Lecture 10/Chapter 12 Flashcards
Learning Objectives
- Meaning of health care costs and trend review
- Factors that led to past cost escalations
- Describe regulatory and market-oriented approaches to contain costs
- Why some regulatory cost-containment approaches were unsuccessful
- Discuss the access to care framework and various dimensions of access to care
- Describe access indicators and measurements
- The nature, scope, and dimensions of quality
- Differentiate between quality assurance and quality assessment
- Implications of the ACA for health care costs, access, and quality
Cost, access, and quality introduction
- 3 cornerstones of health care delivery:
- cost
- access
- quality
- expansion of access will increase health care expenditures
- cost of health care from a macro and micro perspective
- equal access to high quality care
- cost is important in the evaluation of quality
quality
-up to date capabilities, evidence-based processes, and measuring outcomes
cost of health care
- trends in national health expenditures
- should health care costs be contained?
- consumer price, national perspective, provider perspective
- 3 sources to assess if spending too much:
- international comparisons
- rise in private sector health insurance premiums
- government spending on health care for beneficiaries
reasons for cost escalation**
- third-party payment
- moral hazard
- provider induced demand
- imperfect market -> health care market in the US is neither free***
- growth of technology and specialization
- increase in the elderly population
- medical model of health care delivery
- multipayer system and administrative costs
- defensive medicine
- fraud and abuse- upcoding and anti-kickback statute
- practice variations- small area variations (SAV)
cost containment: regulatory approaches
- health planning
- price controls
- peer review
health planning
- government undertaking steps to align and distribute health care resources so that the system will achieve desired health outcomes for all people
- health planning experiments in the US
- certificate of need statutes (CON)
cost containment: competitive approaches
- competition refers to rivalry among sellers for customers -> technical quality, amenities, access or others
- demand-side incentives
- supply side regulation
- payer-driven price competition
- utilization controls
cost containment under health reform
- medicare payment cuts to providers
- new taxes imposed
- reforms contributed to a health care spending slowdown
- tightening provider payment rates
- providing incentives to reduce costs
- medicare projected to spend $1 trillion less by 2020
access to care
- key implications of access for health and health care delivery
- access to medical care, along with environment, lifestyle, and heredity factors
- access in a benchmark in assessing the effectiveness of the delivery system
- measures of access reflect if delivery is equitable
- access is linked to quality of care and efficient use
- framework of access
five dimensions of access
- availability
- accessibility
- accommodation
- affordability
- acceptability
4 main types of access
- potential access
- realized access
- equitable or inequitable access
- effective and efficient access
measurement of access
- current status of access
- using conceptual models access is measured at 3 levels
- individual
- health plan
- delivery system
affordable care act and access to care
- insurance coverage and access to health care have increased
- fewer report problems with medical bills and financial barriers
- gaps in access to and affordability of care
- preventive services without cost sharing expanded
quality of care
- IOMs quality implications:
- quality performance has a range from unacceptable to excellent
- focuses on services provided by the health care delivery system
- quality may be evaluated from the perspective of individuals and populations or communities
- emphasis on desired health outcomes
with managed care, the balance of power shifted towards
- providers- health care professional
- supply side- health care facilities
- demand side- patients**
- risk shifts to providers
- supply side and providers are on one side of the equations and demand side and patients are on the other
- third party of the demand side is insurance
dimensions of quality
- micro view focuses on services at the point of delivery and their subsequent effects:
- clinical aspects
- interpersonal aspects
- quality of life
-macro view looks at quality from the standpoint of populations
quality assessment and assurance
- quality assurance is based on the principles of total quality management (TQM)
- referred to as a CQI
- donabedian model
Donabedian Model**
- three parts of quality assessment
- structure- the capacity to delivery quality -> building, staff, finance, equipment
- process- how health care is delivered -> transaction between patients and providers
- outcome- effects or results obtained -> effects on the health
