Midterm Flashcards
pillars of healthcare
access
quality
cost
getting better outcomes
more effectiv
getting better outcomes with same or fewer resources
more efficient
what system in teh US is the closest to a socialized single payer system
the model with this look is the VA (owned and operated by fed government and they are the single payer for this system)
f
Currently (2023), what percent of its GDP does the United States spend on healthcare?
about 17.6% - most of it goes to hospitals (⅓ of it) and those in hospital are those in the last few years of life (spening a lot of money)
expected to reach 19.7% by 2026
What does GDP stand for and what does it mean?
gross domestic product
sum of goods and services added together produced in the country in one year
What area accounted for approximately 32 % or 1/3 of healthcare spending?
hospital care
Name the two key ideas underlying the concept of insurance
the foundational idea is risk transfer - you bear the risk for me
risk is the money that might be lost due to insuring people who utilize health care services
insurance transfers risk from one person to many people by pooling the risk across a large number of subscribers or members
risk pooling - when individuals purchase coverage they join others and pool their resources to protect against losses & in doing so they pool the potential risk for losses that might be experienced and cost of risk is shared among the manye
cost sharing
the larger number of health people lower the risk and the greater number of sick people greater the risk
What is the 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
what is cost sharing
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
What are some of the more significant factors that are driving up healthcare cost?
new technology & aging population
Healthcare finance & delivery
fee for service generates strong incentive to perform high volume of tests and services regardless of whether those services improve quality or contribute to a broader effort to managed care
providers are paid for volume instead of outcomes generating less efficient care
population needs for care
aginging increases spending growth
chronic disease
advancing medical technology
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 tests and treatments
lawsuit awards themselves have minimal impact on the cost of healthcare but the fear of being sued does (overprotecting and treating more thean necessary so spending more)
defensive medicine has a greater impact on healthcare cost and drives overutilization
How do the number of specialist and/or hospital beds in an area impact cost?
if you have more dr, more specialists in community, they have to work so they do more treatment
the more beds/dr thee higher the cost and the higher the utilization
greater access/availability per person makes dr think equipment needs to be used
more access to care doesn’t produce better outcomes to care. what do you see if you see more care?
window for something to go wrong if you do more procedures than necessary
Confronted with healthcare cost rising at a greater pace than GDP, officials trying to fund public programs like Medicare are left with what two economic alternatives?
if we want to bring down cost we decrease/restrict access or reduce reimbursement (increase taxes)
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 healthcare kept increasing relative to what people were earning
employers were not keeping up with the cost of healthcare and small businesses dropped it as an option
rose faster than the pay and couldn’t afford to buy it
what was done following this gap
ACA was created but didn’t solve the problem; the govt was going to subsidize the cost of care for those they can’t afford, and that you couldn’t discriminate against anyone from receiving care
how did we reduce the 45 mill uninsured
subsidized government (tax credits) & allowing insurers to discriminate against those with previous conditions
form of access - financial accessibility & cost (two big things
What are the three categories of payment sources for healthcare in the United States?
public
private
OOP
public payments
(public - tricare, medicaid, medicare) - sources include funding from funding federal, state and local government programs including tricare, medicaid, medicare, Children’s Health Insurance (CHIP)
private payments
employer
payments made by individuals and/or their employters for healthcare premiums which in turn covers costs of payments made by various health plans
includes conventional indemnity plans, preferred provider organization plans (PPO), point of service plans (POSs), health maintenance organizations (HMOs) & catastrophic plans like high ded health plans (HDHPs)
OOP
(pay myself) - payments by individuals who buy individual insurance policies, pay for services themselves, and/or pay for part of those services thorugh copayments and/or deductibles
Describe the continuum of managed care and how it is interpreted.
Left - Indemnity, higher premiums, no control over cost or quality of care. Increases risk for the insurer.
Middle - Preferred Provider Organization (PPO). Do not always fall in the middle of the continuum, depends on the individual plan. Can be free or restrictive.
Right - Traditional HMO (insurer was also the one delivering care), lower premiums, 100% control over cost and quality of care.
