Physicians Flashcards
Physician services as % of medical spending trend. How do they impact spending directly and indirectly?
Physician services as % of medical spending trend. How do they impact spending directly and indirectly?
- stable
-
directly:
- patients visiting the doctor
-
indirectly:
- prescribe medicines
- Decide to admit patients to a hospital
Over time there’s been a shift away from solo practices and smaller group practices towards larger group practices
Why?
3 advantages of group practices
Over time there’s been a shift away from solo practices and smaller group practices towards larger group practices
Why?
- impact of increases in managed care
Physician groups can
- better negotiate payment rates with insurers
- handle the risk associated with capitated payments
- pool the administrative resources necessary to handle increasingly complex contracts
_ in the number of physicians per capita has been concentrated in the number of _
of physicians per 1000 is _ in US compared to other countries
Growth in the number of physicians per capita has been concentrated in the number of specialists
of physicians per 1000 is lower in US compared to other countries
Physician Supply: Shortage v. surplus
Too few physicians? (2)
Too many physicians overall? Too many specialists?
Physician Supply: Shortage v. surplus
Too few physicians?
- Poor access to care (main reason)
- High prices (or lower quality) due to a lack of competition (secondary reason)
Too many physicians overall? Too many specialists?
- Higher spending potentially due to “supplier induced demand”
Increased in med school enrollment (2)
Increases in enrolled
- Med school subsidies from government
- New med school openings
Concerns that the match system benefits the residency programs too much (3)
-
Compensation
- Residents have little ability to negotiate with programs; programs don’t really compete with salary and benefits
-
Hours
- Residents work long hours
-
Quality and errors in work
- Long hours during residency programs also raise issues regarding quality/errors
Physician salaries in US and other countries
Specialist _ Primary care
Medicine _ other occupations
US _ other countries
2 reasons why this might be
Physician salaries in US and other countries
Specialist > Primary care
Medicine > other occupations
US > other countries
Why?
- the private orientation of the financing of health care in the US
- higher amounts of student loan debt incurred by graduates of US medical schools
Explain physicians’ real income increase or decrease
Explain physicians’ real income increase or decrease
Nominal change in income - change in price inflation
Why did real physician incomes fall between 1995 and 2003?
what kind of doctors were impacted the most?
Why did real physician incomes fall between 1995 and 2003?
- private and public insurers reduced payments
what kind of doctors were impacted the most?
- decreases in real income were larger in magnitude for primary care physicians compared to specialist
decreasing real physician incomes between 1995-2003. How did private contribute? How did public contribute
decreasing real physician incomes between 1995-2003 (slowed growth)
Private
- Increase in managed care
Public
- SGR caused small increase in Medicare fees
- state budgetary pressures small increase in Medicaid fees
What caused the increase in physician real income in the early 2000s?
What caused the increase in physician real income in the early 2000s?
- retreat from more aggressive forms of managed care
describe the 2 major factors that impact the number of medical school applicants?
increase
decrease
describe the 2 major factors that impact the number of medical school applicants?
Increase
- federal policy to increase the number of physicians after the introduction of Medicare and Medicaid
- Income Rises
Decrease
- falling incomes
- physicians became less autonomous due to the rise of managed care utilization review
IOM definition of quality:
The degree to which _ for individuals and populations increase the likelihood of _ and are consistent with current _
IOM definition of 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
Three types of problems regarding quality:
Three types of problems regarding quality:
- Underuse: the failure to provide an appropriate service
- Overuse: a service’s risk outweighs its benefit
- Misuse: the right service provided incorrectly
Example of Overuse: The Dartmouth Atlas Data
Example of Overuse: The Dartmouth Atlas Data
- additional spending on Medicare isn’t generally associated with relatively better outcomes or relatively better quality of care*
- supplier-induced demand (agressive)
Examples of Misuse (2)
Examples of Misuse (2)
- Medical errors lead to preventable deaths
- never events
Two ways to incentivize quality for physicians
Two ways to incentivize quality for physicians
- Report cards
- Pay for performance
Describe the argument for report cards
What?
Why?
Impact?
What? Report cards
- provide information to consumers on provider quality
Why?
- help patients select providers
Impact?
- In result, cause competing providers to improve quality scores
- ex: mortality rate in surgeons
How can providers and health insurers game report cards?
How can providers and health insurers game report cards?
Providers
- Avoiding sicker patients (unless measures are risk adjusted)
- Avoiding harder classes
Insurers
- Focusing on what’s actually measured
- Teaching to the test
Describe p4p
P4P
Efforts to link the insurer’s payment to the provider’s quality
- The rationale is to provide financial incentives to providers to improve their quality
Until recently, Medicare payments haven’t distinguished high vs. low quality. Why? (2)
- Think medicare vs private insurance
Until recently, Medicare payments haven’t distinguished high vs. low quality. Why? (2) (private vs public)
Networks
- Medicare generally accepts any willing provider, while private insurers have the ability to establish networks based in part on the providers quality
Payment
- Medicare payments, at least historically with the DRG and RBRVS payments have been uniform across providers, while private insurers would have the ability to pay more to higher quality providers and less to lower quality providers
Potential issues with p4p?
- Reward
- Measuring quality (3)
Potential issues with p4p?
Reward
- Reward overall quality or improvements in quality?
Measuring quality (3)
- Health outcomes
- need risk adjustment
-
Process best practices
- Flexible w/ research or stifle innovation
-
Patient experience
*
Even if EHRs are cost-effective, the incentives for adoption might not be aligned.
Goal?
Why slow adoption?
Solution for slow adoption?
Even if EHRs are cost-effective, the incentives for adoption might not be aligned.
Goal?
- EHRs might be helpful in collecting the data for quality measures, (help improve quality)
Why slow adoption?
mismatched incentives
- Medical providers generally incur the cost
- taxpayers and policyholders that would benefit the most from having these EHRs in place
Solution for slow adoption?
- Grant money (HITECH provision stimulus)
- Demonstrating meaningful use
Medical Malpractice
Two reasons for allowing civil claims in the legal system
Medical Malpractice
Two primary reasons for allowing civil claims in the legal system
- Risk of a jury award ought to help deter provider’s negligent behavior
- Jury awards ought to financially compensate the victims for the losses incurred
Evidence of too few and too many malpractice claims. Explain
Evidence of too few and too many malpractice claims. Explain
too few
- Many of the victims of negligence don’t actually sue
too many
- not every one of these people filing claims is truly a victim
Increase, decrease, stable?
of awards:
Size of typical (median) awards:
Size of largest awards:
Increase, decrease, stable?
of awards: stable
Size of typical (median) awards: stable
Size of largest awards: increased
Tort Reform proposals
Why?
Result?
Tort Reform proposals
Why?
large jury awards are inappropriate
Result?
Many states have passed laws to limit the size of jury awards
CBO estimate of tort reform impact on healthcare spending
why? (2)
CBO estimate of tort reform impact on healthcare spending
- A federal tort reform would cause a 0.5% reduction in healthcare spending
why? (2)
- Reduction in liability premiums providers pay
- Reduction is utilization of “defensive medicine”
Describe defensive medicine
Describe defensive medicine
doctors order tests, procedures, or visits, or avoid certain high-risk patients or procedures primarily because of concern about malpractice liability
Describe tort reform: Safe Harbor
Safe harbor
provider immune from being sued if adhering to evidence-based medicine
Describe tort reform: medical courts
Medical courts
use medical experts to judge malpractice, no jury
