Health Care Delivery Systems 2 (10/25b) [Integrative] Flashcards
Access
the means to have health insurance and medical care
Financial Cost
Financing
- the flow of dollars (premium/tax) from individuals and employers to the health insurance plan
Reimbursement
- the flow of dollars from insurance plans to hospitals and health care providers
Quality
The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Cost Effective Analysis (CEA)
tool for assessing the value of an intervention
identifies the procedures that provide the greatest improvement in outcome at the lowest cost
Value
Value = (Quality + Outcomes) / Cost
Important Health Related Outcomes Data
Life Expectancy
Mortality <5 Years Old
Mortality 15-60 Years Old
Also consider Per Capita Spent on Health
Health Related Outcomes Data for US
US spends significantly more per capita on health, but outcomes aren’t better
More civilized countries have what kind of health insurance?
More privately funded, employer funded, more entrepreneurial
Third world countries have what kind of health insurance?
More communist, government funded
Socialist Economy (United Kingdom)
Financing comes more from government, less from employer/employee/individual
More gov involvement in setting prices and allocation of goods/services
Less incentive to see more pt
Universal coverage, can have private insurance for elective procedures
EX: United Kingdom
Socialist (UK) - Financing
Mostly general taxes, some employer/employee contributions, user fees
No employment relationship
Used of private insurance to hop over queues for services
Socialist (UK) - Reimbursement
All healthcare workers are salaried government employees
Periodic negotiation and evaluation of salaries
Socialist (UK) - Access
Access generally through general practitioner (66% of physicians)
Free general services
GPs not in hosp, work closely with social service agencies/home care
Socialist (UK) - Quality
59% satisfaction
80% waited less than 13 weeks to see specialists
Comprehensive Economy (Germany) - Financing
Taxes, pooled employer/employee contributions managed by nonprofit sickness funds
Minimal OOP payments
Comprehensive Economy (Germany) - Access
Separation of IP and OP physician practice
51% generalist
Dispersed model with little coordination between OP physicians and hospitals
Fee for service, copayments
Comprehensive Economy (Germany) - Reimbursement
Sick funds pay global fee to regional physician associations, which pays docs on fee schedule
Sick funds pay hospital a DRG which includes salary of hosp-based docs
Comprehensive Economy (Germany) - Quality
Ease of access and timeliness
Poor communication between IP and OP causes significant errors
Welfare (Canada) Economy
Based on social philosophy that health service is a right
There are still more private providers
Welfare (Canada) - Financing
Completely by gov/tax
Medicare paid ~70% of all health service spending
Private paid 13%, OOP was 15%
Welfare (Canada) - Access
50% GPs who act as gate keepers
GPs care for hosp inpatients
Specialist fee higher with referral, waiting lists for elective procedures
Welfare (Canada) - Reimbursement
Total spending on health services ~9.9% of GDP
PTs in hosp are salaries
OP services at private clinics are paid mostly through public health plans, private insurance, or by patients depending on area
Welfare (Canada) - Quality
2.1 GPs per 1000 pts, low ratio and high waiting times
Waiting lists exist for some diagnostic tests, specialists, surgeries, etc
Avg wait time 18 weeks
Entrepreneurial (US) Economy
Solve advanced industrialized nation where not everyone has health care
HHS is fed gov department responsible for health related services, role in financing and managing services is limited to gov-initiated social/health benefit programs focused on helping most underserved
Entrepreneurial (US) Economy - Financing
Large private (nongovernment) component
Smaller public (government) component
Entrepreneurial (US) Economy - Access
Variety of ways
One of the few countries where you can bypass GPs and see specialists
Right to Choose
Entrepreneurial (US) Economy - Why Don’t People Access Healthcare
Mostly too expensive (48%)
Unemployed/work doesn’t offer (12%)
Entrepreneurial (US) Economy - Quality
Lowest wait time for non emergent care compared to similar systems
Spends more of GDP on healthcare than any other country, but not high spender when considering health and social services
Lowest ration of social service spending to health care spending in OECD (correlated w lower health outcomes)
Limited attention to social determinants of of health, leads to high costs and poor outcomes
Spending vs Quality
The amount spent on health care does not correlate with the perceived quality
EX: France spends little, but high quality
France Economy
Universal health care mostly financed by gov national health insurance
Spent 11.6% of GDP
GPs in private practice but reimbursed by public insurance funds, gov sets premium levels related to incomes
Reimburses 70% costs, 100% of long term ailment, better at managing chronic ailments and incentivizes more GPs
Supplemental insurance available, most non for profit
France Economy - GP vs Specialists
Only GP they are registered with can refer pt
Specialists charge higher fees, apply tariffs higher than official rates
Official rates forms the basis on which pt are reimbursed, must be referred by GP
Osteoarthritis
most common form of joint disease and disability in older people and ranks amongst the top 5 causes of disability
Osteoarthritis - Access
Interventions
- Conservative
- Pharmacologic
- Procedural
- Surgical
Osteoarthritis - Financing
Germany - financing from taxpayers, reimbursement from private sickness funds
UK - financing from government and employer/employee, reimbursement depends
Canada - financing from taxes, reimbursement from government, start with conservative treatment
US - financing depends on age/disability
Osteoarthritis - Cost of Replacement
HIP
Highest – $20k in US
Lowest – $2.6k in Mexico
KNEE
Highest – $42k in US
Lowest – $9k in India
Knee Osteoarthritis - Quality
Depends on societal/payer/individual perspective
From societal, direct (hospital stay, med cost) and indirect costs (productivity loss)
From payer, only direct costs
Cost Effectiveness Approach
Between different procedures for the same condition
Between same procedure over different countries
Between settings