What are the changes related to the demand for and use of health insurance over the past 100 years discussed in the text?
60 yrs ago, health coverage was purchased on an individual basis like car insurance and they bought policies to protect them and their families against catastrophic illness
this was when it was not as expensive as today
individuals paid OOP for routine care and used insurance for catastrophic events or protect against income loss
now with increased demand
Modern health insurance plans typically offer a wide range of services, including hospital stays, visits to primary care physicians (PCPs), and other essential health services. This reflects the shift from more basic, limited health insurance plans to ones that cover a broader array of healthcare needs
Both the government (public sector) and private companies (private sector) have become more involved in providing health insurance over time
companies would purchase health insurance plans for their employees, often at a lower cost than individual plans, because the group (i.e., the company’s workforce) benefits from shared risk
insurance systems shifted to a prepaid model, where providers received a set amount of money in advance (e.g., capitation or per-member per-month payments) for providing care to a group of patients, regardless of how many services were used
Pertaining to the model discussed in class, what eventually happens to healthcare outcomes (quality) as healthcare cost increase and what does shifting this curve up represent?
as cost goes up there is only so much that quality can increase to until it plateaus. the only way to shift this curve is to use our resources more efficiently and be more effective to get better quality with the same cost
curve is pushed up, at any point along cost curve, now we get higher quality & requires use of resources more efficiently
What were some of the key characteristics of the uninsured population in the US in 2008
percentage of those without health insurance coverage vary across states
more in states in south and west were more uninsured than those in the midwest and east
without coverage the uninsured
do not have PCP
delay seeking care until they are worse
use hospital ER - most expensive entry point to health care system, to access the system and receive healthcare
all resultsin financial consequences with many not able to pay resulting in medical debt
cost of insurance and job loss are also contributors
ACA & Uninsured
lecture - one of the pushbacks against ACA for ex was that this is just another welfare program for people who are lazy and don’t work
truth - even nicest neighborhoods had people w/ no health insurance
reduced number of uninsured
not by affordability
What does it mean to gain access to care
physical access doesn’t mean you can pay, do they speak my language, do they respect my culture, ect.
access to healthcare is a multifaceted concept involving the physical ability to get care and other facts
what are the facets that determine real access?
availability - having healthcare providers, clinics, hospitals, and other facilities that can meet the needs of the population in a given area
accessibility - ease with which individuals can reach healthcare services
includes physical accessibility, such as the distance to health facilities, as well as financial accessibility, which refers to the affordability of care
affordability - even if healthcare services are available and accessible, they are of little use if individuals cannot afford them
acceptability - how well healthcare services meet the cultural, social, and individual needs of the patient population
accommodation - flexibility of appointment scheduling, wait times, hours of operation, and the convenience of the healthcare setting in general
quality of care - Real access also involves the quality of the healthcare provided
How do the majority of Americans get their healthcare insurance?
employers
when was the “great divide” in healthcare reached and what was it?
a random patient with a random disease consulting a doctor chosen at a random time stood better than a 50-50 chance of benefiting from the encounter
after 1912, PTs expected they would survive the encounter visit and enjoy improved health as a result of the care they got
What two issues related to health policy have been central issues concerning healthcare since the early 1900s?
medical care became more desired because it became more effective leading to expanding utilization & increasing cost
financial accessibility & cost of healthcare
Accessibility and cost
How far back in US history does concern about the cost of care go and have attempts been made to address it?
about 100 years ago
invented insurance, employer based coverage, risk pooling & risk transfer concepts, etc
What factors contributed to the rapid increase in healthcare spending in the early 1970’s
High Medicare expenditures
rapid inflation of the economy
expanses of hospital expenses and profits
changes in medical care: new technology, medications, and conservative approaches to treatment
all the pieces were in place but there was not any control
What act was passed in response to this increase in 1973?
The Health Maintenance Act (HMO) presented by Nixon to congress
Response to health care cost surge as % of GNP
Promoted prepaid helath plans & HMO
Name the most significant piece of healthcare legislation in the last century
Title 18 Social Security Act of 1965
created the Medicare program
How successful was managed care at controlling cost?
