Midterm Flashcards
Currently what precent of its GDP does the united states spend on healthcare?
17.6%
What does GDP stand for?
Gross Domestic Product
What does GDP mean?
GDP is the sum of the value of all the goods & services produced in a country in a years time.
what area accounted for approximatley 32% or 1/3 of the heathcare spending?
Hospital care
Name the two key ideas underlying the concept of insurance
Risk Transfer
* Risk is transfered from the individual to the group
Cost sharing (risk pooling)
* With cost sharing of any covered losses are incurred by the group members
( risk transfer & risk pooling you are going to bear risk for me)
What is risk transfer?
Risk is transferred from the individual to the group
shifting the cost of a risk away from the (insured) who runs it to an external party (insurer) in exchange for payment of premium
* insurance allows individuals (insured) to transfer their financial risk to an insurance company (insurer).
* The insurer takes on the risk in exchange for a premium
What is risk pooling?
Combining the risks of multiple individuals so any loss will be spread across a larger group
* Spreading impact of risks across a lrage group – pooled togetehr to cover losses
How does risk transfer and risk pooling work together?
- Risk transfer moves risk from an idividual to an insurer
- Risk pooling allows the insurer to manage that risk by spreading it across many policyholders
What are some of the more significant factors that are driving up healthcare cost?
- fee-for-service model generates a strong incentive to perform a high volume of test and services
- aging of the population will have significant impact on health care spending growth
- Advancing Medical Technology increases health system efficiency and encourages unnecessary utilization of expensive treatments in FFS
Distinguish between the effect of malpractice lawsuits and the impact of defensive medicine
Medical malpractice - fearing malpractice lawsuits, many physicians significantly drive up costs to our health care system by ordering unnecessary test and treatments
* Contribute less than 1% to overall cost
Defensive medicine: “you might not need this test, but I am going to do it because you are worried.”
* Contributes 12% to overall cost
* Drives overutilization
law suit themselves have minimal effect on cost it’s more due to the fear of getting sued that drives the cost.
How do the number of specialist and/or hospital beds in an area impact cost?
More bed, more doctors more structure etc = higher the cost - because you are increasing the access → you get more utilization
More care does not produce better outcomes, bc you are increasing risk → Each time you are doing the procedure you are increasing the risk
Confronted with healthcare costs rising at a greater pace than GDP, officials trying to fund public programs like Medicare are left with what two economic alternatives?
decrease access or we can reduce reimbursement
- At first, spending more improves quality and access over time, the gains level off. goal should be to shift the entire curve upward.
Between 1960 and 2006 gap between health care spending and GDP was 2.5 percentage points per year. How has this gap contributed to a large percentage of the long-term decline in coverage?
Cost of health care became more and more expensive over time = More people could not afford it because cost was rising faster than pay is rising = unaffordable = more uninsured individuals. = decrease in access to healthcare.
What are the three categories of payment sources for healthcare in the United States?
Out of pocket -paying it yourself
Private - employer based
Public - Medicare, medicaid, tri core
Describe the continuum of managed care and how it is interpreted.
As you move from left to right on the continuum, the insurer has increasing control over cost, and increasing control over quality, which results in reduced premiums.
Left: Less Managed →More Control, More choice, higher costs (Indemnity plans, Fee-for-Service)
Moderately Managed → Balanced choice and cost control PPO)
Right: Highly Managed → Less Control Limited choice, lower costs, coordinated care (HMO)
This Right - Rigid Left - Loose
What are the changes related to the demand for and use of health insurance over the past 100 years discussed in the text?
Increase demand in terms of there being greater accessibility to insurance through the employer and government - consequence = greater access to care = increased cost
what eventually happens to healthcare outcomes (quality) as healthcare cost increases and what does shifting this curve up represent?
- Initially it will go up and up the more you spend, but over time it will begin to level out.
- Since you can’t get the curve to continue to go up, what you’ll want to do is just make the whole curve and move it up.
