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Morphological analysis for health care systems planning
MORPHOLOGICAL ANALYSIS FOR HEALTH CARE SYSTEMS PLANNING RICHARD E. TUBLEY, WILLIAM C. RICHARDSON* and JAMES V. HANSENt Departmentof Mechanical Engineering, University of Utah, Salt Lake City, Utah, U.S.A. (Receiued 16April 1974) Abstract-Health care planners are continually challenged by the difficulty of ordering and understanding of the complexities of health care delivery systems. Methods are needed which can aid in extending thought processes into multi-dimensional solution space and rationalizing the thinking of various health care interests. This paper describes a useful approach to designing and evaluating health care systems utilizing a case study of a large metropolitan community.
represented as a horizontal relevance tree. The vertical axis enumerates individual parts or functions of the system. The horizontal axis describes the available and anticipitated subdimensions. Morphological analysis may be applied at nearly any level of aggregation. It may, for example, be used to investigate alternative methods of designing a public health system, a preventive care program, or a health maintenance organization (HMO). The approach is basically the same for each of these objectives. An important advantage of the morphological method is its formal approach to discovering and examining solution alternatives. It forces the planner to work systematically from “morphological space”, which reflects the known, into nearby space, which is not known. A typical procedure is to vary the parameters of the initial conhguration one at a time keeping the others fixed as the examination moves into the unknown region[5]. Another advantage of this technique centers on its total enumeration approach. It provides a means of examining all possible configurations which may be appropriate to a given objective. This process often reveals gaps in required services (or technology) and forces the analyst to include alternatives which might otherwise be overlooked or summarily dismissed as being infeasible. Under closer examination, combinations having the superficial appearance of absurdity may turn out to be viable alternativesor they may suggest modifications which will promote viability. Zwicky, for example, ultimately identified or invented fourteen new telescope designs as the result of preparing a lecture on the morphological method applied to telescope design[3]. There are, of course, limitations to the morphological method. One is that it is limited to existing technologiesalthough it can prove valuable in pointing up areas of needed technologies. Another constraint is that the analysts must have a thorough knowledge of the field to which it is being applied. The use of a team of experts can generally improve the quality and completeness of solution alternatives. The first step in constructing the morphological space is to formulate the problem to be investigated. The narrower the scope of problem definition, the less complex will be the subsequent analysis. The second step is to select the dimensions upon which the attainment of the objective depends. Next, elements which represent alternatives at each level are identified as entries or vertices of the tree. The fourth step is to establish sets of criteria for each of the levels. Finally, applications of methods drawn from
Health care planners are frequently confronted with the problem of assessing current system effectiveness, and developing and evaluating alternatives for meeting health care needs. This is a particularly difficult task as modern day health care has become a highly complex system having numerous components whose relationships are not generally well understood[l]. Further, major changes in the arrangements for the delivery of personal health services have been occurring in recent years, and many policy questions have arisen as a consequence. Several substantive problem areas appear to be of particular concern in the present process of public policy reformulation. These problems include: the types of care rendered and its continuity, the evenness of access opportunities across various segments of the population, the utilization of scarce manpower, and finally, the structuring and consequences of existing incentives within the health field. Because proposed solutions within any of these areas impact other problem areas in complex ways, increasing attention has been focused on development and evaluation of diverse health care delivery modes[2]. In order to cope with the need for innovation in the face of increasing complexity, methods need to be developed and applied which can upgrade our ability to extend our thinking into multi-dimensional solution space.
MORPHOLOGICAL ANALYSIS
One approach which can facilitate this type of thinking is morphological analysis. This methodology, formulated more than two decades ago by Fritz Zwicky [3,4] has not received wide attention despite his efforts to promote its application to technological and social problems. The general objective of morphological analysis is to visualize all possible solutions to any given problem and to point the way toward the general performance evaluation of these solutions. The methodology is based on graph theory with the morphological space representing a graph consisting of dimensions which are sets of nodes representing parameters. If the morphological space consists of two dimensions it may be expressed as- a matrix. If it consists of three dimensions it may be expressed as a box. An n-dimensional space is best
*School of Public Health and Community Medicine, University of Washington U.S.A. TPacbic Northwest Laboratories, Battelle Memorial Institute Richland, Washington 99352,U.S.A. 83
RICHARD E. TURLEY, WILLIAMC. RICHARDSON and JAMESV.