They were controlling costs by denying medically necessary services to PTs even in life threatening situations or providing low-quality care
control care however, it still received backlash regarding the restricted care and poor outcomes that occurred
big issue = restrictions that were placed
what happened as a result from this backlash to 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
What happened in the mid 1990’s that affected MCO’s significantly and what has happened to healthcare cost (and premiums) as a result.
many thought managed care was the solution to cost
consumers however had negative views of managed care with concerns of the restrictions imposed and the quality of care that was provided
led to PPOs
those plans that provide unlimited access have issues controlling costs but afford higher quality and those that manage and control costs do so by limiting access and utilization
What did the IOM report “To Err is Human” reveal about the US healthcare system?
building a safer health system - focused on PT safety and brought public’s attention to the fact 44-98,000 deaths occur per year due to medical errors
What is the meaning of the component phrases in the IOM definition of quality?
Health Services - applies to many types of healthcare practicioners and to all settings of care
Populations & individuals - broad scope of healthcare quality & draws attention to different perspectives that need to be addressed
do they or do they not have access to care and whether they are defined by culture, sociodemographics, geography or diagnosis
desired health outcomes - emphasizes the ultimate goal of healthcare which is to improve health outcomes
focuses on patient preferences & values taken into account to make decisions
consistent with current professional knowledge - importance of evidence based practice and staying up to date with the latest knowledge in healthcare
increases the likelihood - recognizes there is always an unknown aspect of care but the services provided are expected to provide more benefit than harm
good outcomes are not always associated with quality because poor outcomes can occur despite the best possible health care
When examining quality issues what are the four problems that present themselves
overuse
underuse
variations in use
misuse
overuse
too much care
occurs when a health service is provided when its risk outweights the benefits or simply has no added benefit
quality problem - treatments are used even with evidence showing it is ineffective or dangerous
overuse of antibiotics, unnecessary surgery, excessive imaging use
underuse
too little care
the needed services are not provided
immunizations, screening, effective meds
variations in use
variations within practice protocols
length of stay, invasiveness of procedures, screenings
misuse
(flaws and errors in technical and interpersonal aspects of care) - when right service is provided badly and an avoidable complication reduces benefits they receive
errors in the delivery of medical care
mistakes in care
wrong meds, misdiagnosis, failure to follow up
What are Donabedians measures of quality and how are they defined?
structure - capacity of health systems to deliver care
number of board certified staff, equipment & facilities
process - interactions bw PTs and clinicians
immunization rates, best practice standards
outcomes - changes in the PT health status as a result of health care interventions
recovery rates, mortality, health status
capacity of health systems to deliver care
number of board certified staff, equipment & facilities
structure
interactions bw PTs and clinicians
immunization rates, best practice standards
process
changes in the PT health status as a result of health care interventions
recovery rates, mortality, health status
outcomes
occurs when a health service is provided when its risk outweights the benefits or simply has no added benefit
quality problem - treatments are used even with evidence showing it is ineffective or dangerous
overuse of antibiotics, unnecessary surgery, excessive imaging use
overuse
the needed services are not provided
immunizations, screening, effective meds
underuse
variations within practice protocols
length of stay, invasiveness of procedures, screenings
variations in use
when right service is provided badly and an avoidable complication reduces benefits they receive
errors in the delivery of medical care
mistakes in care
wrong meds, misdiagnosis, failure to follow up
misuse
What are some examples of models of oversight?
peer review - certification of specialty based on professional training, clinical practices, and/or organizations
accreditation - independent org that use published criteria like assess quality in and accredit provider settings/organizations
acute care, long term care, PC, networkds
inspection - national or regional statutes prescribing levels of competence and/or safety
cqi
continuous quality improvement
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
Which part of Donabedian’s quality conception does CQI focus on
the process part
promotes the view that understanding and addressing factors create variation will produce superior quality
if quality varies you are not in control of the process
understanding and addressing this will create variation in an administrative or clinical process and produces superior PT care quality and organizational performance
Why is the control of variation at the heart of CQI ?
