US healthcare system

Question 1

When and where was the first medical school established?

Answer 1

1765, College of Philadelphia, now UPenn

Question 2

What year were Medicare and Medicaid created?

Answer 2

1965

Question 3

What is a DRG?

Answer 3

A diagnosis related group, which is a lump sum for treatments based on the average cost. This was an effort to move away from FFS.

Question 4

What is the distribution of PCPs and specialists in the U.S.?

Answer 4

1/3 are primary care providers

2/3 are specialists

Question 5

What were the 3 main goals of the ACA (2010)?

Answer 5

1. Expand coverage and Medicaid: 60 million people were uninsured in 2009.
2. Lower costs: fight fraud and abuse and build incentives to have “value based” care
3. Improve healthcare: innovation in delivery and payment models, quality improvements, bundled payments, and better coordinate/manage speciality primary care.

Question 6

As of 2020, how many Americans still lack access to healthcare?

Answer 6

30 million people are uninsured, 100 million people are underinsured

Question 7

What %GDP does the U.S. spend on healthcare?

Answer 7

17.5 or 18%

Question 8

What the public and private options for healthcare in the U.S.?

Answer 8

Public: Medicare, Medicaid + CHIP, the VA, the IHS, Tricare
Private: employer-based insurance, individually purchased (11 million of these are in exchanges)

Question 9

How do payments for care work in the U.S.?

Answer 9

Hospitals receive DRGs (FFS)
Physicians receive FFS based on the relative value unit: how sick is the patient? What resources did it take to treat them? There are 6 levels of compensation.

Question 10

What are Alternate Payment Models?

Answer 10

Introduced by the ACA. 1/3 of all healthcare payments are APM although only 1/6 had downside risk. Bundled payments an option as well.

Question 11

How is the readmission rate in the U.S.?

Answer 11

Very high. 1 in 5 patients return for heart failure. Higher readmission and higher complication rates means less money.

Question 12

How many hospital beds are there in the U.S. per 1000 people?

Answer 12

2.4 beds/1,000 people

Question 13

What is the average length of stay in the U.S.?

Answer 13

5.4 days

Question 14

Do hospitals receive financial penalties for readmissions or hospital acquired conditions?

Answer 14

Yes, DRG model.

Question 15

How is ambulatory care financed?

Answer 15

Mostly FFS, there is some capitation for primary care with pay for performance.

Question 16

How much of the U.S. healthcare cost burden attributed to managing chronic illnesses?

Answer 16

80% of ALL costs

Question 17

Generally, how is the U.S. system financed?

Answer 17

50% public, 50% private

Question 18

What are some challenges of the system?

Answer 18

Costs, low value care
Coverage
Admin complexity
Clinical coordination complexity (primary care/specialists issues)
EHR challenges (there is no single EHR system)
Provider and employee burnout
MD and RN shortages 
Poor quality, safety, and outcomes
Equity of access and outcomes

Question 19

What is defacto rationing?

Answer 19

The wealthy can purchase as much care as they want. This is not the reality for lower and middle income individuals. Because of poor access, the U.S. is essentially rationing care

Question 20

What is the total avoidable death toll in the U.S.?

Answer 20

30k die annually as a result of a lack of care
200k die because of medical errors
300k avoidable deaths from issues accessing care for chronic diseases

Question 21

Out of $5, how much goes to healthcare?

Answer 21

Almost $1

Question 22

How much do we spend per capita?

Answer 22

$10,500 (OECD average is $5,700)

Question 23

What percentage of costs can be attributed to administrative overhead?

Answer 23

25%

Question 24

In 2019, how many Hispanic, Black, and White people were uninsured?

Answer 24

Hispanic people = 21%
Black people = 11%
White people = 7%

Question 25

When surveying Americans, Germans, Canadians, and UK, how many respondents said cost is a barrier in accessing care?

Answer 25

UK = 7%
US = 33%
Germany = 7%
Canada = 15%

Question 26

In terms of quality outcomes, where does the US rank?

Answer 26

37

Question 27

What are the maternal and infant mortality rates?

Answer 27

MMR: 17 per 100,000 births
**this rate is worse among Black women, who die at 4x the rate when compared to White women
IMR: 5.8 per 1,000 births

Question 28

What is the risk of death from non-communicable diseases?

