midterm Flashcards
3 pillars of healthcare
quality, accessibility and cost
why are the 3 pillars referred to as the iron triangle
we cannot have very high quality healthcare that is accessible to all at a cost that everyone can afford
-in order to address one of them, something else has to give
GDP (gross domestic product)
the sum of the value of all goods and services produced in a country within a years time
how much of the GDP was healthcare during 2023
17.6%
what part of healthcare has the highest cost associated with it
hospital care
-accounting for nearly 32% of the spending
-majority of hospital was in end of life care
basis of insurance
a risk transfer mechanism that facilitates shifting the cost of risk away from the insured and goes to an external party in exchange for payment
key ides of insurance
risk transfer and cost sharing
cost sharing is ….
when individuals purchase coverage and their resources are pooled together to protect against losses, and together they pool the potential risk for losses that they may experience
with insurance and risk, it is all about …
who is barring the risk
3 types of healthcare paying
out of pocket, private health insurance and public health insurance
out of pocket
payments by the individuals insurance policies, paying for services themselves or paying for part of services through copayments
private health insurance
payments made by individuals and/or employers for premiums, which cover the cost of payments by various health plans
public health insurance
sources include funding from federal, state and local government programs
-such as Medicare, Medicaid and Tricare military
some cost drivers for healthcare
paying in a rewarding manner, growing older/sicker/fatter, wanting new advancements, not enough information to make decisions, hospitals and providers can demand higher prices, have supply and demand problems and risk management (both in malpractice and defensive medicine)
how do malpractice and defensive medicine both contribute to healthcare cost
malpractice contributes less than 1% overall whereas defensive medicine contributes 12% to overall cost
-due to the fact that providers do not want to be sued so they do more than they should
the more beds, structures and resources you have ___________ cost you have
increased healthcare cost
-the more you have, the more work there is to do
even with more doctors or hospitals, this does not necessarily mean better outcomes, why?
everything has its own risk that is associated with it
what were economic alternatives that were discussed in relation with the rising cost of healthcare
decrease access and reduce reimbursement rates for procedures
why was there a 2.5% gap between healthcare spending and GDP?
over time, there was a greater rate of inflation with the GDP and healthcare however healthcare increased at a higher rate
-leading to there being this gap between the two
-the healthcare essentially was rising faster than the economy and therefore the wages were not keeping up with the cost of healthcare
what occurred as a result of the gap between healthcare and GDP
people were unable to afford insurance leading to 44 million people being uninsured
-both employers and employees could not afford it
-leading to access problems
what was done following the 2.5 gap
affordable care act was created
-subsidized the healthcare and restricted discrimination from healthcare
-if they could not afford healthcare, they would be given tax dollars (tax credit or tax money would cover)
-this did not address cost, but did address access
what type of access was addressed by the affordable care act
financial accessibility
what have been two core social issues of healthcare
financial accessibility and cost of healthcare itself
continuum of managed care
there is an increase in control and quality as you move from the left to the right
-indemnity is on the far left with no control over cost/quality
-traditional HMO is on the far left with complete control over cost and quality
on the continuum of managed care, what falls in the middle
PPO as they can be free or restrictive based on the plan
why are HMO plans all the way to the right with complete control
they are the ones who bare the risk while providing the care
what are some changes that have occurred in a result from the demand of health insurance
private and public sectors have expanded, most insurance included a comprehensive set of healthcare benefits, group health insurance began to be offered as a benefit, mechanisms for reimbursement have expanded and as a result cost has increased
when discussing quality and cost, what is the relationship and how does the curve relate to our job
as cost goes up, there is only so much that quality can continue to increase until it plateaus out
-this level off is the point where we can say that yes we may be spending more but the quality is not continuing to improve
-our job is to “shift this curve up” so that there is better quality at the same cost
-done by continuing education
those who are uninsured have been shown to use the healthcare delivery system in different ways including …
not having a PCP, delaying seeking care and utilizing the emergency department more often
-leading to financial consequences and unable to pay the medical bills
what does it mean to gain access
able to receive appropriate healthcare services to preserve or improve health
-having access does not mean that you gain the access!!
