Practice Development Midterm Flashcards
Currently (2023), what percent of its GDP does the United States spend on healthcare?
17.6%
What does GDP stand for and what does it mean?
Gross Domestic Product & it’s a measure of the value of all goods and services produced in a country during a specific period of time (1 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
- Risk transfer
- Risk pooling
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 costs?
New Technology & Aging Population
Distinguish between the effect of malpractice lawsuits and the impact of defensive medicine.
defensive medicine has a greater impact on healthcare costs, drives overutilization
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
How do the number of specialists and/or hospital beds in an area impact cost?
If you have more doctors/specialists in the community, they can do more healthcare (More OB Doctors = More OB appts).
The more beds/doctors the higher the cost and the higher the utilization. Greater access/availability per person makes doctors think the equipment needs to be used.
Confronted with healthcare costs rising faster than GDP, officials trying to fund public programs like Medicare are left with what two economic alternatives?
- decrease access
- reducing reimbursement rates
raise taxes - tax more to pay for more. this is another alternative but everyone would much rather the first 2 options.
Between 1960 and 2006, the gap between healthcare 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?
The gap increased over time which is how we ended up with 44 million people being uninsured. The cost of healthcare rose faster than the GDP, which meant people couldn’t afford it and stopped paying for health insurance (aka stopped being insured). Healthcare costs were rising but people’s salaries were not.
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 are the three categories of payment sources for healthcare in the United States?
- public - federal, state, & local gov programs like medicare, Medicaid, & tricare
- private - made by individuals &/or employers
- out of pocket
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?
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 of healthcare has increased meaning there is a higher demand for health insurance
What does it mean to gain access to care?
gaining access to care = taking steps to receive healthcare services like finding a provider, getting insurance, & making an appointment
having access to care = availabilty of healthcare services within reach, whether or not you use them
-having access does not mean that you gain the access!
What are the facets that determine real access?
service availability
utilization of services
barriers to access
relevance and effectiveness and equity
Pertaining to the model discussed in class, what eventually happens to healthcare outcomes (quality) as healthcare costs increase and what does shifting this curve represent?
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
What were some of the key characteristics of the uninsured population in the US in 2008?
- % of people w/o health insurance coverage varies across states (more in south & west)
- they use healthcare systems differently, they don’t usually have a PCP and they delay seeking care until they get sicker which results in serious financial consequences (unable to pay bills & medical debt)
- the cost of insurance & being jobless are also major contributers to being uninsured
How do the majority of Americans get their healthcare insurance?
Through their employer
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 Affordable Care Act more people got insurance, we went from 44 million people uninsured to 15 million.
What type of access was addressed by the affordable care act?
financial accessibility
When was the “great divide” in healthcare reached, and what was it?
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
What two issues related to health policy have been central issues concerning healthcare since the early 1900s?
Financial Accessibility & The Cost of Healthcare
What is adverse selection?
those who were sick would seek coverage and those who were healthy would not
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
invented insurance, employer-based coverage, risk pooling, risk transfer
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?
Health Maintenance Act (HMO)
promoted prepaid health plans as a more cost-effective way to provide health care services
Name the most significant piece of healthcare legislation in the last century.
Social Security Act of 1965 - Created Medicare
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 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
What happened in the mid-1990s that affected MCOs significantly and what has happened to healthcare costs (and premiums) as a result?
- cost did not rise as much as we were expecting in the 1980’s due to HMO’s (HMO=type of MCO)
- premiums went up when we switched from HMO to PPO
- they are bearing greater risk so they are charging more
What did the IOM report “To Err is Human” reveal about the US healthcare system?
44,000-98,000 people die each year from medical errors
What is the meaning of the component phrases in the IOM definition of quality?
- a wide array of services (mental & physical health)
- good quality = increases likelihood for good outcomes
- highlights the link b/w care that is provided & its effect on health
- healthcare professionals need to be prepared to revise the way they practice as new knowledge is generated
What are the 4 problems in quality of healthcare?
underuse (too little care)
overuse (too much care)
variation in use (variations within practice protocols)
misuse (mistakes within care)
What are Donabedian’s measures of quality and how are they defined?
Structure - the capacity of health systems to deliver care. the number of board-certified staff, equipment, and facilities.
Process - interactions b/w patients and clinicians. Immunization rates & best practice standards.
Outcomes - changes in the patient’s health status as the result of health care interventions. Recovery rates, mortality, & health status.
What are some examples of models of oversight?
Peer Review: certification of specialty based on professional training, clinical practices, and/or organizations
Accreditation: Independent organization that uses published criteria such as assess quality in and accredit provider settings/organizations (i.e. acute care, long term care, primary care, networks)
Inspection : National or regional statutes prescribing levels of competence and/or safety
Which part of Donabedian’s quality conception does CQI focus on?
Process
Why is control of 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
2 types of variation - common (small) and special cause (large)
What role do measurement and metrics (statistics) play in CQI? Why is the role so critical?
foundational and central to the process. can not control quality without measuring the data consistently and accurately.
What is 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
What is PDCA?
Plan, Do, Check, Act
The improvement cycle
What are the common elements of quality improvement programs?
