Health Care Delivery Systems Flashcards
Over the past 30 years, there has been a shift from the illness model of disease treatment to the
wellness model of chronic disease prevention
4 means of healthcare financing
out of pocket, individual private insurance, employer sponsored private insurance, and government
What is the national distribution of health care expenditure?
private insurance> Medicare> Medicaid> out of pocket
Employer-sponsored insurance generally uses principles of__________ to control costs
managed care
Most are either HMO or PPO
An HMO is
a managed care insurance plan where the payer is accountable for both the cost and the quality of care within a closed system
A PPO is
mainly concerned about reducing the cost of care, creates a larger but still restrictive network of physicians who agree to a contracted rate before care delivery
Accountable care organizations (ACOs)
An evolution of HMO and PPO, ACOs are models of managed care that tie payment to cost control and quality of care, theoretically keeping health care providers more accountable for resource use and quality of care
Pharmacy benefit manager
If a healthcare insurer does not manage prescription benefits for its beneficiaries, a pharmacy benefit managers will separately administer the benefits, including formulary development, customer service, and pharmacy contracting
Trends in innovation in health care
growth in retail clinics, expansion of telemedicine and technology, and advances in personalized medicine
From the 1980s onward, the United States healthcare system focus has been
cost and quality
Premiums
The amount of money paid each month by the insured for the plan
Deductibles
Specified amounts of money that the insured must pay before an insurance company will pay a claim
What is the largest payer of healthcare in the United States?
Government-funded
What created Medicare and Medicaid?
When President Lyndon B Johnson signed the Social Security Amendments of 1965 into law
Medicare Part A
Hospital insurance
Helps cover the costs of inpatient hospital care, skilled nursing facility care, hospice, and home health care. For most people who choose part A, part B is required and premiums must be paid for both
Medicare Part B
Medical insurance
Helps cover the costs of doctors services, outpatient care, and some preventative services.
Preventative measures include the flu, hep B, and pneumococcal vaccines, durable medical equipment, diabetes screenings, etc
Medicare Part C
Medicare Advantage Plan
Coverage includes Medicare Parts A and B plus other coverage, which usually includes prescription drug costs
Medicare Part D
Prescription drug coverage
Operated by private insurance companies on behalf of medicare, like Medicare part C
Enrollment is optional
MTM
Individuals enrolled in Part D may qualify for MMS if they meet 3 criteria:
-have multiple chronic diseases
-take multiple drugs
-be likely to incur expenses that exceed a level specified by the Department of Health and Human Services
Only pharmacists and pharmacy interns can provide under part D
Medicaid eligible
Those classified as poor
Children
People with chronic disabilities
People suffering from HIV/AIDS
Managed care
An evolutionary concept reflecting a different approach to provision and reimbursement for healthcare services. It focuses on appropriate use of health care resources. The 2 main configurations of managed care are health maintenance organizations HMOs and preferred provider organizations PPOs.
Affordable Care Act (passed in 2010)
An individual mandate (requiring, under financial penalty, US citizens to purchase some form of health insurance.
Expansion of Medicaid
Creation of insurance exchanges (marketplaces for individuals to buy insurance)
Vertically integrated health systems
One large organization takes responsibility for the delivery of care across all levels of care.
Financed under HMO
Semi-integrated health system model
Health care providers are not employed under the same organization, but still coordinate their services to reduce costs and optimize care.
Physicians in this model join HMOs as part of networks, but will still see patients outside of the HMO
Nonintegrated health system model
Allow broader access to the multitude of physicians.
PPOs
What are the most common measures in pharmacoepidemiological studies?
Incidence and prevalence quantify the rate of disease
Mortality rates quantify the rate of death
Incidence rates
Incidence proportion- does not take into account the different times in which a given population is at risk. It is computed as the number of new cases within a specified period divided by the number of population initially at risk.
Incidence rate controls for the different times during which each population member is at risk. The need to control for the different time at risk exists because the population may lose or gain members
When is an incidence rat more appropriate?
When the time that each individual is at risk differs among the population
Prevalence rates
Prevalence is a measurement of the number of all individuals affected by a certain disease (existing as well as new cases) within a particular period.
Prevalence can be viewed as
A snapshot of the population at a point in time which all the members of a population are screened for the disease.
Prevalence rates do not control for
disease duration.
Chronic diseases last longer; thus, more chronic cases will accumulate over time than will acute cases.
Thus, chronic diseases have higher prevalence rates than acute diseases.
When are prevalence and incidence rates useful?
Prevalence is useful in chronic diseases
Incidence is useful in acute diseases
Mortality rate
The number of deaths in a given year, scaled to the size of that population.
Case series
May refer to a study of a single patient (case report) or a small group of patients (case series) who are experiencing a disease.
Purely descriptive and cannot be used to make inferences about the general population.
May lead to hypothesis formation.
Case control studies
Compare rates of exposure to risk factors for a specific condition between subjects who have that condition (cases) and subjects who do not have that condition (controls). The cases and control groups must come from similar populations.
Data is sorted into a 2x2 table and an odds ratio (OR) can be calculated to measure the associated between the exposure factor and the outcome.
OR
The ratio of the 2 odds, reported in case control
OR= (a/c)/ (b/d)
Measures the association between the exposure to a disease risk factor and the disease outcome.
OR >1, OR=1, OR<1
OR=1: No association between the risk factor and disease outcome.
OR >1: Those with the disease are more likely to have been exposed to the risk factors than those without the disease.
OR <1: Those with the disease are less likely to be exposed to the risk factor than those without the disease.
What is faster/more effective, a case control or cohort study??
Case control
What are case control studies best for?
The study of rare diseases because they guarantee a sufficient number of cases with the disease.
What are the issues with case control studies?
They are prone to bias
The main challenge is to identify the appropriate control group.
Cohort studies
Compare the risk of developing a disease between those who are exposed to a risk factor and those who are not exposed. A cohort is a group of people who share a common characteristic within a defined period.
The selection of a cohort is independent of the occurrence of the condition of interest.
Relative risk (RR) and absolute risk reduction (ARR)
Used in cohort studies
RR- a ratio of the risk of getting lung cancer in those who are exposed to smoking versus those who are not exposed.
ARR- the absolute difference in the risk of getting lung cancer in those not exposed to smoking and those who are exposed.
RR values
> 1= Those with the exposure are more likely to have the disease outcome.
=1: No outcome
<1= The exposure is protective against developing the disease.
ARR values
0= no association <0= the exposure indicates an increased risk. >0= exposure indicates an absolute decrease in risk
NNT
the number of patient who need to be treated during a time period to prevent the development of one outcome
2 types of surveillance systems
passive and active
Passive surveillance
Involves health care providers voluntary reporting of unwanted medication effects. Such reports are submitted voluntarily or by contract by pharma companies, consumer organizations, or regulatory authorities.
Active surveillance
Aims to obtain the most complete data possible on drug safety problems. It uses a meticulously planned process to capture comprehensive data on drug safety problems.
Include sentinel sites and registries
Sentinel sites
Type of active surveillance
A limited number of selected reporting sites, from which the information collected may be extended to the general population. Sentinel surveillance systems are useful because a rich source of data collected enables more accurate estimation of a risk than is available from passive surveillance programs
