Enhanced Multi-Service Markets: An Evolution in Military Health System Governance.

Background: The evolution of governance models for the Military Health System's (MHS) large hospitals, called medical treatment facilities (MTFs), has culminated with the effort to implement Enhanced Multi-Service Markets (eMSM). The term eMSM refers to two separate concepts. First, MSM refers to those geographic areas, that is, markets, which have the following characteristics: they have MTFs that are operated by two or more Department of Defense (DoD) Services, that is, Army, Navy, or Air Force; there is a large beneficiary population; there is a substantial amount of direct care (i.e., beneficiaries are treated at MTFs instead of TRICARE's purchased care from civilian providers); and there is a substantial readiness and training platform. Second, the term "enhanced" refers to an increase in management authority over clinical and business operations, readiness, and MTF workload. Methods: A retrospective review was conducted to study the evolution of military and civilian health care delivery models for the purpose of understanding how governance models have changed since the 1980s to design and manage MTFs with overlapping catchments areas. Primary and secondary data sources were analyzed through a comprehensive literature review. Findings: Since the 1980s, the MHS governance models have evolved from testing various managed care models to a regionally focused TRICARE model and culminating with an overlapping catchment area model entitled eMSMs. The eMSM model partially fulfills the original vision because the eMSM leaders have limited budgetary and resource allocation authority. Discussion: The various models sought to improve governance of overlapping catchment areas with the intent to enhance medical readiness, community health, and individual health care while reducing costs. However, the success of the current model, that is, eMSMs, cannot be fully assessed because the eMSM model was not fully implemented as originally envisioned. Instead, the current eMSM model partially implements the eMSM model. As a result, the current eMSMs operate solely through cooperation and collaboration, without directive authority. Nevertheless, there have been some market-specific initiatives. Further analysis is necessary in the event that eMSM market managers are granted governance authority. This authority would include the ability to allocate the overall market's budget, determine common clinical and business functions, optimize the readiness of both the medical and the operational forces assigned to the market, and reallocate resources to optimize MTF workload. The results of this analysis may determine whether the fully implemented eMSMs optimize patient-centric initiatives as well as improve the market's efficiency and effectiveness.

El proceso de fusión hospitalaria en la ciudad de Tarragona (1464) / The Merging Process of the Hospitals in Tarragona (1464)

Los hospitales, en cataluña, se inscribieron desde la Baja edad Media hasta nuestros días dentro un modelo de gobierno específico que dio lugar a la creación y mantenimiento de una densa red de nstituciones asistenciales en prácticamente todos los municipios, incluso en los más pequeños, cuyo marco legal fue el derecho privado o civil. dicho modelo tiene sus fundamentos, en primer lugar, en la constatación de cómo los individuos legaban al hospital no sólo por la filantropía o caridad, sino también por la necesidad de aportar algo a la comunidad después de su muerte, en una suerte de consigna con el fin de devolver parte de los activos que los testadores habían acumulado durante su vida como instrumento para asegurar la reproducción social de la comunidad. En segundo lugar, se observa que a partir de los procesos de fusión del siglo XV las pequeñas instituciones asistenciales locales privadas –laicas o religiosas– se fu sionaron con los hospitales de titularidad municipal, y los activos patrimoniales resultantes de dicha fusión se gestionaron por separado de los de la municipalidad a través de una estructura administrativa propia y, a priori, autónoma respecto de los poderes políticos. en tercer lugar, además de la función de cuidado, el hospital era también un agente económico que operaba de manera similar a los Monte dei paschi italianos. por consiguiente, el significado de la institución resultó ser más complejo que la simple prestación de servicios asistenciales. Adquirió un valor específico en la identidad de la comunidad, se convirtió en uno de los centros de debate en la vida pública y adquirió un significado económico y financiero que contribuyó a fortalecer la construcción de la identidad colectiva de los ciudadanos, tal y como refleja el presente artículo a partir del ejemplo de la ciudad de tarragona (AU)

The aim of this paper is to highlight how hospitals in catalonia, from the late Middle Ages to the present, adopted a governance model which resulted in the creation and preservation of hospitals or care institutions in virtually all municipalities, even the smallest, whose legal framework was private or civil law. Firstly, we observed how individuals were motivated not only by philanthropy or charity, but also by a need to contribute something to the community after their death, to give back part of the assets they had accumulated during their lifetimes, as citizens who had benefitted from their positions. Secondly, we observed that, from the XVth century, small local private care institutions –secular or religious– merged with Municipal hospitals, but managed the resulting assets separately from those of the municipality. thirdly, as well as its care function, the hospital was also an economic agent that operated along similar lines to the Italian Monte dei paschi. It provided loans to working class citizens at a modest interest rate. the significance of the institution was more complex than the simple provision of care services. It acquired a specific value in the identity of the community, it became one of the centres of debate in public life and it took on an economic and financial meaning that strengthened the building of the citizens’ collective identity as shown in this article which uses the city of tarragona as its example (AU)