- empowering the people doing the work
- use of metrics/measurement
What is the difference between quality assurance and quality improvement?
quality assurance - retrospective, at the end. not changing anything just saying what the outcome is.
quality improvement - prospective, how do we produce better outcomes and have fewer bad outcomes? wants to change the system so we have less bad outcomes
What is the definition of a risk?
exposure to the chance of injury or financial loss (adverse possibility)
Tell me about the 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
How does the cost of risk management for any given risk play into the equation in determining if the effort is worth it?
If it costs more to manage than it costs to endure. As the cost/risk of liability goes up we want to decide what is worth spending more money on.
James Reason’s explanation of the cause of errors – the basis for the “Swiss Cheese Model” and “Blame” culture.
-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
What is ALARP and why is it used?
“As Low as Reasonably Practicable”
we want the chance of risk to be as low as possible but we need to consider cost and time that would be needed to control it to decide if it is worth it
What is the “Duty of Reasonable care” and how does such a ‘duty” come about?
Anytime a healthcare professional treats a patient they have a duty to reasonable care. The duty comes into being when you accept someone as a patient by seeing them as a patient.
Is any form of payment necessary for the duty of reasonable care to come about?
They do NOT have to pay you for this to come into existence.
How do ongoing training and continuing 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 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?
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
What is a tort?
civil wrong committed by one person against another person
-unintentional tort is the most common civil litigation to be brought against us
What is the definition of Malpractice?
negligence or carelessness of a professional person, can either be civil (tort) or a criminal concern
How to avoid a malpractice suit?
understand state law, understand hospital and institution policies, communicate with the patient, ongoing risk management and document!!
What is Root Cause Analysis?
a step-by-step method that leads to the discovery of a fault’s first or root cause. the process should be “thorough and credible.”
What is an 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
What is a Sentinel Event?
an unexpected occurrence that involved death or serious physical or psychological injury or risk
What is 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
IMPORTANT ***
What is a co-payment?
a set amount of money you pay out of pocket when you get a medical service and the insurance covers the remaining amount of the allowed. it is a way to share costs between you and your insurance
What is coinsurance?
set % amount you pay out of pocket and the insurance covers the remaining %
cost-sharing arrangement in health insurance where the PT pays a % of the cost of healthcare service and the insurance company covers the remaining % to the allowed amount
typically applies after PT meets their deductible
a percentage of the allowed amount
What is a deductible?
amount you pay before insurance will pay anything
set amount of money you must pay out of pocket for covered healthcare services before your health insurance starts to share the costs
What is a prospective payment?
A method of reimbursement in which healthcare providers are paid a predetermined, fixed amount for each case or patient, regardless of the actual cost of care.
What are captivated costs?
set amount to care for a set number of people for a set period of time
Set amount of $, for a set amount of patients, for a set amount of time.
A capitated contract is a payment arrangement in healthcare where a provider is paid a fixed amount per patient for a specific period (usually monthly), regardless of the actual number or cost of services provided to the patient.
(likely intended to be Capitated Costs): A payment arrangement where a healthcare provider is paid a set amount per patient per period (e.g., per month) regardless of the number or type of services provided. This is often used in managed care systems to control healthcare costs.
What is moral hazard?
The concept is that individuals may take more risks or use more healthcare services when they are protected from the full cost of those services, such as when they have insurance coverage. It highlights the potential for increased utilization due to reduced personal financial responsibility.
if you have the coverage you do not care what it costs, you just go and go as much as you want and the doctor treats you without concern for cost because of the guaranteed source of payment
Moral hazard refers to a situation in which an individual or organization is more likely to take risks because they do not bear the full consequences of their actions. This typically occurs when one party in a transaction is shielded from risk, leading to potentially careless or irresponsible behavior.
What are the 3 pillars of healthcare?
access
quality
cost
What is the hill-burtons act?
passed in 1946 by Congress and made direct government grants for communities to build hospitals, leading to an increase in access to care and hospital beds
What is the concept of insurance?
Risk
Pulling - multiple members put into towards their health insurance
Those with greater health have less risk and are paying into the insurance
We want to have more healthy people = more money
This leads to being more likely to cover everyone who is sick
If everyone is sick it won’t work as well
What is a contracted rate?
allowed amount
what the insurance will pay the physician for the service
Coinsurance & Copayments are similar in that?
they are a portion of the allowed amount owed by the patient
not both set amounts bc coinsurance is a % so it’s not a set amount, it varies
Which government program helps older Americans over 65 pay their healthcare costs?
Medicare
A very generous PPO plan that makes provision for patients to see any provider out of network and only pay 15% of the providers bill.
appears close to traditional indenmity plans on the continuum of managed care
Prior to the backlash against managed care in the 1990’s it can be said that?
managed care beat the predicted rise in cost by controlling cost and utilization
The inclusion in the IOM definition of quality in the terms populations and individuals draws attention to
the need of all populations for have access to necessary and appropriate services
What are the 3 pillars of healthcare?
cost, quality, & accessibility
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
How can quality oversight occur?
peer review, accreditation and inspection
