study how benefits are grouped together and differences between benefits packages at for-profit, not-for-profit, and government employers. The empirical analysis provides evidence consistent with all three factors in the model contributing to firms’ decisions about which benefits to offer.

Through content analysis, the study traces the relative prominence of “biomedical” and “public health” approaches in congressional bills aimed at improving the health of racial and ethnic minorities over a 28-year period. It documents a surge of interest in minority health during the late 1980s and early 1990s and highlights the dominance of biomedical initiatives during this period. Drawing on historical methods and interviews with key informants, the paper explains these patterns by detailing the ways in which policy legacies shaped the interests, opportunities, and ideas of interest groups and policy-makers.

Objective – Tanzania, Mexico, and the United States are at vastly different points on the economic development scale. Yet, their health systems can be classified as “developing”: they do not live up to their potential, considering the resources available to them. The three, representing many others, share a common structural deficiency: a segregated health care system that cannot achieve its basic goals, the optimal health of its people, and their possible satisfaction with the system. Segregation follows and signifies first and foremost the lack of financial integration in the system that prevents it from serving its goals through the objectives of equity, cost containment and sustainability, efficient production of care and health, and choice.

Method – The chapter contrasts the nature of the developing health care system with the common goals, objectives, and principles of the Emerging Paradigm (EP) in developed, integrated – yet decentralized –systems. In this context, the developing health care system is defined by its structural deficiencies, and reform proposals are outlined.

Findings – In spite of the vast differences amongst the three countries, their health care systems share strikingly similar features. At least 50% of their total funding sources are private. The systems comprise exclusive vertically integrated, yet segregated, “silos” that handle all systemic functions. These reflect and promote wide variations in health insurance coverage and levels of benefits – substantial portions of their populations are without adequate coverage altogether; a considerable lack of income protection from medical spending; an inability to formalize and follow a coherent health policy; a lack of financial discipline that threatens sustainability and overall efficiency; inefficient production of care and health; and an dissatisfied population. These features are often promoted by the state, using tax money, and donors.

Policy implications – The situation can be rectified by (a) “centralizing” – at any level of development and resource availability – health system finance around a set package of core medical benefits that is made available to the entire population and (b) “decentralizing” consumption and provision of care. The first serves equity and cost containment and sustainability. The second supports efficiency and client satisfaction.

Originality/value of chapter – The chapter views commonly discussed problems of the health care system – a lack of insurance coverage and income protection – as symptoms of a large problem: health system segregation.

The purpose of this paper is to provide an overview of post-Soviet and demographic challenges faced by the government in Moldova that have posed as challenges to reform of the healthcare system. Since independence from the Soviet Union in 1991, Moldova has undergone significant challenges and reforms throughout the society. Healthcare has been no exception. Changes in family structures due to migration, a decreased birthrate, and an aging population have placed strain on the healthcare system which is working to both modernize and provide specialized care. Legislation has helped to streamline and reform the healthcare system but systemic challenges are still faced by at-risk populations including the elderly, women, and rural populations.

Information presented in this paper is based on a review of independent research, United Nations and government reports.

Findings show that progress has been made through legislative reform, new government programming, and most recently volunteer/nonprofit involvement in healthcare reform. Currently, the government is working to establish holistic patient centered care and to bridge the healthcare divide between rural and urban populations. Healthcare reforms include basic universal health care services and family support programming. Additionally, there has been a renewed emphasis on how environmental factors, like housing and nutrition, interact with health quality.

Moldova faces an increasing challenge of caring for elderly populations at the family and societal level due to the increased number of elderly, shifts in family structures, and international migration for employment. A discussion of the developing role of nonprofit and nongovernment organizations is included.

Over the last few decades, information technology (IT) has significantly altered the nature of work and organizational structures in many industries, including health care. The purpose of this analysis is to compare how system-level differences affect IT implementation in health care (HIT) and the implications of these differences for health care equity.

We critically analyzed selected claims concerning the capacity of HIT to provide better care to more individuals at lower costs, thus contributing to health care equity, in the context of current health care reform efforts in the United States. We used the case of HIT implementation in Taiwan’s National Health Insurance system as a contrasting case.

We argue that however much HIT may yield in quality improvements or savings in the context of a universal and publicly financed single payer system, such savings simply cannot be accrued by a system of multiple health plans competing for better customers (i.e., less costly patients) and driven by profit.

It is important to define the level of analysis in debates about the potential of HIT to produce better health care at lower costs and the equity implications of this potential. In these debates, US policy makers should consider the commitment to health care equity that informed the design of Taiwan’s health care system and of HIT implementation in that country. HIT merely provides enabling tools that are of little value without major systemic changes

To our knowledge, the health IT expert literature has overlooked when not ignored the ethical principles informing health care systems, an omission which makes it difficult if not impossible to evaluate the potential of HIT to increase equity in health care.