Lecture 1/Chapter 1 & 2 Flashcards
1
Q
Access to healthcare
A
- is access equitable (fair)
- who has access
- if we increase access to healthcare cost goes up
- ways to restrict access to healthcare: referrals and copays
2
Q
cost of healthcare
A
-if we limit cost of healthcare we lower quality and restrict access to healthcare
3
Q
quality of healthcare
A
- how do we maintain quality
- no one wants low quality healthcare
- quality is going to depend on access and cost of healthcare
- if we increase a
- we always want to maintain quality
4
Q
American health care
A
- not everyone is automatically covered by health insurance
- no real health care “system”
- financing, insurance, delivery and payment
- not coherent
- no cooperation
5
Q
organizations and individuals involved in american health care
A
- educational and research institutions
- medical suppliers
- insurers
- payers
- claims processors to health care providers
6
Q
MCO’s
A
managed care organizations
7
Q
government programs
A
- finance and insure health care for select groups of people who meet programs prescribed criteria for eligibility
- sometimes deliver certain health care services directly to certain recipients like veterans and military, native americans, some uninsured
- finances public insurance through medicare, medicaid and childrens health insurance program (CHIP)
- government doesnt oversee the whole “system”
8
Q
employers
A
- purchase health insurance for employees through private sources
- employees receive health care from private sectors
9
Q
public insurance
A
- medicaid
- medicare
- children health insurance program (CHIP)
- provide insurance low income, elderly, disabled, government employees, and pediatrics
- insurance arrangements for many publicly insured people are made through private entities like health maintenance organizations (HMO) -> blends private and public
- tax revenue is used
10
Q
HMOs
A
health maintenance organizations
11
Q
characteristics of US health care “system”
A
as a result of the mix of public and private:
- multiplicity of financial arrangements for health care services
- numerous insurance agencies or MCOs that have various mechanisms for insuring against risk
- multiple payers that make their own determinations regarding how much to pay for each type of service
- diverse setting where medical services are delivered
- numerous consulting firms offering expertise in planning, cost containment, electronic systems, quality and structuring of resources
12
Q
US consumes more health care services than any other country
A
- no one is in control of the “system”
- capitalistic health care
- represents a greater proportion of the countrys total economic output
- not cost efficient service but some of the best
- not everyone has access
13
Q
ideal health care system
A
- two primary objectives:
- enable all citizens to obtain needed care
- ensure that services are cost effective and meet certain established standards of quality
- US doesnt provide to all citizens and does not have cost effective services, but there is quality
14
Q
quad function model
A
- health care delivery system incorporates 4 components
- financing
- insurance
- delivery
- payment
- degree of overlap varies between private and government run systems
15
Q
financing
A
- necessary for obtaining health insurance or to pay for health care services
- employers mostly finance health care for employees (can extend to family)
- government finances in public programs
16
Q
insurance
A
- protects the insured against financial catastrophe by providing expensive health care services when needed
- determines the package of health services that the insured person is entitled to receive
- specifies how and where health care may be received
- MCO or insurance company also functions as a claims processor and manages disbursement of funds to health care providers
17
Q
delivery
A
-provision of health care services by various providers
18
Q
provider
A
- refers to any entity that delivers health care services and either independently bills for those services or is supported through tax revenue
- physicians
- dentists
- optometrists
- therapists
- hospitals
- diagnostics
- imaging clinics
- suppliers of medical equipment
19
Q
payment
A
- deals with reimbursement to providers for services delivered
- insurer determines how much is paid
- funds for actual disbursement come from the premiums paid to the MCO or insurance company
- at time of service pt usually pays copay
- remainder is covered by MCO or insurance company
- in medicare and medicaid tax revenues are used to pay providers
20
Q
medicare
A
- for elderly and certain disabled individuals
- public insurance
- administered by federal government
21
Q
medicaid
A
- for the indigent
- administered by federal and state government
22
Q
Childrens health insurance program (CHIP)
A
- for children from low income families
- administered by state and federal government
23
Q
problems with employee insurance
A
- some small businesses cant get group insurance at affordable rates
- in some places, participation in health insurance programs is voluntary -> some people dont join bc health insurance premiums are too expensive
- employers dont pay 100% of the insurance premiums
- self employed need to find their own insurance -> individual rates are higher
24
Q
premium cost sharing
A
-when the employee offers health insurance premium and requires the employees to pay for a portion of it (its expensive)
25
health care reform
-refers to the expansion of health insurance to cover the uninsured
26
uninsured
those without public or private insurance coverage
27
patient protection and affordable care act of 2010
- affordable care act (ACA)
- reduce # of uninsured
- required all US citizens and legal residents must be covered by either public or private insurance
