EXAM Flashcards
What are the three intermediate performance measures considered by Roberts?
Efficiency
Access
Quality
In the reading by Roberts, are efficiency, access and quality the root cause or problem in health systems?
No. They are causally intermediate between root causes and ultimate performance goals.
Define the ‘production possibility frontier’
The only way to get more of one output is to produce less of another.
I.e. when everything in a system is produced at minimum cost i.e. technically efficient.
What are the type types of efficiency in the Roberts reading?
Technical and allocative efficiency.
Define ‘technical efficiency’.
Situations where the good or service is produced at minimum cost.
How does technical efficiency relate to health systems and whose primary responsibility is it?
Maximum output for money includes questions about the right mix of personnel, equipment, supplies and facilities.
It is mostly the domain of health-care system managers.
Define ‘allocative efficiency’
Is a nation producing the right collection of outputs to achieve its overall goals?
Is the mix of health services maximising health-status gains?
What is the relationship between allocative efficiency and the production possibility frontier?
Allocative efficiency asks ‘are we at the right point on the production possibility frontier’ in relation to whether the services (outputs) are achieving the system’s overall goals.
Describe ‘diminishing marginal returns’ in relation to health care.
Treatment of high needs patients with expensive services can be very cost-effective. However when those services are extended to more of the population, the cost-effectiveness diminishes.
I.e. costs per case increase at the same time case-by-case benefits decline.
What do health system managers need to decide when considering diminishing marginal returns?
What services should be provided, and to whom.
I.e. how many cardiac bypass surgeries and who gets them.
From a political perspective, which is easier to improve: allocative or technical efficiency?
Technical.
It is easier to make production more efficient than to move people and plant from producing one thing to producing another. E.g. moving from high-tech tertiary services to primary care.
What is the overall combined definition of efficiency (using both allocative and technical efficiency) in the Roberts reading?
Each relates to the relationship of inputs to desired results.
Is a health system achieving society’s goals at minimum cost?
Are efficiency and equity necessarily in competition according to Roberts?
No. Their position is efficiency can advance equity by making it less costly to reach equity objectives.
Roberts highlights a type of availability as central to their definition of access. What is this?
Effective availability.
Describe physical availability in Roberts definition of access.
The physical availability of services. Geographic distribution of resources (beds, doctors, nurses) compared to the population.
Describe effective availability in Roberts definition of access.
How easy is it for citizens to get care?
Access is a means to reach a country’s goals in the desired distribution of health and satisfaction.
What dimension of access is particularly prone to political interference?
Physical availability. Regardless of effective availability consideration. E.g. closing a regional hospital that is under-utilised.
What are the three dimensions of quality used by Roberts?
Quantity
Clinical quality
Service quality
What aspect of ‘quality’ is the Amercian health system praised for?
Quantity
Describe quantity in reference to quality in the Roberts reading.
The quantity of care provided to a patient. I.e. getting ‘lots’ of health care.
Describe clinical quality in reference to quality in the Roberts reading.
Quality of caregivers and equipment. The combination of the two with the right inputs at personnel and drugs/facilities.
Describe service quality in reference to quality in the Roberts reading.
Hotel services: food, cleanliness, amenities
Convenience: wait time, travel, appointment delays
Interpersonal relations: care, politeness, respect.
What type of ‘quality’ is most often invoked by patients? Why?
Service quality. It’s easier for patients to judge than clinical quality.
Do assessments of quality tend to look at inputs or evaluating processes or outcomes?
Inputs generally are easier to impact. I.e. educational requirements, availability of drugs and facilities.
What is the relationship of quality to equity issues?
If quality varies across a population (for e.g. urban vs rural) some groups will be disadvantaged compared to others.
When citizens bypass local health services for national health services (i.e. urban hospitals), what aspect of health system performance is this related to?
Clinical quality.
What are the three considerations regarding quality that need to be taken into account,
Is each service being produced in a way that results in the highest possible quality given the costs being incurred?
Even if a service is operating on the quality possibility frontier, are the producers offering an appropriate mix of qualities?
What level of resources should we devote to each service?
What is the quality possibility frontier?
The point at which, within a given budget, service and clinical quality are of the highest possible quality given the costs being incurred.
This accounts for the fact that spending on one aspect of quality takes resources away from the other.