a4
systems analysis and operations research may be utilized to order the analysis into a logical framework. A MORPHOLOGY
OF HEALTH CARE DELIYERY
The authors were recently engaged in a study of health care delivery in a large metropolitan community with the objectives of assessing the current system’s effectiveness and developing and evaluating alternatives for meeting community health care needs. The impetus for this research derived from a group of concerned community health care providers who felt that unmet health care needs existed in the community and that its health care resources could be utilized more effectively. Subsequent investigations supported this concern. In particular, it was determined that a double standard of health care was being perpetuated in the community. The individual or family adequately insured or able to pay for health care was able to exercise freedom in choosing a provider. Freedom of choice for the poor was, however, greatly limited. As a consequence, the poor felt rejected by the county system of health care. While access to the nongovernmental system was restricted, the poor were concerned that even if barriers to access were removed there would be no assurance that they would receive the same level of treatment and consideration as the non-poor. Preliminary analysis suggested that much of the problem could be eliminated if a means could be found to pay providers adequately for their services, while at the same time encouraging the establishment of patient-physician relationships between the poor and primary care practitioners. This prompted the need for a framework for thinking about the problem which would enhance the prospects for developing a sound solutionone which would (1) be operationally feasible, (2) meet the unsatisfied health care needs of the cornunity, and (3) receive support from community providers and recipients of health care, as well as government agencies and the community at large. It was clearly evident that in order to promote development of such a solution there was need for an approach which would: (1) minimize the possibility of overlooking an important combination of system dimensions; and (2) help in organizing and directing the thinking of community health care providers, as well as those whose cooperation would be necessary for any concept to be successfully implemented. Morphological analysis
HANSEN
appeared to offer a framework which would facilitate meeting this need. DESIGN
Alternatives were derived using five primary dimensions and their associated subdimensions. The subdimension, “Other”, was used to include dimensions not considered critical to the analysis. Major dimensions of the system which were of concern were determined to be the following: 1.O Patient 2.0 Type of care needed 3.0 Organizational base for services 4.0 Ownership 5.0 Provider reimbursement These major dimensions along with their respective subdimensions are outlined below and shown in morphological form in Fig. 1. 1.0 Patient: The patient was designated either as (1.1) Private pay or Insured, or as (1.2) Medically indigent. 2.0 Type of care needed: Three levels of care were considered as the major subdimensions applicable to the study. These types of care were as follows: (2.1) Primary, (2.2) Specialty, (2.3) Inpatient, and another subdimension was added, (2.4) Other, as a catch-all for any other conceived type. 3.0 Organizational base for services: Five primary subdimensions were used to further break down the organizational base for delivery of the care as described under major dimension (2.0). These were as follows: (3.1) Physician’s office, (3.2) Primary ambulatory health care center, (3.3) Primary-specialty hospital outpatient department, (3.4) Specialty outpatient clinic, and (3.5) Hospital. The set was left open by adding (3.6) Other. 4.0 Ownership: For the purposes of analysis, ownership of organizations or facilities was classified as either: (4.1) Nongovernmental, or (4.2) Governmental. It may be possible, of course, to have a governmental facility operated by a nongovernmental organization and vice versa. 5.0 Provider reimbursement: Reimbursement to the provider was divided broadly into two general categories: (5.1) Open market fee-for service, and (5.2) Contracted services. Under the subdimension (5.2) were included contracted services, either on a capitation basis or a feefor-service basis.
Fig. 1. Dimensions used to derive alternatives for health delivery system.
Morphologicalanalysisfor healthcare systemsplanning SELECTEDSYSTEMALTERNATIVES
Figures 2-4 illustrate the manner in which morphologies were described as possible alternatives for a community health delivery system. The horizontal relevance tree served not only to suggest new or different morphologies, but, importantly, to clearly define the structure underlying each alternative. The latter greatly aided in making later evaluations as to how well each alternative satisfied each selection criterion. The nine morphologies initially designed were identified as: Physicians in private offices with hospital privileges A medical foundation The nongovernmental hospital with an associated network of neighborhood health care centers (NHCC’s), i.e. primary ambulatory health care centers A prepaid group practice with neighborhood health care (NHC) clinics A new county general hospital with an associated network of neighborhood health care centers A new county general hospital-health maintenance organization (HMO) with an associated network of neighborhood health care centers The nongovernmental hospital outpatient department A hospital-based health maintenance organization The classical county hospital
85
Physicians in private o&es with Hospital Privileges This morphology assumed that primary care and most likely specialty care would be delivered in the private offices of practitioners in the community. In following the dimensions in Fig. 2 this organizational alternative was described by the following coordinates: (1.1)+ (2.1) or (2.2)+(3.1)+(4.1)+(5.1). This alternative represents the traditional private practice, fee-for-services model which is evident generally in U.S. society. Practitioners collect fees for services rendered, with only informal referral relationships among practitioners and with the hospital medical staff organization as the only formal control mechanism. Hospitals were envisioned as being reimbursed on a cost basis. The two sets of dimensional coordinates outlined did not necessarily describe all the alternative paths which may be descriptive of this model. They did, however, serve as primary examples.