- relaxed standards to qualify additional numbers of people for medicaid
- uninsured received insurance through webbased government run exchanges -> if they didnt they paid a tax
- failed to achieve universal coverage
28
health insurance marketplaces
- determine whether an applicant qualified for medicaid or CHIP programs
- if they dont then the exchange would enable the person to purchase government approved health plan offered by private insurers through the exchange
29
utilization of health services
-quantity of health care consumed
30
managed care
- system of health care delivery that:
- seeks to achieve efficiency by integrating the 4 components of health care
- employs mechanisms to control utilization of medical services
- determines the price of services and how much providers are paid
- cost control
- greater integration of health care delivery
- ensuring access to health services, emphasizing preventive care, maintaining broad provider network -> cost control
31
enrollee
-individual covered by the insurance plan
32
health plan
- arrangement between the MCO and enrollee -> whats covered health services that the enrollee is entitled to
- selected providers
33
10 major characteristics that set the US apart from other health care delivery systems
- no central agency governs the system
- access to health care services is selectively based on insurance coverage
- health care is delivered under imperfect market conditions
- insurers from a third party act as intermediaries between the financing and delivery functions
- existence of multiple payers makes the system difficult
- balance of power among various players prevents any single entity from dominating the system
- legal risks influence the practice behavior of physicians
- development of new technology creates and automatic demand for its use
- new service settings have evolved along a continuum
- quality is no longer accepted as unachievable goal
34
no central agency
- US is not administratively controlled by department or agency
- private agencies decide their own financial state
35
global budgets
- used to control costs
- determine the total health care expenditures on a national scale and allocate resources within budgetary limits
- not in US
- controls technology, resources, specialized services
36
standards of participations
- federal government formulates through health policy and regulation
- providers must comply with the standards established by the government to be certified to provide services to medicare, medicaid, and CHIP
- minimum standards of quality
37
access
- ability of a person to obtain health care services when needed
- american can access health care if they:
- have health insurance through their employers
- are covered under a government health care program
- can afford to buy insurance with their own private funds
- are able to pay for services privately
- can obtain charity or subsidized care
- even uninsured people are observed by emergency departments (not continual)
38
primary care
-continual basic and routine care
39
universal access
- ability of all citizens to obtain health care when needed remains mostly theoretical
- even universal coverage doesnt mean you can always be seen when needed
40
imperfect market
- US health care is only partially governed by free market
- considered a quasi-market or imperfect market
- power isnt in hands of pt but in the health administrators of health plans
- health plans are the real buyers (not pts)
- prices are determined by payers (MCOs, medicare, medicaid)
- limited choice of providers (not open choice)
- regulations involved (licensed)
- different providers different prices
41
free market
- patients and providers act independently
- pts can choose services from any provider
- prices are governed by free and unencumbered interaction of forces of supply and demand
- quantity demanded increases as price is lowered
- quantity demanded will decrease as the price increases
42
demand
-quantity of health care purchased
43
moral hazard
-once enrollees have purchased health insurance, they may use more health care services than if they were to pay for these services on an out of pocket basis
44
need
-amount of medical care that medical experts believe a person should have to remain or become healthy
45
limits to ability of pts to make decisions in health care system
- need (do they NEED the treatment)
| - delivery of health care can result in demand creation (artificial demand)
46
provider induced demand
- suppliers induced demand
- practitioners who have a financial interest in additional treatments also create artificial demand
- physicians prescribe medical care beyond what is clinically necessary
- scheduling too many follow up that arnt necessary, prescribing unnecessary medical tests, unnecessary surgery
47
phantom providers
- anesthesiologist, nurse anesthetists, pathologist
- function in an adjunct capacity and bill for their services separately
- makes it difficult to know the price of something before hand
48
package pricing
- a bundled fee for a package of related services
- one all inclusive price for ex. -> the surgeons fee, hospital facilities, supplies, diagnostics, pathology, anesthesia, postsurgical follow up
- lets you gauge a better idea of the final price
49
single payer system
- national health care system
- one primary payer -> the government
- providers send bill to government agency -> subsequently sends payments to each provider
50
national health insurance
- canada
- Financed by government taxes
- Deliver of health care is done by private providers
51
national health system
- Britain
- not everyone has health insurance
- Government finances through taxes and delivers public care
- Single payer!
