Chapter 5 - Healthcare Flashcards
Define Healthcare
It is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings. It is delivered by health professionals.
requirements of the WHO well-functioning healthcare system
RAWR
- ROBUST financing mechanisms
- A well-trained and adequately-paid workforce
- WELL-maintained health facilities and logistics to deliver quality medicines and technologies
- RELIABLE information on which to base decisions and policies
What is Primary care
- What is the scope of healthcare provided
It is the work of health professionals who act as a first point of consultation for all patients within the healthcare system. e.g: A GP, independent practitioner such as a physiotherapist
It offers the widest scope of health care including:
- all ages of patients
- all socioeconomic and geographic origins
- patients seeking to maintain optimal health
- patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases
Depending on the nature of the health condition,patients may then be referred for secondary or tertiary care
Secondary care
Refers to healthcare services provided by medical specialists and other health professionals who generally do not have first contact with patients. e.g cardiologists.
It includes acute care and skilled attendance during childbirth, intensive care, and medical imaging services
Patients may be required to see a primary care provider for a referral before they can access secondary care.
This restriction may also be imposed under the terms of the payment agreements in private or group health insurance plans.
Tertiary care
It is specialised consultive healthcare, usually for in-patients and on referral from a primary or secondary health professional,
- in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital.
eg. Cancer management, surgery
Public healthcare sector
These services are usually heavily subsidised or offered for free, but are often associated with significant queues, prescribed protocols and limited alternatives.
It is primarily used by South African citizens and foreigners who are not part of medical schemes or other healthcare insurance products.
The use of public services is not free in all countries. The South African public sector is subject to a nominal income-based charge. This charge is waived for those that cannot afford it
Private healthcare
Any members of the public can use these providers, as long as they can fund the cost, or are covered by a funding structure such as a medical scheme or health insurance.
Supply-side key providers
the provision of effective and efficient healthcare requires interaction between the following key providers:
- Doctors
- Nurses
- Support medical personnel and clinical associates
- Hospitals
- Upstream service providers:
– Pharmaceutical manufacturers
– medical distributers
– suppliers of medical equipment
Public hospitals
Poorer countries have shifted from tertiary to primary healthcare and from better-funded healthcare in urban areas to underfunded healthcare in rural areas.
Tertiary sector suffered the most. The overall number of hospital beds have declined due to budgetary constraints ,and demand has increased.
Private hospitals
Number of beds has been increasing. They have continued to invest in medical equipment, staff management, training services.
Structure and ownership of private hospitals (3)
- Not-for-profit: Faith-based hospitals
– They have played a large role in providing hospitals to the rural poor - Not-for-profit: Mining hospitals
– Geographically remote mining companies provide a range of healthcare services to their staff and sometimes the families of staff. - For-profit private hospitals
– These are either privately owned of listed companies with a direct profit motive
Upstream service providers
The provision of healthcare services is only possible because various other industries supply the necessary goods and services. Eg. pharmaceuticals, food, cleaning products, water, electricity, computers
Funders of healthcare
COGENT
- COMMERCIAL insurance products
- OUT-of-pocket expenditure by users themselves
- GOVERNMENT
- EMPLOYERS
- NON-government organisations and donors
- TRADE-related employer groups
Government as a funder of healthcare
- They are administratively and financially responsible for public sector healthcare
- Funded by taxes, grants, funding from the asset finance reserve
- Sometimes government may partially fund private healthcare to alleviate demand pressure on public sector healthcare. Eg. personal tax rebate or direct funding of certain private institutions.
Non-government organisations and donors as funders of healthcare
Donors, including foreign governments, and non-government organisations, often contribute to the funding of healthcare
OUT-of-pocket expenditure by the users themselves as a funder for healthcare
There are 3 forms
- Payment of invoiced medical services by users of commercial health insurance products who require to:
– make co-payments
– fund the difference between the actual and the covers price of services
– pay for services if threshold payments have been met - Payments by those who do not have any commercial health insurance products
– Young and healthy who elect to not buy any insurance products on the grounds that they do not add sufficient value
– the wealthy who choose to self-insure
– lower income groups who have elected to use private services or facilities above public sector facilities - Payments for medical services that are not invoiced. Eg. surgeons and midwives, traditional healers such as herbalists
Trade-related employer groups as funders of healthcare
They may join to form bargaining councils which may establish and manage schemes or funds to benefit their parties or members. This could include funds to pay for certain healthcare expenditure.
Benefits are usually limited to primary healthcare and managed care options.
Commercial insurance as funders of healthcare (Insurance policies designed to fund healthcare can be divided into four groups)
Insurance policies designed to fund healthcare can be divided into four groups:
- Optimal alternative: This would be for a person who opted not to use the public service facilities and took out insurance to cover expenses in the private sector
- Optimal complement: A person who took out a ‘waiting policy’ designed to pay for elective procedures sooner than the state would otherwise provide. Eg Gap cover
- Compulsory alternative: This may be used in an environment in which there are people that the government considers can afford to buy comprehensive cover
- Compulsory complement: Compulsory top-up plans would be used in an environment where individuals are compelled to buy policies to pay for dental plans and other services not provided by the state
What are medical Schemes?
They are not-for-profit entities that operate like trusts and undertake liability on behalf of the beneficiaries in return for a monthly contribution
Employers as funders of healthcare
They contribute to the financing of employee health in various ways:
1. Full or part payment of commercial insurance products such as medical scheme contributions
2. Full or part payment of bargaining council premiums
3. Payment for off-and on-site health services
4. Wellness programmes
5. Payments to healthcare providers for acute medical treatment
6. Payment towards social security funds such as UIF
What is the third-party payer problem
- It is when the provider has the incentive to provide more expensive or comprehensive treatment than is actually required
- or the users of healthcare abuse the “free” service
How to manage the third-party payer problem
Use administrators and managed care organisations. These are for-profit entities. They combine both clinical and statistical techniques to manage risk, reduce cost and improve quality by encouraging the delivery of cost-effective, high-quality healthcare
What are the causes of increased costs in healthcare over recent years
- A misalignment of incentives between the provider and the payer (ie. in a fee-for-service environment with a third-party payer, there is no incentive for healthcare providers to limit unnecessary care)
- Medical technology advancements combined with user expectations, resulting in high cost treatment
- Cost increases resulting from a fairly static population
- Fraud
Managed care interventions objectives
HIM RN
- ensuring that HIGH-risk members are managed and receive appropriate care
- IMPROVING the quality of care provided
- ensuring that MEDICAL services are delivered in an appropriate setting
- REDUCING the cost of medical events
- reducing the NUMBER of unnecessary medical services