Answer 28

13.8%

Question 29

What is the rate of avoidable deaths per 100,000 people? (preventable mortality)

Answer 29

112 per 100,000

**preventable mortality is perhaps the best indicator of healthcare delivery quality, as opposed to other SDOH

Question 30

What is the cancer survival rate?

Answer 30

89%

Question 31

How many insured Americans experienced wait times longer than 2 months to see a specialist?

Answer 31

16%

Question 32

Why does the US perform poorly?

Answer 32

1. A high percentage of uninsured people (drives outcomes)
2. Admin inefficiency (drives cost): numerous health plans offered, separate systems
3. Poor coordination and chronic care management
4. Lack of primary care performance
5. Lack of investment in SDOH (healthcare and social systems are split)
6. Acute care “sick” system
7. FFS system promotes overuse and volume rather than value
8. Unequal access/inequity
9. No central governance agency to coordinate system components and resources
10. Multiple payers with interests that often compete
11. Excessive waste
12. Underuse errors/poor quality of care
13. Misuse errors/medical errors

Question 33

What is the total health service and social service expendiatures?

Answer 33

16% GDP on health services

13. 3% GDP on social services
    * **most other OECD countries spend more on social services and less on health services

Question 34

What are the biggest creators of waste in the U.S. system, and how much money do they generate in waste?

Answer 34

In total, $800B or 25% of total costs

• Admin complexity, $250B
• Failure of delivery, $100B
• Failure of coordination, $50B
• Overtreatment, $75B
• Pricing failures, $230B
• Fraud, abuse, $60B

Question 35

What is the admin overhead for Medicare versus private providers?

Answer 35

Medicare has a 5% overhead. Private insurance has a 25% overhead.

Question 36

What is “no value” care?

Answer 36

Treatments are being done, but they should not be

Question 37

What incentives does the FFS system create?

Answer 37

Volume, poor coordination, overdiagnosis and overtreatment (there are more risks to this than benefits) , and it drives expenses upward

Question 38

How many Medicare patients receive “no value” care each year?

Answer 38

25%

Question 39

What is the craftsman model?

Answer 39

• No organized system
• Consists of individuals
• Much variation in practice and outcomes
• Little teamwork
• Low reliability
• Individual actors

Question 40

What is a manual system?

Answer 40

Some regional or group processes present

Question 41

What is a production system?

Answer 41

• Consistent approaches and processes present
• Move to equivalent actors, aka one person is able to replace another
• High reliability

Question 42

What is the triple aim?

Answer 42

Improved population health
Reduced per capita costs
Better patient care: experience, quality, access

Question 43

How is value assessed?

Answer 43

Value = quality/cost
Value = quality (O + S + S2) / Costs
Value = A (O + S + S2) / W
A = appropriateness (assess how appropriate a treatment is... FFS system)
O = outcomes
S = service, S2 = safety
W = waste

Question 44

How are microsystems facilitated?

Answer 44

Patient: patient-guided care
Microsystem: interface with frontline care teams
Mesosystem: integrated speciality groups, support personnel
Macrosystem: regional and national systems

Question 45

What factors tie into determining value?

Answer 45

Productivity
Adherence-improving factors
Reduction in uncertainty
Fear of contagion
Insurance value
Severity of disease
Value of hope 
Real-option value 
Equity
Scientific spillovers
Net costs
Quality-adjusted life years gained

Question 46

What are the policy levers of the U.S. system?

Answer 46

1. Care delivery (micro): Diagnosis, Treatment, Prevention, Variation. Organization of care PCMHs, systems, ACOs. Population Management
2. Knowledge: Innovation, Research, Clinical Training, Technologies, Data
   Analytics, QI
3. Payer: Insurance. Insurance coverage. Reimbursement (P4P, VBP)
4. Medical-Legal: Malpractice, Payment to patients
5. Regulator: policies related to: billing, payments, Privacy, IT, licensure, quality, safety, state
   specific insurance rules

Question 47

What is the partial structure of the ACA?

Answer 47

One part is insurance reform: more people covered and better coverage
One part is delivery reform: innovation, quality focus, integrated care