52
socialized health insurance
- delivery is characterized by private arrangements but overall controlled by government
- Germany
- Government mandated contributions from employers/employees finance
- Sickness funds collect funds and pay providers
53
free market system
US is a
| quasi market system
54
*health care delivery system in US
- American's are not automatically covered
- true system does not exist
- health care system is fragmented
- continues to undergo periodic changes
55
*the size of the system
- *health care workforce= 16.4 million*
- 838,000 active MDs
- 70,480 DOs
- *2.6 million nurses*
- 5,795 hospitals
- 15,700 nursing homes
- 1,375 health centers
- 180 medical and osteopathic schools
- 1,500+ nursing programs
56
multiple payers
- US
- multiplicity of health plans
- multiple payers represent billing and collection for providers of services
- makes things more difficult bc:
- hard for providers to keep tabs on numerous health plans
- hard to keep up with which services are covered under each plan and how much each plan will pay
- providers must hire claims processors to bill for services and monitor receipt of payments
- billing is not standardized -> Each payer has own format
- payments can be denied for not precisely following requirements set by each payer
- denied claims necessitate rebilling
- when only partial payment is received some health plans allow the provider to balance bill the pt for the amount the health plan did not pay (difference between provider charges and insurance payment) -> other plans dont allow this
- providers have lengthy collection efforts
- government programs have complex regulation for determining whether payment is made for services actually delivered
57
administrative costs
- US spends way more on administrative costs (compared to national health care systems)
- billing
- collections
- bad debts
- maintaining medical records
58
*characteristics of US system
- *multiplicity* of financial arrangements
- *numerous insurance agencies*/MCOs that employ various mechanisms for insuring against risk
* multiple payers* that make their own determinations about the cost for each service
- *diverse settings* where services are delivered
- *numerous consulting firms* offering expertise in planning, cost containment, electronic systems, quality, and restructuring of resources
59
*standardization
- very little in US
- bad planning
- bad direction
- bad coordination from a central agency
- creates inefficiencies in:
- duplication
- overlap
- inadequacy
- inconsistency
- waste
60
*cost control
- financial manipulation
- two primary objectives:
- enable all citizens to obtain needed health care services
- ensure cost effective services and meet quality standards
61
*leads in the world
- *medical technology*
- medical training
- research
- sophisticated institutions, products, and processes
62
*financing and insuraance mechanisms
- *employer based* health insurance (private)
- *privately purchased* health insurance (private)
- *government programs* (public):
- state employees group
- medicare -> elderly and certain disabled people
- medicaid and CHIP -> indigent, poor (if meet eligibility criteria) children)
63
*insurance and health care reform
-medicare (federal), medicaid (state), and childrens health insurance program (CHIP)
64
*reasons employment based system left some *uninsured*
- small businesses cannot get group insurance at affordable rates and are unable to offer insurance
- participation in insurance programs *may be voluntary* -> changed after ACA
65
*affordable care act
-required all US citizens and legal residents to be covered by public or private insurance
66
*health insurance
- relies on healthy people paying into it
| - people who need health care coming out of it
67
*major characteristics of US health care system
- political climate
- economic development
- technological progress
- social and cultural values
- physical environment
- population characteristics (demographics, health trends)
- global influences
68
*10 basic characteristics differentiate the US health care delivery system
1. no central agency governs the system
2. access to health care services is selectively based on insurance coverage
3. health care is delivered under imperfect market conditions (purchase health care but there is a lot of regulations)
4. third party insurers act as *intermediaries* between the financing and delivery functions
5. the existence of multiple payers makes the system difficult
6. balance of power among players prevents any single entity from dominating the system
7. legal risks influence practice behavior of physicians (cover your assets - CYA medicine) -> malpractice
8. development of new technology creates an automatic demand for its use (tyranny of tech)
9. new service settings have evolved along a continuum (urgent cares)
10. quality is not accepted as an unachievable goal
69
*no central agency
- most developed nations have national health care
