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Health Care Systems Flashcards

0
Q

Complexity of health care delivery (components)

A 
Education/research
Suppliers
Insurers
Providers
Payers
Government
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1
Q

Objective of health care delivery system (2)

A

Enable all citizens to receive health care services

Deliver services that are cost effective and meet standards of quality

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2
Q

General facts about US health care

A

16% of GDP - highest of all countries
Per capita spending ~$8000 - also highest
Per capita spending projected to continue to rise.
Life expectancy and mortality measurements worse than most other countries

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3
Q

Who finances health care?

A

Private - employer based or patient purchases individually

Public - Medicaid, Medicare, other (VA, IHS, etc)

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4
Q

Medicaid

A

For the impoverished poor diasbiled

Joint venture between federal and state govt
States choose how to run them
Some federal requirements

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5
Q

Medicare

A

For the elderly

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6
Q

External forces affecting health care delivery

A 
Social values and culture
Global influences
Population characteristics
Physical environment
Technology development
Economic conditions
Political climate
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7
Q

Description of US health care delivery

A

Large and complex
Fragmented
Many organizations and individuals

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8
Q

Major characteristics of US health care delivery (10)

A 
No central agency governs
Access is based on insurance coverage
Under imperfect market conditions
3rd party insurers act as intermediary between finance and delivery function
Multiple payers makes cumbersome
Balance of power between all players - no single dominant entity
Legal risks influence physician behavior
New technology creates automatic demand
New service settings over continuum
Quality not seen as unachievable
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9
Q

No central agency

A

Mostly private financing and delivery
Hospitals and physicians independent of govt
No monitor of budget or utilization
(Exception is Medicare and Medicaid)
Govt sets standards thru policy and regulation
Minimum standards of quality

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10
Q

Partial access

A 
Access restricted to:
1-have health insurance thru employer
2-are covered by govt plan
3-can afford insurance out of pocket
4-can pay for services at time of delivery

Emergency room - catastrophic insurance

Primary care access is lacking - reason for deficit in US health

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11
Q

Imperfect market

A

Consolidation and alliances

Quasi-market
1-patients and providers are not independent
2-prices not set by interaction of supply and demand
3-not unrestrained competition
4-patients lack info on different services
5-patients lack info on prices and quality
6-patients don’t bear full cost of services
7-patients don’t make decisions

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12
Q

Types of pricing

A

Item pricing

Package pricing

Capitation

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13
Q

Capitation

A

All services include one set fee per person

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14
Q

Package pricing

A

Bundled fee for group of related services

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15
Q

Phantom provider

A

All services billed separately; pathologist, anesthesiologist, supplies, hospital facility use

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16
Q

Third party insurers and payers

A

Wall is separation between financing and delivery

Quality of care is secondary

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17
Q

Multiple payers

A

Many different plan options available

Cumbersome

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18
Q

Power balancing

A

Multiple players

Fragmented self-interests

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19
Q

Legal risks

A

Litigious society

Defensive medicine

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20
Q

High technology

A

Creates demand despite cost
Need utilization of capital investments
Legal risk if don’t provide