The medical foundation As with the preceding alternative, this model presupposed that primary care and most likely specialty care would be delivered in the private offices of practitioners in the community. Both models would operate with collec-
4.0 OWNERSHIP
Fig. 2. Dimensionsusedto derivealternativesfor healthdeliverysystem.
Fig. 3. Dimensionsused to derivealternativesfor healthdeliverysystem.
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RICHARD E. TURLEY,WILLIAM C. RICHARDSON and JAMES V. HANSEN
Fig.4. Dimensionsused to derivealternativesfor healthdeliverysystem. tion on a capitation basis, but in the latter payment to both primary and specialty physicians generally would be on a prorated fee-for-services basis under contractural arrangements. There would also be contractual relatronships with local hospitals. This morphology assumed a dual system of provider reimbursement, i.e. patients having the option of paying the customary fee-for-services and being free to enter and leave the system, or patients enrolling to receive care through contracted services. The dimensional coordinates from Fig. 2 were the same as in the case of the physician in his private office, except that the subdimension (5.2) was added. The nongovernmental hospital with NHCC’s The third alternative was identified as the nongovem-
mental hospital with an associated network of primary ambulatory health care centers or neighborhood health care centers. This model was characterized by a primary ambulatory care center, or centers, located in the community and operated under voluntary nongovernmental auspices. This was a three-level-of-care model with the primary care delivered in the * borhood and the specialty care not necessarily prov ?Zh ed nearby but at a related hospital. Physicians in the NHCC would have privileges on the staff of the nongovernmental hospital and follow their patients into the hospital as a consequence. Physicians in the NHCC would be organized as a group and paid on a negotiated basis. Revenues received by the NHCC would be generated from contracts for selected populations and from fee-for service reimbursement. One of the coordinate sets which describes this alternative was (1.1)+(2.1)+(3.2)+(4.1)+(5.1)+or (5.2) (Fig. 2). The prepaid group practice with NHC clinics The prepaid group practice model with NHC clinics was depicted as a nongovernmental organization operating on a capitation (contracted services) basis with primary ambulatory health care clinics located in selected neighborhoods and a centrally located outpatient unit at a nongovernmental hospital. The clinics and the hospital. The clinics and the hospital would be owned and operated by the prepaid group organization.
Physicians in this organizational system might be paid on a salary basis or alternatively on a capitation or other basis as a group by the parent organization. This organizational arrangement may be derived from one or more of the following coordinate sets: (1.1)+ (2.1)+(3.2) or (3.3)+(4.1)+(5.2); (l.l)t(2.2)+(3.3) or (3.4) + (4.1)t (5.2); or . (1.1)t (2.3) t (3.5) t (4.1) t (5.2) (Fig. 3). A new county general hospital with NHCC’s
Construction of a new county hospital presupposed full government ownership and. operation. It was expected that if this alternative were selected it would operate with a network of NHCC’s and have arrangements for specialty care at the hospital. Physicians in this system were to be salaried. However, the organization would receive payment on a fee-forservices basis for physician services and on a cost reimbursement or other arrangement for hospital services. In addition, both physician and hospital services under this alternative could be subsidized directly from local tax revenues. The primary care coordinate path was derived from the morphological space of Fig. 3 as follows: (1.1) or (1.2) t(2.1)+(3.2) or (3.3)+(4.2)+(5.1). A new county genecal hospital-HMO
with NHCC’s As with the two previous models, this organizational alternative was based on a group practice or health center practice as the primary and possibly the specialty level. This model of county HMO with NHCC’s was characterized by capitation payment for a broad range of health services, with full ownership of the financing and operating organization by the government. In addition, both physician and hospital services could be subsidized directly from local tax revenue. Figure 3 structures the appropriate dimensions as (1.1) or (1‘2)t (2.1) or (2.2) t (3.2) or (3.3) t (4.2) t (5.1) or (5.2). This model assumed one or more primary care centers with salaried positions, a specialty referral outpatient center probably associated with the county hospital, although the more common specialties could be represented in the primary care center location or locations. The hospital would be owned and operated by the county government.