What is the impact of different philosophical perspectives on assessment of quality in health care systems?
Differences in opinion over where resources should be concentrated.
I.e. objective utilitarians interested in health maximisation would want tho produce the maximum clinical quality for any given budget.
What are the four worlds of the general hospital?
Community (trustees)
Control (managers)
Cure (doctors)
Care (nurses)
How is the quadrant of ‘cure’ (doctors) oriented?
Manage down, into operations and out because they don’t report into the hospital’s hierarchy.
Functions through an arrangement of chiefs and committees.
How is the quadrant of ‘care’ (nurses) oriented?
Manage down, into operations and in because they report into the hospital administration.
NB: nurses and other care management.
How is the quadrant of ‘control’ (managers) oriented?
In because they’re involved in hospital administration, and up because they are removed from operational day to day matters.
How is the quadrant of ‘community’ (trustees) oriented?
Not directly connected to the hospital’s operation or personally beholden to it’s hierarchy. Therefore oriented up and out.
NB: represented by the trustees of the hospital and informally by those who volunteer their time to it.
When applied to the health system in general, what occupies the four quadrants of the Glouberman and Mintzberg model?
Cure = acute cute (acute hospitals) Care = community care (primary care, long term care facilities, alternative health services) Control = public control (public health authorities, regulatory agencies, insurance companies) Community = community involvement (elected officials, advocacy groups)
What is represented in the ‘cure’ quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Cure = acute cute (acute hospitals)
What is represented in the ‘care’ quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Care = community care (primary care, long term care facilities, alternative health services)
What is represented in the ‘control’ quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Control = public control (public health authorities, regulatory agencies, insurance companies)
What is represented in the ‘community’ quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Community = community involvement (elected officials, advocacy groups)
What is the main contention of the Glouberman and Mintzberg article?
No matter how necessary the divisions of labour inherent in the four quadrants might be, the associated divisions of organisation and of attitude or mindset render the system unmanageable.
What is the difference between doctors’ and nurses’ orientations and behaviour?
Down and out versus down and in.
Doctors intervene and leave the care to the nurses.
What are the four elements of medical intervention from intrusive to interpretive?
Incursion (cutting)
Ingestion (feeding)
Manipulation (touching)
Mediation (talking)
In medical practice, whose domain is ‘touch’ and why?
Seen as less scientific and therefore less the domain of the doctors (cure) and more of the nurses and associated care practitioners (care).
What is different about the degree of specialisation for physicians versus nurses and managers?
While nurses and managers are increasingly specialised, they can retrain relatively easily whereas physicians tend to focus on one area and lose the ability to appreciate other specialisations in medicine let alone the work of nurses and managers.
How is the acute hospital similar to doctors?
It has a highly specialised, interventionist approach which leaves much of the ‘care’ aspect to others.
Which professional role comes closest to being responsible for the complex coordination of the workflows in a hospital?
Nobody is formally responsible, but nurses come the closest.
How does the nurse’s informal role as coordinator come into conflict with doctors and managers?
Doctors claim responsibility for patients, despite their absence and managers claim responsibility fro control, despite their distance.
Where does the distinction between ‘cure’ and ‘care’ become less useful?
As interventions become less invasive and tend more towards interpretive measures of cure, the distinction is less useful.
E.g. in geriatric hospitals there is less professional demarkation between doctors and nurses.
What is a consequence of the division and hierarchy associated with ‘cure’ versus ‘care’?
Care can be relegated to poorly resourced and supported areas of the health system.
Patients are less able to/less attracted to access alternate care services like dietary care.
What is problematic about the relationship between doctors and managers?
Managers purportedly control the administration of the institution in which the doctors work, but the doctors respect their own professional medical hierarchy far more.
Unless managers have clinical training of their own, it is difficult to establish authority in the operational setting. It follows that, if a manager can’t control the operational aspect of the hospital, in what sense are they controlling the hospital at all?
How are managers supposed to manage? What does this mean?
Through measurement.
The problem is measurement is hard to define and differs depending on who you talk to.
How do the problems of hospital managers compared to those of public managers of health systems?
They are very similar. Managing disparate and competing hierarchies. They are removed from the institutions they manage in a similar way that the managers are removed from the clinical operations they manage.
Intervention occurs in the cure quadrant, where else does it occur?