processes that improve quality
- clinical practice guidelines
- cost-efficiency
- critical pathways
- risk management
public reporting of quality
- CMS programs on quality
- AHRQ quality indicators
- states public reporting of hospital quality
CMS programs on quality
AHRQ quality indicators
-prevention, inpatient, patient safety, and pediatric
3 objectives of affordable care act and quality of care
- make health care more accessible, safe, and patient centered
- address environmental, social, and behavioral influences on health and health care
- make care more affordable
affordable care act and quality of care
- organizations are incentivized to provide high quality care in 2 ways:
- penalized for failing to report quality measures
- sharing in the savings generated by quality measures
- the number of patients safety and medical errors has decreased since 2010
- patient centered outcomes research institute (PCORI)
summary
- increasing costs, lack of access, and quality concerns pose the greatest challenges
- lack of universal coverage negatively affects the health status of uninsured groups
- access to medical care is one of the key determinants of health status
- health care quality at the micro and macro levels
financing equation
- Cost of health care = (cost for each health care service) x (how often that service is utilized)
- E = P x Q
- insurance extension to uninsured increases health care expenditures (E)
- insurance with payment (price=P) influences supply
- insurance and supply of services determine access and service utilization (quantity of services consumed = Q)
high quality care
- achieved when: accessible services are efficient
- cost effective
- provided in an acceptable manner
consumer price
- physicians bill
- prescription bill
- premiums
national perspective
-how much nation spends on health care (health care expenditures)
provider perspective
-cost of production (staff, salaries, capital, supplies)
evaluating national health care expenditures
- compared to consumer price index (CPI)
- CPI measures general inflation in the economy and calculates the annual changes
- compared to gross domestic product (GDP)
trends in national health expenditures**
- US uses a larger precentage of economic resources on health care
- 2005, 15.2% of GDP was spent on health care -> 5,3
reasons for cost escalation
- 3rd party payments
- moral hazard
- provider induced demand
technology and specialization: reasons for cost escalation
- belief and values
- high R&D spending
- innovation that leads to utilization
- surplus of specialists
increase in elderly population: reasons for cost escalation
- increased longevity
- baby boomers
- the elderly use nearly three times as much health care as younger people
medical model of health: reasons for cost escalation
- misplaced emphasis on medical treatments
- health promotion/diseases prevention takes a back seat
multipayer system and administrative costs
- inefficiencies related to:
- financing
- insurance
- delivery
- payment functions
- enrollment process
- ]contracts
- claims processing
- utilization
- denials and appeals
- marketing
defensive medicine: reasons for cost escalation
-medial tests and treatments that are not justified, but done for self-protection (CYA) -> cover your assets
fraud and abuse: reasons for cost escalation
- waste and abuse
- inefficiencies and fraud
- major problem in medicare and medicaid
- unnecessary services may be provided
- misallocation of costs to increase reimbursement (in cost plus reimbursement systems)
- receiving kickback for referrals
- self-referral (stark laws)- referring to someone you know
practice variations : reasons for cost escalation
- small area variations
- signal gross inefficiencies in the system
- people practice medicine differently
- compromise both cost and quality
all-payer (single-payer) system: cost containment regulatory approaches
- top down control (global budgets)
- the US does not have an all-payer system
- bottom up cost control
- cost shifting occurs
health planning: cost containment regulatory approaches
- governments efforts to align and distribute health care resources to achieved health outcomes
- no system wide planning and controls in the US
- certificate of need planning used by some states
price controls:: cost containment regulatory approaches
economic stabilization program used during the nixon presidency
- provider induced demand mitigated the effects of price controls
- DRG based prospective payment systems shifted costs to the outpatient sector
- PPS extended to other health care sectors
- arbitrary rate setting by medicaid
- pay for performance (Provider incentives)
peer review: cost containment regulatory approaches**
- Peer review organizations (PROs)
- statewide private organization
- review by physicians and other health professionals
- paid by federal government
- to review care provided to medicare patients
- is care reasonable? necessary? appropriate?
- meets quality?