a7
Morphological analysis for health care systems planning
The nongovernmental hospital outpatient department This organizational alternative was hospital based. The coordinates from Fig. 4 which trace the morphology of this organizational arrangement are as follows: (l.l)t (2.1) or (2.2) t (3.3) + (4.1) t (5.1). The expanded nongovernmental outpatient department exemplifies this alternative. Physicians would be reimbursed on a fee-for services basis or under negotiated contract with the hospital. A hospital-based HMO This alternative was described as an organization operated by a nongovernmental hospital on a capitation basis. Physicians would serve as salaried employees of the hospital. The organizational arrangement was derived from the following coordinates as shown in Fig. 4: (1.1) t (2.1) or (2.2)t (3.3) t (4.1) t (5.1) or (5.2). The classical county hospital This alternative was the classical county hospital model, with the entire operation owned and conducted by local county government. Physicians in this model would be on salary, and the organization reimbursed on a cost basis to include physician services. In addition, the hospital could be subsidized directly from local tax revenues. The set of coordinates which describes the system is graphed in Fig. 4 as follows: (1.1) or (1.2) t (2.1) or (2.2)t (3.3) or (3.4) + (4.2) + (5.1). RESULTS
Evaluation based upon predetermined criteria identified the preferred morphologies as: (2) a medical foundation (Fig. 2), (3) the nongovernmental hospital with NHCC’s (Fig. 2), (4) a prepaid group practice with NHC clinics (Fig. 3), and (8) a hospital-based HMO (Fig. 4). An iterative assessment of the top-ranked alternatives suggested that no one of them could by itself meet the total health care needs of the community. For example, Alternative 8 would require an unacceptable length of time to implement. Alternative 4 as a single choice was not viewed as being sufficient since the vast majority of physicians in the community were currently in private practice, and it became increasingly evident that any viable system would have to include elements of Alternative 1. Utilizing the morphological space once again, a tenth alternative was formulated drawing from the mor-
phologies of Alternatives 1, 2 and 3. Figure 5 illustrates the health care system recommended for implementation in the community. Under this morphology physicians would continue to practice in their private offices, while retaining privileges on the medical staff of one or more of the nongovernmental hospitals. A medical foundation would be established which would explore the possibility of contracting with the county and state to take care of certain segments of the population on a contracted services or capitation basis. The individuals covered under such an arrangement would either be the entire categorical group in an agreed upon geographical area, or a random selection of such patients to insure an acceptable underwriting risk. The medical society of the community would form the nucleus for such a foundation. The society would set up a separate organization or other acceptable alternative as the administrative agency for the foundation. The more physicians participating in the foundation, the more likely that suitable arrangements could be made with the county or state. The foundation would reimburse the physicians on a fee-for-services basis. Immediately upon billing, the physician would receive partial payment of his fee based upon a maximum fee schedule. At the end of an agreed upon fiscal period, the remainder of the fee would be prorated or paid in full depending upon the fiscal soundness of the program. Surplus funds could be set aside as reserves for future underwriting losses or for broadening the benefit program. The medically indigent would also be treated by the foundation, provided that a satisfactory arrangement could be made with the county to serve their needs. DISCUSSION I The
authors’ experience in assisting health care planners suggests that a major obstacle to effective planning is the inability to cope with the complexities of the health care system. This tends to stifle creativity and to foster dogmatism, and is a particularly severe problem in health care delivery because of the number of special interests involved. Tools to facilitate communication among these interests and to aid in rational thinking are badly needed. In this study, it was especially important that health care experts representing the various interests have the opportunity to suggest solutions or innovations from their particular point of view. The morphological framework provided a useful vehicle for subsequent analysis. First,
88
RICHARDE. TURLEY, WILLIAM C.
the expert could readily determine whether all the dimensions he perceived as being relevant were represented. Second, his suggestions for systems configurations could be quickly understood and analyzed by others. Both of these processes stimulated rigorous discussions which often produced new alternative structures. It was another of the researchers’ objectives that no important alternative be overlooked. While there is no surety that this was accomplished, the range of alternatives considered (as well as modifications thereof) was well beyond that which had been proposed initially. Additionally, since the structure of each alternative system was clearly defined, evaluations as to how well each one satisfied the selection criteria was more easily rationalized by the group. This was evidenced by several preliminary evaluations which were unable to be supported under close examination of the structure and intent of the particular alternative. Finally, the numerous interations through the morphological graph generated the thinking which resulted in the recommended alternative. CONCLUSION
Many of the most pressing problems of our society lie unsolved or partially solved because of our limited ability
RICHARDSON and
JAMESV.
HANSEN
to extend our thinking into a multidimensional solution space. As a tool for stimulating ideas, morphological analysis represents a useful approach to invention, discovery, and innovation. Devices or ideas in a set representing the state-of-the-art may be reduced to their basic parameters and these parameters categorized to establish the dimensions of morphological space. These may, in turn, be expanded by adding other appropriate parameters. The best combination of parameters may be suggested through the application of elements of graph theory and decision theory.