- We look at both, being more effective (getting better outcomes) and efficient (getting the same outcome with the same or fewer resources)
If we lift up the curve we are getting better quality - how do you lift the curve? - you are being more efficient with your resources, you have to be more effective.
What were some of the key characteristics of the uninsured population in the US in 2008?
- do not have a PCP
- delay seeking care until they are sicker
- utilize hospital emergency departments, the most expensive entry point to the health care system, to access the system and receive health care
- all of which results in “serious financial consequences, with many unable to pay their medical bills, resulting in medical debt”
What does it mean to gain access to care and what are the facets that determine real access?
There is a difference between having and gaining.
* you may have (having) physical access, but ask yourself are you able to afford it, do they speak my language etc. what are the barrier stopping you from gaining access to healthcare
* Gaining is where you are able to access the healthcare that is available.
How do the majority of Americans get their healthcare insurance?
Through their employer = private
What has been happening to employer based insurance over time and has the Affordable Care Act changed that trend
- Changes to private health insurance coverage will no doubt continue, but the evidence of the impact of the ACA shows that “it has had no impact on employer coverage”
- Shifting from traditional HMOs to a PPO, premiums went up.
when was the “great divide” in healthcare reached and what was it?
- between 1910 and 1912
- After 1912, patients had an ever increasing expectation that they would NOT only survive the encounter (50/50), but enjoy improved health as a result of the care they received.
- Due to progression in modern medicine (science turned into intervention to actually save peoples lives)
What two issues related to health policy have been central issues concerning healthcare since the early 1900s?
Cost & Access
* Financial Accessibility (the ability to pay for care or obtain and pay for insurance)
* The cost of healthcare itself
How far back in US history does concern about the cost of care go and have attempts been made to address it?
- 1920s
- Yes - e.g. Affordable Care Act, Insurance, employer based concepts, etc.
What factors contributed to the rapid increase in healthcare spending in the early 1970’s.
- Due to unexpectedly high Medicare expenditures,
- rapid inflation in the economy,
- expansion of hospital expenses and profits,
- changes in medical care including greater use of technology, medications, and conservative approaches to treatment.
What act was passed in response to rapid increase in healthcare spending in 1973?
President Nixon sent the Health Maintenance Act to congress in 1973. (HMO)
* The act was in response to a surge in health care cost as a percentage of GNP. The bill promoted prepaid health plans as a most cost effective way to provide health care services.
Name the most significant piece of healthcare legislation in the last century.
Title XVIII (18) of the Social Security Act of 1965 created the Medicare program.
* Reimbursement was based on reasonable cost
How successful was managed care at controlling cost?
- Managed care had achieved market dominance by the mid 1990’s. Some argue that it was managed care that stemmed the tide of ever increasing healthcare costs.
- With success came scrutiny. The media features stories of restrictive care and poor outcomes. Federal and state legislation was passed to ensure patient rights. The system had to be the blame for all woes.
(people did not like it because they did not have much control)
(HMO)
What happened in the mid 1990’s that affected MCOs significantly and what has happened to healthcare cost (and premiums) as a result.
Early 90s there was pushback such that you saw patient rights, legislation brought up, and employers getting pushback from employees about policies. This caused them to move towards PPOs.
* More people were in PPOs rather than HMOs= increase in premiums.
* Then went from the far right of the continuum to the far left (premiums increase)
* 18 years later we had a reform that allowed people to gain access - affordable care act.
* Impacted employers because you would see and decrease in productivity. Uninsured population direct relationship to lower productivity
What did the IOM report “To Err is Human” reveal about the US healthcare system?
- Brought public attention to the issue of medical errors, concluding the fact that between 44,000 and 98,000 people die every year from medical mistakes.
- It also diagnosed the quality problem as not one of poorly performing people, but of people struggling to perform within a system that is riddled with opportunities for mistakes to happen, i.e., system failures.
What is the meaning of the component phrases in the IOM definition of quality?