if you dont understand or explain why you are getting good outcomes you are not in control of the system
The more variation, the more waste and inability to consistently produce the outcomes desired
variation is at the heart of understanding what it is you are doing
if you have no control over the system variation occurs on its own
special & common types
What role does measurement and metrics (statistics) play in CQI?
all quality improvement efforts require numerical data because you cannot manage what you can’t measure therefore it is driven by data and evidence rather than subjective judgements, anecdotes or opinions
Why is the role so critical?
because you cannot manage what you can’t measure
All quality improvement efforts require numerical data because you cannot manage what you cannot measure.
what is observed into metrics
measurment
translation of observable events into quantitative terms
measurement
means used to record what is observed
metrics
means used to record observable events
metrics
PDCA
plan
do
check
act
what is pdca
scientific method applied to improvement process and is incorporated into a number of methodologies (six sigma & Lean)
plan
take the process improvement from S phase in FOCUS & create a plan for its implementation
do
implement the process improvement
check
study whether the process is improving using measures identified and measured in U phase of FOCUSa
act
- determine if the process improvement was successful
What are the common elements of quality improvement programs
from lecture - empowering and using the metrics
process focus - understanding and addressing this will create variation in an administrative or clinical process and produces superior PT care quality and organizational performance
customer focus - every effort must be taken to delight them
views any person, group or organization impacted by a process at any point as a customer
data-based decision-making - use of carefully collected data to reduce uncertainty and dependence on uninformed impressions or biases for improving the process
employee empowerment - improvement efforts are often led by teams made up of people who are very familiar with the inner workings of a system or process
those that do the work have a say in improving the work
organization-wide impact - accomplished through coordinated and continous improvement of various operational processes across organizational levles
systemic monitoring and evaluation of various aspects of a project, service or facility to maximize probability that minimum standards of quality are being attained by the production process
it is reactive
quality assurance
about building and executing a quality program
it is proactive
quality improveent
risks whose cost of occurrence is higher than their cost of management and whose occurrence may invoke additional legal sanctions
normally prevented risks - risks whose cost of occurrence is greater than the cost of their management but whose occurrence will be considered only as negligent
prevented risks
risks whose cost of occurrence is only slightly greater than their cost of management
managed risks
risks whose cost of occurrence is less than their cost of management
unprevented risks
risks whose occurrence is unmanageable
unpreventable risks
reduces likelihood of an adverse event or frequency of event
computer files as a back up
risk prevention
used when risk poses significant threat and cannot be prevented or reduced to acceptable levels
risk avoidance
define risk
exposure to adverse possibilities
exposure to the chance of injury or financial loss
emphasis with risk
managment of PT injuries
injuries result in finanacial losses when the PT brings claim for compensation
component steps in the risk management process
Identify the risk - discern which risks are present; become aware of all potential exposures
analyze the risk - in terms of probably loss, frequency & severity
develop alternative risk control & risk financing techniques & choice of the proper technique or combination
implement the chosen technique
monitor program’s effectiveness and modify/improve as risks change over time
What are some sources that can help identify risk in a setting?
self observation - walking around, looking at incident reports, reports from accredited bodies, etc.
internal incident reports
reports and surveys from accrediting bodies (JCAHO, NCQA, etc.)
risk identification from insurers
professional practice guidelines
regulatory guidelines & 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?
how much is it going to cost
more cost to manage - as risk to individuals or cost goes up or risk to reliability does it is worth spending more on this and finding an ideal point where we spend te right amount (alarp)
if it was minimal risk we may manage as best we can or choose to do nothing about it
how much is it worth to prevent this thing from happening
if it does and its low cost, do our best to not have it happen
if it does and ti will kill everyone, even if likeliness is low, it might happen so we spend money on it
James Reason’s explanation of the cause of errors – the basis for the “Swiss Cheese Model” and “Blame” culture
errors in healthcare happen not due to a single even or one person’s error but due to a combination of risk factors within the system itself that have aligned and made the error more likely to happen
swiss cheese - holes in the system align and open up opportunities for errors to happen
What is ALARP
as low as reasonably practical
how to determine what we want to spend; used to determine the cost/benefit of an action. does the risk outweigh the cost
we want the level of risk and amount of money spent to be appropriate
why is ALARP used
risks should be reduced to a level that is as low as is reasonably practicable. This involves considering the costs, time, and effort required to reduce the risk further, balanced against the potential benefits
seeks to reduce risks to a point where the remaining risk is acceptable considering the potential consequences
If the cost of reducing the risk outweighs the benefits, the risk might be deemed “as low as reasonably practicable.”