- to control costs, use global budget to determine total health care expenses
- government controls proliferation of health services
- US has mostly private financing and delivery
- financing via employers 52% and government 48%
- private health care, hospitals, and physicians are independent of government
- no one monitors total expenses through global budgets and utilization
- US determines public sector expenses and reimbursement rates for medicare/medicaid/CHIP
- government sets standards of participation
- providers must comply with standards to be certified to provide care to medicaid and medicare pts
- regarded as minimum standards of quality
70
*access
ability to obtain health care when needed
- health insurance helps ensure access
- amercians can access health care services:
- through employers
- under a government health care program
- by buying insurance using private funds
- by paying for services privately
- by obtaining charity or subsidized care
71
*uninsured american's
- able to obtain medical care for acute illness
- form of universal catastrophic health insurance -> $50,000+ -> lower rates for emergency situations
- usually forego basic and routine care
72
*universal access
- countries with national health care programs provide universal coverage
- ability of all citizens to obtain health care when needed is mostly a theoretical concept
73
*imperfect market
- US has a quasi market where health care is a partially managed by free markets
- in a free market, multiple pts and providers act independently
- providers do not collude to fix prices
- prices are set by the interaction of supply and demand
- inverse relationship between quantity of services demanded and price of services
- equilibrium is achieved without interference
- unrestrained competition
- pts must have information about the availability of different services
- consumers are seizing some measure of control
- internet as a source of medical information
- pts must bear cost of services received (Copays)
- moral hazard (access issue)
74
*moral hazard
- access issue
- concept that if it doesnt cost me anything why not use it
- excessive use of health care bc its free
- this is why we have copays -> limits
- makes sure we only use health care when necessary
75
*2 factors that limit pts decisions
- need
| - demand
76
*item based pricing
-fees charged for service (surgeons price)
77
*phantom providers
- ex. anesthesiologist
| - bill for services separately
78
*package pricing
-bundled fee for a group of related services
79
*third party insurers and payers
- pt is first party
- provider is second party
- intermediary is third party
- insurance company is third party
- insurance company sets limits on what services are covered
- a wall of separation between financing and delivery
- quality of care is a secondary concern
80
*single payer system
-a national health care system that is usually the primary payer, the government
81
*multiple payer
- administrative costs are more
- companies can choose different plans
- billing and collection nightmare
- difficult for providers to track various health plans
- providers must hire claims processors
- Payments can be denied for not following requirements, which necessitates rebilling
- Some plans allow providers to balance bill whereas others do not
- Providers must engage in collection efforts
- Government programs have complex regulations
82
*power balancing
- multiple players
- key players:
- physicians, administrators, insurance companies, large employers, and the government
- have own economic interests to protect
- self interest are often at odds
83
*litigation risks
- US is a litigious society
- private health care providers are increasingly susceptible
- risk of malpractice lawsuits
- practitioners engage in *defensive medicine* -> doing things that will hold up in court -> you did your due diligence
- prescribe diagnostic tests, return checkups, documentation
- defensive medicine- you see a nodule -> probably nothing but you send out for tests to protect urself
84
*high technology
- US is a hotbed of research and innovation in new technology
- increase quality of health care and outcome
- high costs
- creates demand for new services despite high costs
- with capital investments, must have utilizations
- legal risks for providers denying new technology
85
*continuum of services
- 3 catagories of medical care services
- curative- treating sickness, most expensive (illness)
- restorative- therapies
- preventative- least expensive -> reduce amount of curative measures needed (wellness)
- health care is not confined to the hospital
- additional settings
86
*quest for quality
- increased pressure to develop quality standards
- demonstrate compliance
- higher expectations
- continuous quality improvement
87
*trends and directions
- promotion of health while reducing costs
- focus is changing from illness to wellness
- dont wait for sickness -> prevent!