Health services: applies to many types of health care practitioners and to all settings of care
Increases the likelihood: likelihood recognizes that there is always an unknown aspect of care, but the services provided are expected to provide more benefit than harm
Population and individuals: draws attention to the different perspectives that need to be addressed
Desired health outcomes: highlights the crucial link between the care that is provided and its effect on health.
Current professional knowledge: emphasizes that health professionals must stay abreast of the rapidly expanding and changing
When examining quality issues, what are the four problems that present themselves and how are they defined.
Under use: Too little care. Needed services not provided. Immunizations, Screening, effective medication
Overuse: Too much care. The overuse of antibiotics, unnecessary surgery, excessive use of imaging.
Variation in Use: Variations in practice. Length of stay, invasiveness or procedures, screenings.
Misuse: Mistakes in care. Wrong Medications, Misdiagnosis, Failure to Follow Up
Too little care. Needed services not provided. Immunizations, Screening, effective medication
Under use
Under use
Under use: Too little care. Needed services not provided. Immunizations, Screening, effective medication
Too much care. The overuse of antibiotics, unnecessary surgery, excessive use of imaging.
Overuse
Overuse
Overuse: Too much care. The overuse of antibiotics, unnecessary surgery, excessive use of imaging.
Variations in practice. Length of stay, invasiveness or procedures, screenings.
Variation in Use
Variation in Use:
Variation in Use: Variations in practice. Length of stay, invasiveness or procedures, screenings.
Mistakes in care. Wrong Medications, Misdiagnosis, Failure to Follow Up
Misuse
Misuse
Misuse: Mistakes in care. Wrong Medications, Misdiagnosis, Failure to Follow Up
What are Donabedian’s measures of quality and how are they defined?
Structural: The capacity of health systems to deliver care. The number of board certified staff, equipment, facilities
Process: Interaction between patients and clinicians. Immunization rates, best practice standards.
Outcomes: Changes in the patients health status as the result of healthcare interventions. Recovery rate. Mortality, health status
The capacity of health systems to deliver care. The number of board certified staff, equipment, facilities
Structural
Structural
Structural: The capacity of health systems to deliver care. The number of board certified staff, equipment, facilities
Interaction between patients and clinicians. Immunization rates, best practice standards.
Process
Process
Process: Interaction between patients and clinicians. Immunization rates, best practice standards.
Outcomes
Outcomes: Changes in the patients health status as the result of healthcare interventions. Recovery rate. Mortality, health status
Changes in the patients health status as the result of healthcare interventions. Recovery rate. Mortality, health status
Outcomes
What are some examples of models of oversight?
Peer Review: Certification of specialty based professional training, clinical practices, and/or organizations
Accreditation: Independent organization that use published criteria such assess quality in and accredit provider settings/organizations (acute care, long term care, primary care, metworks)
Inspection: National or regional statutes prescribing levels of competence and/or safety
Certification of specialty based professional training, clinical practices, and/or organizations
Peer Review
Peer Review
Peer Review: Certification of specialty based professional training, clinical practices, and/or organizations
Independent organization that use published criteria such assess quality in and accredit provider settings/organizations (acute care, long term care, primary care, metworks)
Accreditation
Accreditation
Accreditation: Independent organization that use published criteria such assess quality in and accredit provider settings/organizations (acute care, long term care, primary care, metworks)
National or regional statutes prescribing levels of competence and/or safety
Inspection
Inspection
Inspection: National or regional statutes prescribing levels of competence and/or safety
Which part of Donabedian’s quality conception does CQI focus on?
The process is what they focus on.
* We want to push towards outcomes → so we focus on process because we are able to have control over this, what areas of process can we change to improve outcomes.
Why is the control of variation at the heart of CQI ?
- Improvement activities promote understanding and addressing the factors that create variation in an administrative or clinical process (e.g., long wait times, high hospital readmission rates) will produce superior patient care quality and organizational performance.