part of the legal and regulatory framework to ensure risks are managed effectively and responsibly
provides a structured way to make decisions in complex scenarios, guiding risk managers to ensure that the most practical and effective risk controls are implemented without unnecessarily excessive measures
What is the “Duty of Reasonable care” and how does such a ‘duty” come about?
to provide the standard of care
comes into existence when you accept someone as a PT
doesn’t have to have money exchange for this to come
refers to the obligation a healthcare professional has to provide treatment to a patient with the same level of competence, attention, and skill that would be expected from other professionals in the same field, given the circumstances
ensures that patients receive a level of care that is consistent with what is considered appropriate and necessary for their condition
arises when a healthcare professional accepts someone as a patient, whether it’s through an in-person visit or a remote consultation, like over the phone.
Importantly, this duty can be established even if no payment is exchanged. Simply offering advice or care creates this professional responsibility
Is any form of payment necessary for the duty of reasonable care to come about?
no
How does ongoing training and continuing education support patient care risk management?
allows you to provide standard of care because you have current knowledge
The two most important factors influencing a practitioner’s ability to reduce exposure to liability
awareness & education
What elements must be present for a tort of negligence to be viable/pursued?
legal duty must exist between the practitioner and plaintiff
breach of legal duty must exist
proximate cause (cause and effect relationship) must exist bw breach of duty and injury
an actual loss or damage must result from the injury
What is the most common claim against audiologists?
unintentional tort of negligence
define Malpractice?
negligence or carelessness of a professional person
professional’s improper or immoral conduct in performance of duties done either intentionally or through carelessness or ignorance
those who were sick would seek coverage and those who were healthy did not
adverse selection
increase in the hazards presented by a risk arising from the insured’s indifference to loss because of the existence of insurance
if you have coverage you dont care what it costs youll just go and go as much as you want and dr treats without concern for cost because of the guaranteed source of payment
moral hazard
step by step method that leads to the discovery of a fault’s first or root cause
thorough and credible
root cause analysis RCA)
results from acts of commission or omission
injury you cause (iatrogenic)
any harm or injury caused to a patient due to medical care, treatment, or a healthcare intervention
adverse event
unexpected occurrence that involves death or serious physical or psychological injury or risk thereof
sentinel event
measurable capability of a process/procedure to perform its intended function in the required time under commonly and uncommonly occurring conditions
reliability
HMO stands for
health maintenance organizatio
PPO stands for
preferred provider organization
coinsurance
% of the allowed amount
copay
set amount of the allowed amount
deductible
amount PT must pay before insurance will pay anything
Emergency Medical Treatment and Labor Act (EMTALA) law
If you show up at the ER they have to treat you
what is risk transfer
We pay (health, automobile, etc.) another party to assume the risk that we may get sick or get in an accident and if we do its their responsibility to cover that based on the contract written
self insured
baring the risk yourself
why didn’t consumer driven healthcare stick
combine a high-deductible health plan with a health savings account
encourage consumers to consider the cost and quality of their healthcare choices
what did the affordable care act do
Didn’t change quality
Didnt control cost
Increased access - gave more people access and reduced quality and didn’t address cost because it continues to increase
why is direct access to audiologists important and should be considered
Direct access eliminates cost, patient time, etc.
financial accessibility
Ability to pay for healthcare and premiums to get the insurance
foundational concepts that underpin how insurance works
Risk is transferred from the individual to the group
Cost of any covered losses are shared by the group
Coinsurance and Co-payments are similar in that
They are always equal
They are billed to the patient after the insurer portion has been paid
They are both set amounts
They are a portion of the allowed amount owed by the patient
They are a portion of the allowed amount owed by the patient
Which government program helps older Americans over 65 pay their health care costs?