REFFBENCFS 1. William J. Horvath, The systems approach to the national
health problem, Mgmt Sci. 12, B391-B395(1966). 2. Richard E. Turley, William C. Richardson and James V. Hansen, A morphological approach to designing and evaluating health care systems. Proc. Fifth Nat. Meeting Am. Inst. Decision Sci. (1973). 3. Fritz Zwicky, Discovery, Invention, Research. Macmillan, New York (1%9). 4. A. G. Wilson and F. Zwicky, MorphologicalResearch. Springer, New York (1967). 5. Robert U. Ayres, Technological Forecasting and Long-Range Planning.McGraw-Hill,New York (1969).
represented as a horizontal relevance tree. The vertical axis enumerates individual parts or functions of the system. The horizontal axis describes the available and anticipitated subdimensions. Morphological analysis may be applied at nearly any level of aggregation. It may, for example, be used to investigate alternative methods of designing a public health system, a preventive care program, or a health maintenance organization (HMO). The approach is basically the same for each of these objectives. An important advantage of the morphological method is its formal approach to discovering and examining solution alternatives. It forces the planner to work systematically from “morphological space”, which reflects the known, into nearby space, which is not known. A typical procedure is to vary the parameters of the initial conhguration one at a time keeping the others fixed as the examination moves into the unknown region[5]. Another advantage of this technique centers on its total enumeration approach. It provides a means of examining all possible configurations which may be appropriate to a given objective. This process often reveals gaps in required services (or technology) and forces the analyst to include alternatives which might otherwise be overlooked or summarily dismissed as being infeasible. Under closer examination, combinations having the superficial appearance of absurdity may turn out to be viable alternativesor they may suggest modifications which will promote viability. Zwicky, for example, ultimately identified or invented fourteen new telescope designs as the result of preparing a lecture on the morphological method applied to telescope design[3]. There are, of course, limitations to the morphological method. One is that it is limited to existing technologiesalthough it can prove valuable in pointing up areas of needed technologies. Another constraint is that the analysts must have a thorough knowledge of the field to which it is being applied. The use of a team of experts can generally improve the quality and completeness of solution alternatives. The first step in constructing the morphological space is to formulate the problem to be investigated. The narrower the scope of problem definition, the less complex will be the subsequent analysis. The second step is to select the dimensions upon which the attainment of the objective depends. Next, elements which represent alternatives at each level are identified as entries or vertices of the tree. The fourth step is to establish sets of criteria for each of the levels. Finally, applications of methods drawn from
Health care planners are frequently confronted with the problem of assessing current system effectiveness, and developing and evaluating alternatives for meeting health care needs. This is a particularly difficult task as modern day health care has become a highly complex system having numerous components whose relationships are not generally well understood[l]. Further, major changes in the arrangements for the delivery of personal health services have been occurring in recent years, and many policy questions have arisen as a consequence. Several substantive problem areas appear to be of particular concern in the present process of public policy reformulation. These problems include: the types of care rendered and its continuity, the evenness of access opportunities across various segments of the population, the utilization of scarce manpower, and finally, the structuring and consequences of existing incentives within the health field. Because proposed solutions within any of these areas impact other problem areas in complex ways, increasing attention has been focused on development and evaluation of diverse health care delivery modes[2]. In order to cope with the need for innovation in the face of increasing complexity, methods need to be developed and applied which can upgrade our ability to extend our thinking into multi-dimensional solution space.
MORPHOLOGICAL ANALYSIS
One approach which can facilitate this type of thinking is morphological analysis. This methodology, formulated more than two decades ago by Fritz Zwicky [3,4] has not received wide attention despite his efforts to promote its application to technological and social problems. The general objective of morphological analysis is to visualize all possible solutions to any given problem and to point the way toward the general performance evaluation of these solutions. The methodology is based on graph theory with the morphological space representing a graph consisting of dimensions which are sets of nodes representing parameters. If the morphological space consists of two dimensions it may be expressed as- a matrix. If it consists of three dimensions it may be expressed as a box. An n-dimensional space is best
*School of Public Health and Community Medicine, University of Washington U.S.A. TPacbic Northwest Laboratories, Battelle Memorial Institute Richland, Washington 99352,U.S.A. 83
RICHARD E. TURLEY, WILLIAMC. RICHARDSON and JAMESV.
