Module 10 lecture, part 2 Flashcards

1
Q

What is defensive medicine?

A

Unjustified medical tests and txs done for self-protection against the possibility of litigation
Along with malpractice insurance, this is costly and inefficient

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2
Q

How does fraud and system abuse contribute to cost escalation?

A

Knowing disregard of the truth
Major problem in Medicare and Medicaid
Falsified billing claims or cost reports
Unnecessary svcs provided
Upcoding: billing for a higher-priced svc when a lower-priced svc was delivered
Receiving kickbacks for referrals and self-referrals

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3
Q

How do practice variations contribute to cost escalation?

A

Geographic variations in tx patterns and utilization
Signal gross inefficiencies in the system and unfairness
Compromise both cost and quality

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4
Q

What are the two main approaches to cost-containment?

A

Regulatory approaches
Competitive approaches

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5
Q

Aspects of the single-payer system in other industrialized countries

A

Global budgets
Top-down control over total expenditures

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6
Q

Aspects of fragmented approaches in the US

A

No system-wide planning and controls
A combination of gov’t regulation and market-based competition
Some regulatory cost control: not comprehensive
Bottom-up cost control
-Providers and MCOs determine own fees and premiums
Total expenditure determined by competition created by employers and MCOs

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7
Q

What are the regulatory approaches of cost containment?

A

Supply-side controls (health planning)
Price controls
Peer review (for utilization control)

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8
Q

Where does restriction occur in supply-side controls?

A

Restriction on capital expenditures
-Certificate of need (CON) statutes by state legislation
Restriction on supply of physicians
-Entry barriers for foreign medical graduates

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9
Q

Types of price controls

A

DRG-based PPs: shift of costs from inpt to outpt sector
Medicare’s use of various reimbursement methods
Pay for performance payments

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10
Q

Definition of peer review

A

The general process of medical review of utilization and quality by or under the supervision of physicians

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11
Q

Aspects of quality improvement organizations

A

Evolved from peer review organizations (PROs) from 1984
Statewide private organizations
Review by physicians and other health professionals who are paid by federal gov’t
To review care provided to Medicare pts
Is care reasonable? Necessary? Provided to the most appropriate setting?
Can deny payment if care not necessary or appropriate

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12
Q

What are competitive approaches to cost containment?

A

Demand-side incentives
Supply-side regulation
Payer-driven price competition
Utilization controls

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13
Q

Aspects of demand-side incentives

A

Cost-sharing by consumers leads to a self-rationing mechanism
RAND experiment: cost sharing leads to low utilization, no effect on health

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14
Q

Aspects of supply-side regulation

A

Antitrust laws: anticompetitive practices can be illegal
MCOs and HC orgs should be cost efficient to survive

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15
Q

What are the two levels of payer-driven price competition?

A

Employers shop for value in health insurance plans
Managed care shops for best value from providers

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16
Q

Aspects of utilization controls

A

Employed by MCOs
Cut some of the unnecessary or inappropriate svcs
MCOs overcame the information gap that pts face

17
Q

Definition of access to care

A

The ability to obtain needed, affordable, convenient, acceptable, and effective personal health svcs in a timely manner
Whether an individual has a usual source of care
The ability to use HC svcs
The acceptability of particular svcs

18
Q

Key implications of access to care for health and HC delivery

A

A determinant of health
A benchmark in assessing effectiveness of the HC delivery system
Reflects equity of HC delivery
Linked to quality of care and the efficient use of needed svcs

19
Q

Factors affecting HC utilization according to the access framework by Anderson (1968) and Aday et al (1980)

A

Health need
Predisposing conditions: socio-demographic characteristics
Enabling conditions: individual’s means to use medical care
Health policy characteristics
Health care delivery system’s characteristics

20
Q

Access framework by Docteur et al (1996)

A

Updated for managed care environment
Two-stage process of access to care:
-1st stage: selecting among available health plans
-2nd stage: seeking medical care, constrained by plan-specific and non-plan factors
Accounts for ppl enrolling, staying, and disenrolling
Links actual utilization with clinical and policy outcomes

21
Q

What are the dimensions of access?

A

Availability
Accessibility
Affordability
Accommodation
Acceptability

22
Q

Avalibility and access to care

A

Fit between svc capacity and individual’s requirements

23
Q

Accessibility and access to care

A

Fit between the locations of providers and pts

24
Q

Affordability and access to care

A

Individuals’ ability to pay

25
Q

Accommodation and access to care

A

The fit between how resources are organized to provide svcs and the pt’s ability to use those svcs

26
Q

Acceptability and access to care

A

Compatibility between pts’ attitudes about provider’s personal and practice characteristics
Providers’ attitudes toward clients’ personal characteristics and values