- Furthermore, quality improvement should not be viewed as a one-time project; rather, it should be a normal on-going activity, resulting in a continual flow of improvements.
- When you understand the process you are able to control the outcomes by making - changes to the process = better outcomes
- If you don’t have control of the system variation will occur on its own
What role does measurement and metrics (statistics) play in CQI? Why is the role so critical?
- Critical because all quality improvement efforts require numerical data because you can’t manage what you can’t measure.
- Quality and improvement are driven by data and evidence rather than subjective judgments, anecdotes, or opinions.
What is PDCA?
Plan, Do, Check, and Act = improvement cycle.
* Plan means to take the process improvement and create a plan for its implementation.
* Do, means to actually implement the process improvement.
* Check means to study whether the process is improving, using the measures identified.
* Act means to determine whether the process improvement was successful.
What are the common elements of quality improvement programs
Two Main: Empowering the people who are doing the work. And the use of metrics
* Measurement. All quality improvement efforts require numerical data because “you can’t manage what you can’t measure.”
* Process variation - the range of values that a metric can take as a result of different causes within the process.
Special cause variation
Common-cause variation
* Statistical process control - useful for addressing special cause and common-cause variation.
What is the difference between quality assurance and quality improvement?
Quality Assurance: the systematic monitoring and evaluation of the various aspects of a project, service or facility to maximize the probability that minimum standards of quality are being attained by the production process, It is reactive
* Retrospective
Quality improvement: about building and executing a quality program. It is proactive
* How do we produce better outcomes consistently.
* Prospective
the systematic monitoring and evaluation of the various aspects of a project, service or facility to maximize the probability that minimum standards of quality are being attained by the production process, It is reactive
Quality Assurance:
* Retrospective
Quality Assurance
Quality Assurance: the systematic monitoring and evaluation of the various aspects of a project, service or facility to maximize the probability that minimum standards of quality are being attained by the production process, It is reactive
* Retrospective
about building and executing a quality program. It is proactive
Quality improvement:
* How do we produce better outcomes consistently.
* Prospective
Quality improvement:
Quality improvement: about building and executing a quality program. It is proactive
* How do we produce better outcomes consistently.
* Prospective
What is the definition of a risk?
A risk is an exposure to the chance of injury or financial loss.
Understand the component steps in the risk management process
identifying the risks so you can decide how to manage them
Identification of risks
* The goal of risk identification is to discern which risks are present.
Analysis of those risk in terms of probable loss, frequency and severity
* Risk classification: risks are classified based on the relative values of the cost of managing the risk weighed against the cost of the occurrence and frequency of occurrence and degree of liability applied to an occurrence of the risk.
* They ask questions to determine what they are going to do about something.
Development of alternative risk control and risk financing techniques and choice of the proper technique or combination thereof
Implementation of the chosen technique
Monitoring the program’s effectiveness and modifying/improving it as risks change over time.
What are some sources that can help identify risk in a setting?
- Internal incident (occurrence) reports
- Reports and surveys from accrediting bodies such as Joint Commission and NCQA
- Walking the Beat
- Risk identification aides from insurers
- Professional practice guidelines
- Professional ethics documents
- Regulatory guidelines and requirements
- Equipment maintenance and operation manuals
How does the cost of risk management for any given risk play into the equation in determining if the effort is worth it?
A level of risk that is tolerable and cannot be reduced further without the expenditure of costs that are disproportionate to the benefit gained or where the solution is impractical to implement.
* Question is how much is it going to cost: is it going to cost more than it will bring in. = not worth it but if the cost is “just the right amount” then what it will bring in = what you want.
James Reason’s explanation of the cause of errors – the basis for the “Swiss Cheese Model” and “Blame” culture.
- Errors in healthcare occur because a combination of risk factors within the system itself have aligned and made the error more likely to happen.
- Swiss cheese is where you have holes in the barriers from error and sometimes those holes in the barriers will align - allowing for adverse outcome
Errors in health care happen not because of a single event, or because of a single person’s error, but because a combination of risk factors within the system itself have aligned and made the error more likely to happen.