a4
systems analysis and operations research may be utilized to order the analysis into a logical framework. A MORPHOLOGY
OF HEALTH CARE DELIYERY
The authors were recently engaged in a study of health care delivery in a large metropolitan community with the objectives of assessing the current system’s effectiveness and developing and evaluating alternatives for meeting community health care needs. The impetus for this research derived from a group of concerned community health care providers who felt that unmet health care needs existed in the community and that its health care resources could be utilized more effectively. Subsequent investigations supported this concern. In particular, it was determined that a double standard of health care was being perpetuated in the community. The individual or family adequately insured or able to pay for health care was able to exercise freedom in choosing a provider. Freedom of choice for the poor was, however, greatly limited. As a consequence, the poor felt rejected by the county system of health care. While access to the nongovernmental system was restricted, the poor were concerned that even if barriers to access were removed there would be no assurance that they would receive the same level of treatment and consideration as the non-poor. Preliminary analysis suggested that much of the problem could be eliminated if a means could be found to pay providers adequately for their services, while at the same time encouraging the establishment of patient-physician relationships between the poor and primary care practitioners. This prompted the need for a framework for thinking about the problem which would enhance the prospects for developing a sound solutionone which would (1) be operationally feasible, (2) meet the unsatisfied health care needs of the cornunity, and (3) receive support from community providers and recipients of health care, as well as government agencies and the community at large. It was clearly evident that in order to promote development of such a solution there was need for an approach which would: (1) minimize the possibility of overlooking an important combination of system dimensions; and (2) help in organizing and directing the thinking of community health care providers, as well as those whose cooperation would be necessary for any concept to be successfully implemented. Morphological analysis
HANSEN
appeared to offer a framework which would facilitate meeting this need. DESIGN
Alternatives were derived using five primary dimensions and their associated subdimensions. The subdimension, “Other”, was used to include dimensions not considered critical to the analysis. Major dimensions of the system which were of concern were determined to be the following: 1.O Patient 2.0 Type of care needed 3.0 Organizational base for services 4.0 Ownership 5.0 Provider reimbursement These major dimensions along with their respective subdimensions are outlined below and shown in morphological form in Fig. 1. 1.0 Patient: The patient was designated either as (1.1) Private pay or Insured, or as (1.2) Medically indigent. 2.0 Type of care needed: Three levels of care were considered as the major subdimensions applicable to the study. These types of care were as follows: (2.1) Primary, (2.2) Specialty, (2.3) Inpatient, and another subdimension was added, (2.4) Other, as a catch-all for any other conceived type. 3.0 Organizational base for services: Five primary subdimensions were used to further break down the organizational base for delivery of the care as described under major dimension (2.0). These were as follows: (3.1) Physician’s office, (3.2) Primary ambulatory health care center, (3.3) Primary-specialty hospital outpatient department, (3.4) Specialty outpatient clinic, and (3.5) Hospital. The set was left open by adding (3.6) Other. 4.0 Ownership: For the purposes of analysis, ownership of organizations or facilities was classified as either: (4.1) Nongovernmental, or (4.2) Governmental. It may be possible, of course, to have a governmental facility operated by a nongovernmental organization and vice versa. 5.0 Provider reimbursement: Reimbursement to the provider was divided broadly into two general categories: (5.1) Open market fee-for service, and (5.2) Contracted services. Under the subdimension (5.2) were included contracted services, either on a capitation basis or a feefor-service basis.
Fig. 1. Dimensions used to derive alternatives for health delivery system.
Morphologicalanalysisfor healthcare systemsplanning SELECTEDSYSTEMALTERNATIVES
Figures 2-4 illustrate the manner in which morphologies were described as possible alternatives for a community health delivery system. The horizontal relevance tree served not only to suggest new or different morphologies, but, importantly, to clearly define the structure underlying each alternative. The latter greatly aided in making later evaluations as to how well each alternative satisfied each selection criterion. The nine morphologies initially designed were identified as: Physicians in private offices with hospital privileges A medical foundation The nongovernmental hospital with an associated network of neighborhood health care centers (NHCC’s), i.e. primary ambulatory health care centers A prepaid group practice with neighborhood health care (NHC) clinics A new county general hospital with an associated network of neighborhood health care centers A new county general hospital-health maintenance organization (HMO) with an associated network of neighborhood health care centers The nongovernmental hospital outpatient department A hospital-based health maintenance organization The classical county hospital
85
Physicians in private o&es with Hospital Privileges This morphology assumed that primary care and most likely specialty care would be delivered in the private offices of practitioners in the community. In following the dimensions in Fig. 2 this organizational alternative was described by the following coordinates: (1.1)+ (2.1) or (2.2)+(3.1)+(4.1)+(5.1). This alternative represents the traditional private practice, fee-for-services model which is evident generally in U.S. society. Practitioners collect fees for services rendered, with only informal referral relationships among practitioners and with the hospital medical staff organization as the only formal control mechanism. Hospitals were envisioned as being reimbursed on a cost basis. The two sets of dimensional coordinates outlined did not necessarily describe all the alternative paths which may be descriptive of this model. They did, however, serve as primary examples.
The medical foundation As with the preceding alternative, this model presupposed that primary care and most likely specialty care would be delivered in the private offices of practitioners in the community. Both models would operate with collec-
4.0 OWNERSHIP
Fig. 2. Dimensionsusedto derivealternativesfor healthdeliverysystem.