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21
Q

Continuum of services

A

3 broad categories
Curative
Restorative
Preventative

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22
Q

Quest for quality

A

Continuous improvement
Higher expectations
Compliance standards

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23
Q

Quad function model

A 
By shi and Singh
4 functional components of healthcare delivery
FIDP
financing
Insurance
Delivery
Payment
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24
Types of financing
Employers Government (Medicare and Medicaid) Self funding
25
Types of insurance
Insurance companies Blue cross/blue shield Self-insurance
26
Types of payment
Insurance companies BCBS third party claim processors
27
Type of delivery
``` Physicians Hospitals Nursing homes Diagnostic centers Vendors medical equipment Health centers ```
28
What is managed care?
System to improve efficiencies by integrating basic functions, control utilization, and set prices for services Integrates the 4 functions of healthcare delivery to better deliver care
29
Financing mechanisms (for MCO)
Capitation - for one set fee per month per member, MCO delivers all needed healthcare Discounted fees 1-insurance- MCO assumes risks 2-delivery-MCO arranges services and controls utilization 3-payment-MCO is payer and pays providers based on capitation or discounted fees
30
Evolution of health services - 3 periods
Pre-industrial era 1700 1800 Post industrial era late 1800s to mid 1900s Corporate era
31
Characteristics of pre industrial era of health service
``` Open entry into medical practice Primitive medical procedures No institutional core - almshouses, mental asylums, penthouses, dispensaries Family based care Substandard medical education ```
32
Characteristics of post- industrial era in health service
``` Physicians gained professional sovereignty Scientific basis for medicine Hospitals Formal medical training Licensing Development of public health Workers compensation starts Private insurance Medicare and Medicaid Prototypes of managed care ```
33
What changed health services in 1900s?
``` Urbanization Science and technology Institutionalizations Patient dependency Autonomy and organization Licensing Educational reform ```
34
Concept of urbanization
People away from families Women enter workforce Physicians more productive Less travel reduces opportunity cost
35
Concept of science and technology
Cultural authority Increased demand for professional services Decreased reliance on family treatment ``` Anesthesia Penicillin X-rays Antiseptics Pasteur and microbiology Hand washing and sanitation ```
36
Concept of institutionalization
Pooling of resources needed Hospital becomes institutional core Urbanization, technology, and professionalization demand pooling of resources
37
Concept of autonomy and organization
Physicians remain independent from hospitals and corporations Physicians organize thru AMA
38
Concept of licensure
Medical practice acts of 1870s Debt vs West Virginia 1888 Need to upgrade medical education Relieves intense competition in medical practice
39
Timeline of health insurance
1914 - workers compensation 1900- present - voluntary health insurance (disability insurance) 1929 - hospital insurance (prepaid plans)
40
Origins of health insurance
1929 - Baylor university - for school teachers; model for blue cross blue shield 1940s - WWII wage freeze - bargain with unions, becomes permanent part of employee benefits, grows to major medical
41
Federal efforts for national health insurance
1917 - American association of labor legislature 1935 - FDR New Deal 1940s - Roosevelt and Truman 1962 - Medicare and Medicaid 1992 - Clinton and Bush proposals 2009 - patient protection and Affordable Care Act
42
Why no national health insurance?
Political inexpediency Institutional dissimilarities Ideological differences Tax averse
43
Characteristics of Corporate Era of health services
``` Corporatization High tech Comfortable surroundings No cost control Managed care - for insurance and delivery Integrated health care organizations Consolidation of physicians Information revolution Globalization (Seen as government dominance) ```
44
Differences between private and public health care systems
Private - focuses on illness, FIDP, markets, biological causes, cure and individuals Public - focuses on wellness, medical and non- medical interventions, social and govt services, biological and non- biological causes, prevention, and populations
45
4 components of health
Physical Social Spiritual Mental PMSS
46
Levels of health determinants
Individual Community State/national Global
47
Blum's model of health determinants
ELHM environmental Lifestyle/behaviors Heredity Medical care (In order of importance)
48
Determinants of premature death
LEGM Lifestyle Environment Genetic Medical are
49
Define social cohesion
Hospitable environment in which people trust each other and participate Linked to lower overall morbidity and better self-rated health
50
Leading cause of death in US
Heart disease Cancer Respiratory diseases Stroke
51
Actual causes of death
Tobacco Poor diet and physical inactivity Alcohol consumption
52
Define: Acute Subacute Chronic
Acute - relatively severe, short duration (myocardial infarction, kidney interruption) Subacute - less severe phase of an acute illness (rehab for hip fracture) Chronic - less severe, irreversible, long duration but can be controlled (diabetes, -ashrams)
53
Continental poverty divide
Lower usa
54
Measures of health status
``` Morbidity/mortality Incidence/prevalence Disability Demographic change Dimensions of health Utilization ```
55
Define morbidity
Burden of disease, disability, or sickness
56
Define mortality
Death rate
57
Define at risk community
All people in the same community or group that can acquire a disease or condition
58
Define cases
Number of people acquiring a given negative health condition
59
Define incidence
Number of new cases occurring/population at risk
60
Define prevalence
Total number of cases at specific point in time/specified population at same point in time
61
Define life expectancy
Prediction of how long a person will live Two types: Life expectancy at birth Life expectancy at age 65
62
Activities of Daily Living Scale (ADL)
Used to measure disability in the elderly ``` 6 activities of self care and mobility Eating Bathing Dressing Toilet Continence Transfer from bed to chair ```
63
Katz Scale
Modified ADL scale For people in community-dwelling Added tasks Grooming Walking 8 feet
64
Instrumental ADL
For those living independently Self sufficient ``` Phone Driving or public transportation Shopping Making meals Housework Medications ```
65
Utilization
Consumption of health care services or extent to which they are used
66
Examples of measures of utilization
people in given population who visit primary care doctor/#people in study population Crude, specific, institution specific
67
US cultural beliefs and values (5)
``` Advancement of science Capitalism - economic good Capitalism and health care Concern for under privileged Free enterprise/distrust of big govt ```
68
Distributive justice
Equal distribution of/access to health care
69
Market justice
Capitalism and free markets extends to health care In United States Doesn't work when dealing with human problems Market-based demand Health care is economic reward Emphasis on individual Based on ability to pay
70
Social justice
``` Govt distributes health care Assumed more efficient Central planning and rationing Equal access is basic right Community supersedes individual ```
71
Public health
Ensure conditions in which people can be healthy Organized community efforts Maximum positive impact on the health of a population, quality of life, overall satisfaction
72
Roles of public health
``` Prevent epidemics and spread of disease Protect against environmental hazards Prevent injury Promote healthy behaviors Respond to disasters Assure quality and accessibility of health services ```
73
Sciences behind public health
``` Biomedical Environmental Epidemiology Social and behavioral Health policy and management ```
74
Risk factors and disease
Attributes that increase likelihood of developing a disease or negative health condition
75
Epidemiologic triangle
Host Agent Environment HAE
76
3 types of prevention
Primary - prevent occurrence Secondary - minimize damage Tertiary - minimize disability
77
Controversy of public health
Economic impact Individual liberty Moral and religious objections
78
Public policy considerations
Scientifically plausible Politically acceptable Practical implementation
79
Examples of vulnerable populations
``` Minorities racial and ethnic Uninsured children Women Homeless Mentally ill HIV/AIDS disabled Rural populations ```
80
Three categories of vulnerable populations
Predisposing characteristics Enabling characteristics Need characteristics

Health Care Systems (3 decks)

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