James Reason’s explanation of the cause of errors – the basis for the “Swiss Cheese Model” and “Blame” culture.
- Errors in healthcare occur because a combination of risk factors within the system itself have aligned and made the error more likely to happen.
What is ALARP and why is it used?
ALARP “As Low as Reasonably Practicable”
* We want the level of risk and amount of money spent to be appropriate.
* We use it to determine the cost/benefit of an action. Does the risk outweigh the cost?
What does ALARP stand for
As Low as Reasonably Practicable
We want the level of risk and amount of money spent to be appropriate.
We use it to determine the cost/benefit of an action. Does the risk outweigh the cost?
ALARP
What is the “Duty of Reasonable care” and how does such a ‘duty” come about?
- Generally speaking, anytime a healthcare professional treats a patient they have a duty to use reasonable care. The level of care that is reasonable is defined by the standard of performance set by other practitioners in the field.
- This duty comes into beign when you accept someone as a patient by seeing them as a patient.
anytime a healthcare professional treats a patient they have a duty to use reasonable care. The level of care that is reasonable is defined by the standard of performance set by other practitioners in the field.
Duty of Reasonable care
Is any form of payment necessary for the duty of reasonable care to come about?
No form of payments is necessary for the duty of reasonable care. Once established, the duty continues until you give the patient adequate notice of your intentions and see to it that any urgent care issues are attended to or arranged for.
How does ongoing training and continuing education support patient care risk management?
- Your staff’s skills and knowledge must be kept current if you are to safely and effectively deliver the best care possible. Reasonable care is based on the current standard of care. The only way to ensure that everyone is current in an ongoing fashion is a program of continual education.
- Allows you provide standard of care because you contain current knowledge (continuing ed)
The two most important factors influencing a practitioner’s ability to reduce exposure to liability.
Awareness and education
What elements must be present for a tort of negligence to be viable/pursued?
- A legal duty must exist between the practitioner and the plaintiff
- A breach of legal duty must exist
- A proximate cause (cause and effect relationship) must exist between the breach of duty and the injury
- An actual loss or damage must results from the injury
What is the most common claim against audiologists
Unintentional tort of negligence is the most likely civil litigation to be brought against a speech-language pathologist of audiologist
* You made a mistake, and the patient was harmed.
What is the definition of Malpractice?
Negligence; which means that a health care provider did not measure up to the standard of care expected of reputable and careful health care providers under similar circumstances.
step by step method that leads to the discovery of a fault’s root cause. The process should be “Thorough and Credible”
Root Cause Analysis
step by step method that leads to the discovery of a fault’s root cause. The process should be “Thorough and Credible”
Root Cause Analysis
Root Cause Analysis: step by step method that leads to the discovery of a fault’s root cause. The process should be “Thorough and Credible”
“Untoward incidents, Therapeutic misadventures, iatrogenic injuries, or other occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission.”
Adverse Event:
“Untoward incidents, Therapeutic misadventures, iatrogenic injuries, or other occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission.”
Adverse Event
Adverse Event
“Untoward incidents, Therapeutic misadventures, iatrogenic injuries, or other occurrences directly associated with care or services provided. Adverse events may result from acts of commission or omission.”
“An unexpected occurrence that involved death or serious physical or psychological injury, or risk thereof.”
**Sentinel Event: **
“An unexpected occurrence that involved death or serious physical or psychological injury, or risk thereof.”
performing as intended in common and uncommon circumstances
Reliability
performing as intended in common and uncommon circumstances
* We assure reliability through systems (checklists)
** Muy Importante**
Reliability
Reliability: performing as intended in common and uncommon circumstances
* We assure reliability through systems (checklists)
We assure reliability through what?
Reliability: performing as intended in common and uncommon circumstance
We assure reliability through systems (checklists)
In 1972…
1972: HMO; introduced managed care. Nixon discovered it. (Health Maintenance Act)
The 3 pillar
access, quality, and cost
What US system is most like socialized health care?