- providing more effective and efficient quality care
- focus on promoting wellness not caring for illness
- focused more on delivery of services
- mid level health professionals, health coaches, and health information technology
88
*challenges of trends and directions
- managing costs
- focusing on care delivery
- adopting technology
- delivering new operating models
- meeting various federal state regulations
89
*significance for health care practitioners
- can attune health professionals to their relationship with the rest of the health care environment
- integrate themselves into the system
- can help understand changes and the impact of those changes on their practice
- adaptation and relearning
- no practitioner can work alone
90
*significance for health service managers
- positioning the organization
- know organization position in the macro environment
- handling threats and opportunities
- proactively deal with any threats to their institutions *profitability* and viability
- evaluate implications
- understand relevant issues
- planning
- strategic planning of which services should be added or discontinued
- capturing new markets
- known emerging trends before market is overcrowded
- complying with regulations
- following the organizational mission
91
national health insurance
-quad function model
-financing
-insurance
-payment
-delivery
-
92
socialized health insurance
- private health insurance
| - fees are based on income
93
australia
- swtiched form universal national health care program to privately financed system
- returned to a national prpgram called medicare
- Philosophy of everyone contributing to the cost of health care according to their capacity to pay
- Developed health service delivery models to contain costs, and provide quality and accessible care
- Developed a National Primary Health Care Strategy
94
canada
- Medicare consists of 13 provincial and territorial health insurance plans sharing basic coverage
- Nearly all Canadian provinces (except Ontario) have resorted to regionalization
- In 2004 created the 10-Year Plan to Strengthen Health Care
- Transitioning to patient-centered care
95
canada
- Medicare consists of 13 provincial and territorial health insurance plans sharing basic coverage
- Nearly all Canadian provinces (except Ontario) have resorted to regionalization
- In 2004 created the 10-Year Plan to Strengthen Health Care
- Transitioning to patient-centered care
96
china
- Evolved from a public insurance system (government or public enterprise) to a multipayer system.
- Facing the growing problems of a large uninsured population and health care cost inflation.
- Three-tier referral system has been largely abolished.
- Health reform initiatives in five major areas
- Health insurance, pharmaceuticals, primary care, public health, and public/community hospitals
- Establishment of an essential drug system
- In 2015 announced a five-year plan
97
UK
- National Health Service (NHS)
- Better Care Fund in 2013
- Five Year Forward View plan in 2014
98
germany
- Health insurance mandatory for all citizens and permanent residents since 2009
- Pharmaceutical Market Reform Act
- Act to Strengthen SHI Health Care Provision
99
israel
- Universal coverage based on German SHI model
- Employer tax and individual income-based contributions
- National health information exchange in 2014
100
Japan
- Providing universal coverage with two main insurance schemes
- Employer-based and national insurance program
- Japan Primary Care Society will run a training program
101
singapore
- Had a British-style NHS program.
- Medisave provides universal coverage.
- Chronic Disease Management Program.