Medicare
WIC
Social Security
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.
Appears on the far right of the continuum of managed care
Appears close to traditional indemnity plans on the continuum of managed care
Appears close to traditional HMO’s on the continuum of managed care
PPO’s always fall in the middle of the continuum of managed care
Appears close to traditional indemnity plans on the continuum of managed care
Prior to the backlash against managed care in the 1990’s, it can be said that
Limitations on services was not a factor in rising resentment against HMO’s
Managed care failed to meet cost control expectations
Managed care beat the predicted rise in cost estimates by controlling cost and utilization
Managed care plans were of little help to employers in keeping down premium prices
Managed care beat the predicted rise in cost estimates by controlling cost and utilization
The inclusion in the IOM definition of quality of the terms populations and individuals draws attention to
The special efforts needed to prepare for epidemics and pandemics
The IOM’s desire to emphasize the need for person-centered healthcare
The need of all populations to have access to necessary and appropriate services
The importance of getting everyone the outcomes they expect
The need of all populations to have access to necessary and appropriate services
US payment type in 1800s
private insurance
capitation
captiation
pay a set amount of money to take a set number of individuals for a set period of time - shifting risk to the provider
In 1929, a group of Dallas school teachers contracted with Baylor University Hospital to receive up to 21 days of inpatient care a year for monthly payments of 50 cents
capitation
fee for service models
indemnity
pay a premium & they agree to pay the medical bills leaving the insurance on the hook for the cost of the care and you only pay a %
You pay a premium and the insurer bears the risk so you can go wherever you want and sometimes have to pay a %
the more the dr does the more they make; dr sets the price
BCBS plans showed commercial insurers that adverse selection could be overcome by focusing on insuring young healthy groups of employed workers
true
hill burton act
made direct government grants for communities to build hospitals
Increased access to care & hospital beds
Value of all the goods and services we produce in the country every year
GDP
prospective payment systems
the hospital knows the amount they are going to get paid per patient based on the diagnostic related group the patient is labeled with
retrospective payment system
not in managed care; all other before managed care
You get paid for the services you do; can make more $ per PT
You give the treatment and see the patient and bill after the fact; insurance will pay you after you see the PT and treat them - no utilization control
practices and processes used to influence the use of health care services
Pre auth
Case management
Coverage restrictions etc.
utilization management programs
how are indemnity plans and lax PPO plans different
Indemnity plans you can literally go wherever and see whoever tf you want and there are no networks and the insurance will pay; has a set percentage you are reimbursed
PPO lax still has networks so you can see OON providers but it will cost more usually have copays coins deductable
HMOs
DABROWSI
control cost and quality
control everything
money that might be lost due to insuring people who utilize
health care services
risk
what are the 3 constructs of quality
structure
process
outcome
structure (quality construct)
physical and organizational elements that are in place to provide care
environment, resources, organizational framework, dr, nurses, availability of technology, training, etc.
process (quality concept)
actions or activities that take place during the delivery of care
how healthcare is provided, patient assessments, diagnosis, treatment, follow up
outcome (quality construct)
results of healthcare services, or the impact of the care provided on patient health and wellbeing
Patient recovery or improvement after treatment.
Rates of complications, infections, or readmissions.
Patient satisfaction and quality of life.
Mortality rates and overall health outcomes.
Long-term effects, such as survival rates or chronic disease management
what are the pillars of access
avaliability
affordability
acceptability
accessibility
availability (access)
Are healthcare services physically present and enough to meet demand
affordability
Can people afford the care they need, without excessive financial burden
acceptability
Do healthcare services respect cultural, social, and individual preferences
accessibility
Can individuals physically and logistically reach the healthcare services they need?
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 continue but the evidence of the impact of ACA shows that it has had no impact on employment coverage
shifting from traditional HMOs to PPO
premiums have gone up
Normal or natural variations in process outputs that are due to purely chance
Common causes (variation)
Variation in process outputs due to special factors (tools wearing out)
Special causes (variation)