VA - is the only system in the US that is the most similar to socialized health care.
socialized healthcare system
ex: UK
- Funds healthcare primarily through taxes.
- Owns and operates hospitals and clinics.
- Employs healthcare providers (in some models).
- Ensures universal coverage for all citizens.
unsocialized healthcare system
ex: US
- Private entities mainly provide and fund healthcare.
- Individuals pay out-of-pocket or through private insurance.
- There is less government involvement in regulation and funding.
- Healthcare is often market-driven, meaning access depends on ability to pay.
The UK system is
&
Canada is
The UK system is both a socialized and a single payer system (the government owns and operates the system when it is socialized.) Canada is single payer, not socialized.
- Funds healthcare primarily through taxes.
- Owns and operates hospitals and clinics.
- Employs healthcare providers (in some models).
- Ensures universal coverage for all citizens.
socialized healthcare system
ex: UK
- Private entities mainly provide and fund healthcare.
- Individuals pay out-of-pocket or through private insurance.
- There is less government involvement in regulation and funding.
- Healthcare is often market-driven, meaning access depends on ability to pay.
unsocialized healthcare system
ex: US
What did the affordable care act do?
Affordable care act: 2008, it did not fix cost, it fixed access, it overcame the challenge of access with government tax cuts. - Fixed financial access
Coinsurance and Co-payments are similar in that
a. They are always equal
b. They are billed to the patient after the insurer portion has been paid
c. They are both set amounts
d. They are a portion of the allowed amount owed by the patient
D: They are a portion of the allowed amount owed by the patient
not C b/c - Co-insurance is not a set amount because it is a percentage of the allowed amount. It changes based on the amount billed.
Which government program helps older Americans over 65 pay their health care costs?
a. Medicare
b. WIC
c. Social Security
d. Medicaid
Medicare
A very generous PPO plan that makes provision for patients to see any provider out of network and only pay 15% of the provider’s bill.
a. Appears on the far right of the continuum of managed care
b. Appears close to traditional indemnity plans on the continuum of managed care
c. Appears close to traditional HMO’s on the continuum of managed care
d. PPO’s always fall in the middle of the continuum of managed care
B: Appears close to traditional indemnity plans on the continuum of managed care
- The patient can go out of network, therefore the insurer does not have control of the cost or quality = closer to indemnity
- Left: Less Managed → More choice, higher costs (Indemnity plans, Fee-for-Service)
- Moderately Managed → Balanced choice and cost control PPO)
- Right: Highly Managed → Limited choice, lower costs, coordinated care (HMO)
Prior to the backlash against managed care in the 1990’s, it can be said that
a) Limitations on services was not a factor in rising resentment against HMO’s
b) Managed care failed to meet cost control expectations
c) Managed care beat the predicted rise in cost estimates by controlling cost and utilization
d) Managed care plans were of little help to employers in keeping down premium prices
C: Managed care beat the predicted rise in cost estimates by controlling cost and utilization
- The restricted access to care, the population did not like this because the people were not able to go where they want. In the 1990’s the plans moved more to the middle of the continuum, so people had a little more of a choice but the cost of the premium went up.
The inclusion in the IOM definition of quality of the terms populations and individuals draws attention to
a) The special efforts needed to prepare for epidemics and pandemics
b) The IOM’s desire to emphasize the need for person centered healthcare
c) The need of all populations to have access to necessary and appropriate services
d) The importance of getting everyone the outcomes they expect
C:The need of all populations to have access to necessary and appropriate services
The sum of the value of all the goods and services produced in a country in a year’s time.
GDP
Gross Domestic Product
The act was in response to a surge in health care cost as a percentage of GNP. The bill promoted prepaid health plans as a most cost effective way to provide health care services.
Health Maintenance Act to congress in 1973. (HMO)
what is useful for addressing special cause & common cause variation?
Statistical Process Control