- each state has a PRO
- can deny payment if care not necessary or appropriate
- PROs are now called quality improvement organizations (QIOs)
demand-side incentives: cost containment competitive approaches
- cost sharing by consumers
- a self rationing mechanism (reduces moral hazard)
- cost sharing between patient, provider, and insurer
- RAND experiment (cost sharing = lower costs)
- the more they increase out of pocket cost -> less utilization
supply side regulation
- antitrust laws
- anticompetitve practices can be illegal
payer driven price competition: cost containment: competitive approach
- patients are not customers in the economic sense
- payer driven competition occurs at 2 levels:
- employers shop for value in health insurance plans
- managed care shops for best value from providers
utilization controls: cost containment: competitive approach
- employed by MCOs
- they overcome the information gap that patients face
- control how often members utilize services
access
- ability to obtain needed, affordable, convenient, acceptable, and effective personal health services timely
- does patient have a source of care -> Primary Care profession
- use of health care -> availability, convenience, referral
- acceptability of services -> a patients preference and values
- key implications:
- a determinant of health
- a benchmark in assessing effectiveness
- equity
- quality and efficient use of needed services
accessbility
-fit between the locations of approved providers and patients (transportation, convenience)
afforadability
-ability to pay
accommodation
-how resources are organized to provide services and the patients ability to use the services (timely appointments, quick service, walk ins etc.)
acceptability
-compatibility (waiting time, race, culture, gender, etc.)
types of access
- potential
- realized
- potential
- equitable/inequitable
- effective and efficient
potential access
- capacity
- organization
- financing
realized access
- type
- site
- purpose of health care serivces
- are they meeting the needs
equitable/inequitable access
-distribution of health care to patients perceived need
effective and efficient access
-links realized access to health outcomes
institute of medicine definition of quality of care
- increased likelihood of desired health outcomes
- use of current professional knowledge
micro view of quality
- clinical (technical) aspects
- interpersonal aspects
- individual experinces
- quality of life:
- general HRQL
- disease specific HRQL
- institution related quality of life
macro view**
-population
quality assurance
- based on total quality management (TQM) -> allows improving
- similar to continuous quality improvement (CQI) and quality improvement (QI)
- time entering facility to time fully recovered
- a step beyond quality assessment
- cannot occur without quality assessment
- system wide commitment to engage in the improve of quality on an ongoing basis
- analyze what happened and how it can be improved
quality assessment
- measurement of quality against an established standard
- use of data
- subjective measures must be quantified
- measurement scales must have:
- validity- extent to which it actually assesses what it purports to measure
- reliability- extent to which same results occur from repeated applications -> repeatable
structure (resources): donabedian model
- facilities: license, accreditation
- equipment
- staffing levels
- staff qualifications
- staff training
- distribution of hospital beds, physicians, in a given population
process (delivery of care): donabedian model
- clinical practice guidelines (medical practice guidelines)
- evidence based protocols
- professional consensus when scientific evidence is lacking
- critical pathways:
- a timeline
- identifies planned medical interventions
- with expected patient outcomes for diagnosis
aspects of process: cost efficiency and risk management: donabedian model***
COST EFFICIENCY:
-do benefits exceed the costs
-underutilization and overutilization are based on cost efficiency
RISK MANGEMENT:
-proactive
-efforts to prevent adverse events related
outcomes: donabedian model
- final results
- bottom line measure of effectiveness
- recovery, improved health
- postoperative infections, nosocomial infections, iatrogenic illnesses, re-hospitalizations
- malpractice litigation
- patient satisfaction
- HRQL (health related quality of life)
HEDIS
- health plan employer data information sets
- standard for reporting quality in managed care plans
- measures: effectiveness, access and availability, satisfaction, health plan stability, utilization, cost, informed choices
quality report cards***
- HEDIS
- CMS program on quality
managed care increased the rate of growth in health care spending between 1993-2015
health care spending increased (because it always does) BUT the rate went down
-false
prevention and lifestyle behavior changes to promote health is NOT the major focus of the medical model
- true
- wellness is holisitic approach