facets that determine the access
service availability, utilization of services/barriers to access, relevance and effectiveness and equity
how do the majority of americans get their insurance
through their employers
-was accidental after employers began offering insurance as a perk of employment in world war 2
what impact did the affordable care act have on employer based insurance
there may be something known as a cadillac tax, which is taxing high cost employer sponsored health plans
the great divide within 1910-1912
this was when any random patient with any random disease had a 50 50 chance of an encounter with any doctor being successful
two issues related to health policy that has been a central issue since the 1900s
adverse selection and moral hazard
adverse selection
those who were sick would seek coverage and those who were healthy would not
moral hazard
increase in hazards present by a risk arising from the insured indifference to loss because of the existence of insurance
about how far back does the concern of cost go and what has been done to address it
around 100 years ; invented insurance and risk pooling/transfer and lead to health maintenance act and managed care
health maintenance act of 1973
introduced HMO to the national vocab and promoted prepaid health plans as a more cost effective way to provide health care services
-promoted prepaid health plans as a more cost effect health care service
managed care within the 80s
contained the utilization of health care by limiting consumer choices for products and services with the shifting of risk to providers and patients
-additionally added in out of network with higher costs
what is thought to be the most significant piece of healthcare legislation
title 18 of the social security act of 1965
-what created medicare
what occurred following the end of world war 2
people were coming back from the war to spread the word about the new types of medicine, resulting in the hill burton act being passed which produced government grants for communities to build hospitals
what factors contributed to the rapid increase in healthcare spending in the early 1970s
we had the medicine, we built the infrastructure, GI bill trained personnel and there was the developed means to pay
-we have the access, we have the doctors but the problem was that indemnity coverage had no utilization control
-no means of controlling utilization
how successful was managed care at controlling cost
it did control care however, it still received backlash regarding the restricted care and poor outcomes that occurred
what happened as a result from the backlash of managed care
resulted in insurance becoming closer to PPOs from HMOs, ultimately leading to healthcare cost increase
-moving from the far right to the center caused the premiums to increase as there is no control over the cost
overall, the big issue with managed care …
restrictions that were placed
what aimed to bring the number of uninsured people down
the affordable care act
importance of “to err is human”
brought to attention the issue of medical errors and concluding that 44,000 to 98,000 people die every year from medical mistakes
-additionally, identifies that quality is a problem of people struggling to preform within a system that has opportunities of mistakes
quality
the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
health services
wide array of services that affects health, including those for physical and mental illnesses
increases the likelihood within quality
a reminder that quality is not identical to good outcomes and recognized that there is always an unknown aspect of health care, but the services provided are expected to provide more benefit than harm
individuals and populations within quality
draws attention to the different perspectives that need to be address ; all parts of the population having access to needed and appropriate services
desired health outcomes within quality
highlights the link between the care that is provided and its effects on health ; focuses on outcomes requiring clinicians to take patients preferences and values into account to make healthcare decisions
current professional knowledge within quality
emphasizes that health professionals must stay abreast of the rapidly expanding and changing knowledge based and use such knowledge appropriately
-continuing education
donabedian’s measures of quality include ….