Fig. 3. Dimensionsused to derivealternativesfor healthdeliverysystem.
86
RICHARD E. TURLEY,WILLIAM C. RICHARDSON and JAMES V. HANSEN
Fig.4. Dimensionsused to derivealternativesfor healthdeliverysystem. tion on a capitation basis, but in the latter payment to both primary and specialty physicians generally would be on a prorated fee-for-services basis under contractural arrangements. There would also be contractual relatronships with local hospitals. This morphology assumed a dual system of provider reimbursement, i.e. patients having the option of paying the customary fee-for-services and being free to enter and leave the system, or patients enrolling to receive care through contracted services. The dimensional coordinates from Fig. 2 were the same as in the case of the physician in his private office, except that the subdimension (5.2) was added. The nongovernmental hospital with NHCC’s The third alternative was identified as the nongovem-
mental hospital with an associated network of primary ambulatory health care centers or neighborhood health care centers. This model was characterized by a primary ambulatory care center, or centers, located in the community and operated under voluntary nongovernmental auspices. This was a three-level-of-care model with the primary care delivered in the * borhood and the specialty care not necessarily prov ?Zh ed nearby but at a related hospital. Physicians in the NHCC would have privileges on the staff of the nongovernmental hospital and follow their patients into the hospital as a consequence. Physicians in the NHCC would be organized as a group and paid on a negotiated basis. Revenues received by the NHCC would be generated from contracts for selected populations and from fee-for service reimbursement. One of the coordinate sets which describes this alternative was (1.1)+(2.1)+(3.2)+(4.1)+(5.1)+or (5.2) (Fig. 2). The prepaid group practice with NHC clinics The prepaid group practice model with NHC clinics was depicted as a nongovernmental organization operating on a capitation (contracted services) basis with primary ambulatory health care clinics located in selected neighborhoods and a centrally located outpatient unit at a nongovernmental hospital. The clinics and the hospital. The clinics and the hospital would be owned and operated by the prepaid group organization.
Physicians in this organizational system might be paid on a salary basis or alternatively on a capitation or other basis as a group by the parent organization. This organizational arrangement may be derived from one or more of the following coordinate sets: (1.1)+ (2.1)+(3.2) or (3.3)+(4.1)+(5.2); (l.l)t(2.2)+(3.3) or (3.4) + (4.1)t (5.2); or . (1.1)t (2.3) t (3.5) t (4.1) t (5.2) (Fig. 3). A new county general hospital with NHCC’s
Construction of a new county hospital presupposed full government ownership and. operation. It was expected that if this alternative were selected it would operate with a network of NHCC’s and have arrangements for specialty care at the hospital. Physicians in this system were to be salaried. However, the organization would receive payment on a fee-forservices basis for physician services and on a cost reimbursement or other arrangement for hospital services. In addition, both physician and hospital services under this alternative could be subsidized directly from local tax revenues. The primary care coordinate path was derived from the morphological space of Fig. 3 as follows: (1.1) or (1.2) t(2.1)+(3.2) or (3.3)+(4.2)+(5.1). A new county genecal hospital-HMO
with NHCC’s As with the two previous models, this organizational alternative was based on a group practice or health center practice as the primary and possibly the specialty level. This model of county HMO with NHCC’s was characterized by capitation payment for a broad range of health services, with full ownership of the financing and operating organization by the government. In addition, both physician and hospital services could be subsidized directly from local tax revenue. Figure 3 structures the appropriate dimensions as (1.1) or (1‘2)t (2.1) or (2.2) t (3.2) or (3.3) t (4.2) t (5.1) or (5.2). This model assumed one or more primary care centers with salaried positions, a specialty referral outpatient center probably associated with the county hospital, although the more common specialties could be represented in the primary care center location or locations. The hospital would be owned and operated by the county government.