102
who are the stakeholders in our healthcare system
- physicians
- hospitals
- insurers
- employers
- everyone***
103
stakeholder
- anyone who has interest in the outcome
| - someone who wins or loses on the outcome
104
significance of manager and policy makers
- health of a population determines health care utilization
- design appropriate educational, preventive, and therapeutic initiatives
- evaluating the effectiveness of health care organizations
- measures of health status and utilization
105
health
- the medical model defines health as the absence of illness or disease
- complete state of physical and mental well being that facilitates the achievements
- sociologist define health as the state of optimal capacity
- biopsychosocial model- social, positive relationships, self esteem, community and populations well being
- holistic view
106
US health definition
- curative
- restoring health
- existence
107
biomedical model
- governs the US concept of health and health care
- existence of an illness or disease
- seek and use care
- find relief of symptoms and discomfort
- diagnosis of illness and treatment of disease to restoration
- once relief is obtained, the person
- waits for illness and then treats
108
illness
perception of how we feel
109
quality of life
- overall life satisfaction during and following health care delivery system encounter
- indicator of how satisfied a person is with their health care experience
- overall satisfaction with life and self perceptions of health after intervention
110
risk factors and disease
- risk factors increase the *likelihood* of developing a particular disease or health condition
- epidemiology triangle- host, agent, environment
- behavioral risk factors
111
acute condition
sudden onset
| -severe in nature
112
chronic condiditons
- develop slowly
- continue on over a long period of time
- arthritis
- 3 reasons for the rise of chronic conditions:
- new diagnostic methods, medical procedures, and pharmaceuticals
- screening and diagnosis
- lifestyle choices
113
subacute
- between acute and chronic conditions
| - if you catch a disease in the subacute you can prevent the acute condition
114
health promotion and disease prevention
- 3 principles of a health promotion and disease prevention program
- health risk appraisal- taking an assessment
- interventions for counteracting the key risk factors
- things to do that can change progression
- adequate public health and social services
115
affordable care act
- prevention and public health fund (PPHF)
- CDC established the national diabetes prevention program (NDPP)
- organizations nationwide offer diabetes prevention lifestyle programs
- funding to establish and evaluate comprehensive *workplace wellness programs*
- certain screening have no out of pocket costs (mammograms, colonoscopy)
- treatments have costs
116
public health
- public health deals with promoting optimal health for the society as whole
- health protection and environment health
- *health protection during global pandemics*
- protecting population from a variety of old and new threats through global cooperation
- inexpensive to educate promoting wellness -> much less than treating disease
- ex. cost of vaccine vs cost of covid treatment
117
health protection and preparedness
- dealing with threats requires large scale preparations
- tools and training for workers in medical care
- public health
- emergency care
- civil defense agencies at the federal, state, and local levels
118
determinants of health
- blums model of health determinants
- environment
- lifestyle
- heredity
- medical care
119
how do we measure health care/success
- measure of physical health
- morbidity
- mortality
- measure of mental health
- measure of social health- breslows social health dimensions, social contacts and social resources
- measures of spiritual health
- measure of health servuce utilization -> crude or specific measures of utilization and measure of institution-specific utilization
- measure of global health- direct and indirect indicators of global health
120
mortality
-rate of death in a population
121
morbidity
incidence of illness in a population due to a certain thing
122
demographic change
- births- population growth
| - migration
123
anthro-cultural beliefs and values
- beliefs and values in the american culture
- belief in scientific advancement and the application of scientific methods to medicine
- champion of capitalism
- culture of capitalism promotes entrepreneurial spirit and self determination
- principles of free enterprise and a general distrust of big government
- equitable distribution of health care- *market and social justice*
- justice in the US health care delivery system
- limitation of market justice
124
market justice
- distribution of health care
- health care is a commodity
- quality, access, ease is a product that is purchased like any other product
125
social justice
- distribution of health care
| - health care is a right regardless of socioeconomic status or job
126
illness vs disease
illness- persons perception
| disease- profession evaluation, caused by more than one factor