structure (capacity of system to deliver care), process (interactions between patients and clinicians) and outcomes (changes in the patient health status as the result of health care interventions)
4 problems in quality of healthcare
underuse (too little care), overuse (too much care), variation in use (variations within practice protocols) and misuse (mistakes within care)
how can quality oversight occur
peer review, accreditation and inspection
quality improvement
proactive approach that is about building and executing a quality program
-identifying the root of the cause to improve the process
-how to create better outcomes
quality assurance
a retrospective approach that monitors and evaluates the various aspects of a project, service or facility to maximize the probability that standards of quality are being attained
-an after the fact sort of thing
continuous quality improvement (CQI)
focuses on the process part of Donabedian’s quality conception
-should not be a one time process and should be continuous
-identifying factors that create variation, aiding in improvement of quality
two types of variation
common (small causes of variability that are inherent to any system) and special cause (assignable, have large effects on process, occasionally)
why is control variation at the heart of CQI
when understanding and addressing variation, we can go to those areas to improve it and address those problems to get better outcomes
PDCA
plan, do, check and act
common elements of a quality improvement program
measurement, process variation and statistical process control
role of measurements and metrics within CQI
gives us what we need to know about the variation and outcomes in order to improve the process
-translation of observable events into quantitative terms
process variation with CQI
the range of values that a metric can take as a result of different causes within the process
statistical process control with CQI
method by which process variation is measured, tracked and controlled in an effort to improve the performance of the process
-useful for addressing special cause and common cause variation
risk
exposure to the chance of injury or financial loss (adverse possibility)
risk management process
identification of risks, development of alternative risk control/risk financing techniques, implementation of the chosen technique and monitoring the programs effectiveness and modifying it as risks change over time
the initial step within risk management process
recognize and analyze risks to classify and determine how to manage them
-internally through processes or transfer the risk to a third party
classification of risk
based on the relative values of the cost of managing risks weighed against the cost of the occurrence
-looking at how likely they happen and the cost associated with it occurring
prevented risk
cost of occurrence is higher than the cost of management whose occurrence may involve additional legal sanctions
normally prevented risks
cost of occurrence is greater than the cost of their management but whose occurrence is considered only as negligent
managed risks
cost of occurrence is only slightly greater than their cost of management
unprevented risks
cost of occurrence is less than cost of management
unpreventable risk
occurrence is unmanageable
risk and cost
as the risk goes up, we would want to spend more however we are identifying that point where we do not spend more than the risk associated with it
dr. james reason
the pioneer and expert on human error and system safety, discussed the blame culture within healthcare
what was the model that james reason talked about
the swiss cheese model
-revolved around the idea that there are barriers that protect workers from errors however if these barriers all break down at the same time it can lead to an adverse outcome occurring
-errors occur from these holes in the system that align opening up for those error opportunities to occur
ALARP (as low as reasonably practicable)
shows that we should not spend more than we should
-want to maintain a level of risk that is tolerable and can’t be reduced further without costs that are too large
malpractice
negligence or carelessness of a professional person, can either be civil (tort) or a criminal concern
tort
civil wrong committed by one person against another person
-unintentional tort is the most common civil litigation to be brought against us
with malpractice, what are two things we need to discuss in regards to care
duty of reasonable care and standard of care
duty of reasonable care
the standard of performance that is set by others in the field, which comes into play when we accept someone as a patient
-accepting when we see them as a patient in the clinic as a patient
standard of care
possesses the degree of education, credentials and skills ordinarily possessed by the pretensioners in that field
is any form of payment necessary for duty of reasonable care
no, money does not need to change hands for duty of reasonable care to be activated
how does ongoing training and education support patient care risk management
maintaining and keeping knowledge current supports patient care and risk management, as it allows to practice the latest and greatest standards of care
the two most important factors that can reduce exposure to liability
education and awareness
in order for a tort to be pursued, what needs to be present
duty of reasonable care, a breach of legal duty must exist, a proximate cause must exist between breach of duty & injury, an actual loss or damage must result from the injury
how to avoid a malpractice suit
understand state law, understand hospital and institution policies, communicate with the patient, ongoing risk management and document!!
root cause analysis
step by step method that leads to the discovery of a faults root cause
-process should be thorough and credible
adverse event
untoward incident, therapeutic misadventure, iatrogenic injuries or other occurrence directly associated with care or service provided
-may result from acts of commission or omission
sentinel event
an unexpected occurrence that involved death or serious physical or psychological injury or risk
reliability
performing as intended in common and uncommon circumstances
-wanting to to work well every time
-three level design that includes prevent, identify and mitigate