a7
Morphological analysis for health care systems planning
The nongovernmental hospital outpatient department This organizational alternative was hospital based. The coordinates from Fig. 4 which trace the morphology of this organizational arrangement are as follows: (l.l)t (2.1) or (2.2) t (3.3) + (4.1) t (5.1). The expanded nongovernmental outpatient department exemplifies this alternative. Physicians would be reimbursed on a fee-for services basis or under negotiated contract with the hospital. A hospital-based HMO This alternative was described as an organization operated by a nongovernmental hospital on a capitation basis. Physicians would serve as salaried employees of the hospital. The organizational arrangement was derived from the following coordinates as shown in Fig. 4: (1.1) t (2.1) or (2.2)t (3.3) t (4.1) t (5.1) or (5.2). The classical county hospital This alternative was the classical county hospital model, with the entire operation owned and conducted by local county government. Physicians in this model would be on salary, and the organization reimbursed on a cost basis to include physician services. In addition, the hospital could be subsidized directly from local tax revenues. The set of coordinates which describes the system is graphed in Fig. 4 as follows: (1.1) or (1.2) t (2.1) or (2.2)t (3.3) or (3.4) + (4.2) + (5.1). RESULTS
Evaluation based upon predetermined criteria identified the preferred morphologies as: (2) a medical foundation (Fig. 2), (3) the nongovernmental hospital with NHCC’s (Fig. 2), (4) a prepaid group practice with NHC clinics (Fig. 3), and (8) a hospital-based HMO (Fig. 4). An iterative assessment of the top-ranked alternatives suggested that no one of them could by itself meet the total health care needs of the community. For example, Alternative 8 would require an unacceptable length of time to implement. Alternative 4 as a single choice was not viewed as being sufficient since the vast majority of physicians in the community were currently in private practice, and it became increasingly evident that any viable system would have to include elements of Alternative 1. Utilizing the morphological space once again, a tenth alternative was formulated drawing from the mor-
phologies of Alternatives 1, 2 and 3. Figure 5 illustrates the health care system recommended for implementation in the community. Under this morphology physicians would continue to practice in their private offices, while retaining privileges on the medical staff of one or more of the nongovernmental hospitals. A medical foundation would be established which would explore the possibility of contracting with the county and state to take care of certain segments of the population on a contracted services or capitation basis. The individuals covered under such an arrangement would either be the entire categorical group in an agreed upon geographical area, or a random selection of such patients to insure an acceptable underwriting risk. The medical society of the community would form the nucleus for such a foundation. The society would set up a separate organization or other acceptable alternative as the administrative agency for the foundation. The more physicians participating in the foundation, the more likely that suitable arrangements could be made with the county or state. The foundation would reimburse the physicians on a fee-for-services basis. Immediately upon billing, the physician would receive partial payment of his fee based upon a maximum fee schedule. At the end of an agreed upon fiscal period, the remainder of the fee would be prorated or paid in full depending upon the fiscal soundness of the program. Surplus funds could be set aside as reserves for future underwriting losses or for broadening the benefit program. The medically indigent would also be treated by the foundation, provided that a satisfactory arrangement could be made with the county to serve their needs. DISCUSSION I The
authors’ experience in assisting health care planners suggests that a major obstacle to effective planning is the inability to cope with the complexities of the health care system. This tends to stifle creativity and to foster dogmatism, and is a particularly severe problem in health care delivery because of the number of special interests involved. Tools to facilitate communication among these interests and to aid in rational thinking are badly needed. In this study, it was especially important that health care experts representing the various interests have the opportunity to suggest solutions or innovations from their particular point of view. The morphological framework provided a useful vehicle for subsequent analysis. First,
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the expert could readily determine whether all the dimensions he perceived as being relevant were represented. Second, his suggestions for systems configurations could be quickly understood and analyzed by others. Both of these processes stimulated rigorous discussions which often produced new alternative structures. It was another of the researchers’ objectives that no important alternative be overlooked. While there is no surety that this was accomplished, the range of alternatives considered (as well as modifications thereof) was well beyond that which had been proposed initially. Additionally, since the structure of each alternative system was clearly defined, evaluations as to how well each one satisfied the selection criteria was more easily rationalized by the group. This was evidenced by several preliminary evaluations which were unable to be supported under close examination of the structure and intent of the particular alternative. Finally, the numerous interations through the morphological graph generated the thinking which resulted in the recommended alternative. CONCLUSION
Many of the most pressing problems of our society lie unsolved or partially solved because of our limited ability
RICHARDSON and
JAMESV.
HANSEN
to extend our thinking into a multidimensional solution space. As a tool for stimulating ideas, morphological analysis represents a useful approach to invention, discovery, and innovation. Devices or ideas in a set representing the state-of-the-art may be reduced to their basic parameters and these parameters categorized to establish the dimensions of morphological space. These may, in turn, be expanded by adding other appropriate parameters. The best combination of parameters may be suggested through the application of elements of graph theory and decision theory.
REFFBENCFS 1. William J. Horvath, The systems approach to the national
health problem, Mgmt Sci. 12, B391-B395(1966). 2. Richard E. Turley, William C. Richardson and James V. Hansen, A morphological approach to designing and evaluating health care systems. Proc. Fifth Nat. Meeting Am. Inst. Decision Sci. (1973). 3. Fritz Zwicky, Discovery, Invention, Research. Macmillan, New York (1%9). 4. A. G. Wilson and F. Zwicky, MorphologicalResearch. Springer, New York (1967). 5. Robert U. Ayres, Technological Forecasting and Long-Range Planning.McGraw-Hill,New York (1969).