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8. Nested enterprises

8. Nested enterprises (CPRs that are parts of larger systems).   Local boundaries, local conditions, local sanctions, local monitoring, local adjudications, local decision making; locality and peer relationships are the key to understanding, designing, and managing common pool resources. Before the distance, size, or context become too large for local sense-making, local culture, local compassion […]

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7. Minimal recognition of rights to organize

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6. Conflict-resolution mechanisms

6. Conflict-resolution mechanisms Appropriators and their officials have rapid access to low-cost local arenas to resolve conflicts among appropriators or between appropriators and officials. This would be a very new and interesting idea. Especially if what we are adjudicating is participation in activities or training that create happiness and meaningful lives. If it were done […]

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5. Graduated sanctions

5. Graduated sanctions Appropriators who violate operational rules are likely to be assessed graduated sanctions (depending on the seriousness and context of the offense) by other appropriators, by officials accountable to the appropriators, or by both.   Considering the possibility that a community will create negative incentives to encourage healthy behaviors  is a departure from […]

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4. Monitoring

4. Monitoring Monitors, who actively audit CPR conditions and appropriator behavior, are accountable to the appropriators or are the appropriators.   Traditionally in US healthcare “monitors” have been utilization and review nurses and health insurance/plan administrative staff–in other words outsiders from Ostrom’s perspective. Inside monitors, accountable to appropriators are what is needed to meet this […]

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3. Collective-choice arrangements

3. Collective-choice arrangements Most individuals affected by the operational rules can participate in modifying the institutional rules.   Individual participation in operational rule making is a very interesting condition or constraint. First and foremost the conditions must be designed for health and healthcare to be of enough interest that people would engage. Currently it seems […]

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1. Clearly defined boundaries

1. Clearly defined boundaries Individuals or households who have rights to withdraw resource units from the CPR must be clearly defined, as must the boundaries of the CPR itself. —– Defined populations are required for ACOs. The issue is the concept of “clearly” which I believe means clear to all others. And this clarity is […]

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Governing the Health Commons

If health care resources can be usefully though of as common pool resources, as Jane Brock, M.D. has suggested from her analysis of  Grand Junctions, CO health system, then we should design our governance based on Elinor Ostrom’s eight principles: Governing the Commons: an important idea for communities and the management of the limited resources […]

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