In the control quadrant. Managers frequently intervene in operational matters.
Where does the smallest amount of differentiation relating to task occur in the four quadrants?
Community. Among the Board the hierarchy is least pronounced.
Which of the four quadrants has the least direct ability to ‘do’ anything in the health system or hospital?
Community. All members of the other quadrants can physically effect change.
Because of their inability to effect change directly, upon who do the ‘community’ bring their influence to bear?
Managers
When ‘community’ does intervene, what often occurs? What is problematic about this?
They behave in a way similar to physicians - intervening to fire a manager, fund a new piece of equipment.
It can be problematic because idiosyncrasy often plays a part i.e. trustees get their information selectively and have their own biases and personal preferences.
What are the key words associated with each domain in the Glouberman and Mintzberg framework?
Cure: professional chimneys (intervention)
Care: operating workflow (coordination)
Control: administrative hierarchy (containment)
Community: formal board (oversight)
What type of coalition exists between care and control?
Insider coalition
What type of coalition exists between control and community?
Containment coalition
What type of coalition exists between community and cure?
Status coalition
Why type of coalition exists between cure and care?
Clinical coalition
What dictates an increasing need for integration?
Increasing differentiation of the units of an organisation as to its goals, structures and interpersonal orientations.
What are the forces driving integration across the four quadrants?
Commitment to purpose.
Desire to advance knowledge.
Urgency.
What can government intervention involve in health care ‘market’?
Purchasing care on behalf of consumers or providing such care.
What is the basic reason underlying extensive government intervention in health care?
That none of the ideal assumptions of perfect markets works in the case of health care.
What are the characteristics (and consequences) of the health care market which lead to the requirement of extensive government intervention?
Risk and uncertainty of contracting illness (in an unregulated market leads to diseconomies of small scale, moral hazard and adverse selection)
Externalities
Asymmetrical distribution of information about health care between providers and consumers combined with problems of professional licensure.
Do other markets exhibit similar characteristics to health care?
Yes but Donaldson’s contention is that none exhibit all these characteristics simultaneously.
Why is health care versus the impact of adverse events (i.e. psychological problems, anxiety and stress) more likely to be insured?
It is more easily quantified by the insurance company.
What is the distinction between ‘health’ insurance and ‘health care insurance’ (though the former is usually how the latter is referred to)?
Health insurance would cover everything related to health whereas health care insurance only covers impact of an adverse health event in terms of paying for quantifiable services accessed.
What do people typically insure against?
Large unpredictable losses.
Describe ‘diseconomies of small scale’
When there are a number of small providers in a competitive market.
Each provider only services a small number of clients therefore limiting their ability to spread fixed and administrative costs across their clients.
Describe ‘economies of scale’
The relationship between fixed cost and output.
The more goods produced, the lower the cost per unit to produce.
This occurs by distributing fixed costs across the products thus reducing both the fixed and total cost per unit produced.
When do economies of scale fail?
When an organisation becomes to large or too small.
Why do diseconomies of small scale produce market failure in insurance?
People are less likely to pay premiums inflated by high administrative costs caused by too many small providers. Equally they are unlikely to pay premiums to a large, exploitative monopoly.
What is one reason for the increased costs of administration observed in the US after more competition was introduced to the market in the 1980s?
Spending on advertising and hospital utilisation reviews.
What are the two types of moral hazard?
Consumer moral hazard and provider moral hazard.
Describe consumer moral hazard.
When the act of being insured reduces the (financial) costs of treatment at the point of consumption. This makes being sick less undesirable and consequently less is done on the part of the consumer to actively avoid becoming unwell.
What are the implications of moral hazard in terms of the quantity of services accessed when illness occurs?
Potentially more services are accessed than is truly necessary because the consumer incurs no financial cost due to being fully insured.
Describe provider moral hazard.
This can arise from a lack of awareness of costs or in a fee-for-service system when doctors are incentivised to provide more care than is necessary by a system which pays them per-service.
What is provider moral hazard also known as?
Supplier-induced demand.
What are the dangers of a fee-for-service model?
If the fee is a truly competitive price then it operates fine.
If the fee is beyond what would normally be obtained, doctors are incentivised to over-provide.
If the fee is below what would normally be obtained, doctors are incentivised to under-provide.
