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C,Q,A of HC

Cost, Quality, & Access of Health Care

What are the 3 cornerstones of HC delivery? Cost Access Quality
An interactives relationship exists b/t 1. Cost of HC 2. People's ability to get HC when needed 3. Quality of services delivered
Uncontrolled expenditures mitigate a nation's ability to provide access to quality HC Focusing on access b/c # of poeple needing care is increasing Have to counter providing access with quality
Why did HC spending increase a lot in the 1970s? Massive growth in access created by Medicare & medicaid programs in 1965. Signed into law by JFK
The main culprits for the recent rise in expenditures Hospital services Prescription drugs Physician services
Macro Perspective of HC "Cost" HC Expenditure or Spending: Reflects consumption of economic resources in delivery of HC Resources are insurance, pro's skills, drugs, med equipment, discoveries
Gross Domestic Produce (GDP) Gov't tracking of our economy & what we spend on goods & services Dollar amount spent on goods & services How much/what % is gov't spending on HC vs. other goods/services % of what is spent on HC continues to increase yearly
Consumer Price Index (CPI) Comparison b/t general economic inflation & HC cost inflation Measures general inflatoin in economy & calculates annual changes Decreased b/c of managed care & Medicare creating caps
NHE (Nat'l HC Expenditure/HC SPending) GDP- total net value of all goods & services in general economy 2011- US spent 2.8 trillion on HC: 18% of GDP Anticipated to be 20% of GDP by 2015
Micro Perspective, or the "Price" of HC Costs incurred by employers to purchase insurance Out of pocket costs incurred by individuals when they receive HC services Physician's bill Price of prescriptions
Cost of production of HC Staff Salaries Capital equipment/building costs Rental of space to provide services Supplies
Reasons for Cost Escalation VERY IMPORTANT!!*** 3rd party payment HC is an imperfect market Growth of technology Increase in elderly population Medical model of HC delivery Multi-payer system & admin costs Defensive medicine Waste & abuse Practice variations
Third Party Payment Moral hazard Provider-induced demand
Imperfect Market Utilization of HC driven by need, not demand Quantity of HC produced is usually higher than in competitive markets Prices permanently higher than true cost of production
Technology & specialization Beliefs & values High R&D spending Innovation that leads to utilization Surplus of specialists
Increase in elderly population Increased longevity Baby boomers Elderly use nearly 3x as much HC as younger people
Medical model of health Misplaced emphasis on medical treatments Health promotion/disease prevention takes a back seat
Multi-payer system & administrative costs inefficiencies related to Financing Insurance Delivery Payment fxns Enrollment process Contracts Claims processing Utilization Denials & appeals Marketing
Defensive Medicine Medical tests & treatments that aren't justified, but done for self-protection
Waste & Abuse Inefficiencies & fraud Major problem in medicare/medicaid- unnecessary services, upcoding, misallocation of costs to increase reimbursement Receiving kickback for referrals Self-referral
Practice Variations (Small area variations) Differences in practice patterns Associated with geographic areas Signal gross inefficiencies Compromise cost & quality
Cost Containment Pros Increased costs cause people to spend HC>other goods/services HC is imperfect market so pts will utilize as much as they can to get the most use of insurance Increased costs means increased costs to gov't funded insurances, thus increased taxes
Medicare could be depleted by when? 2018 Longevity of Medicare already a concern, which is why the balanced budget act of 1996 was created
Cost Containment Cons Increasing costs creates more jobs Increasing costs encourages more resources into a positive sector of our economy Positive sector as opposed to factories that pollute air/destroy lives (HC saves lives)
Cost Shifting Providers make up for lost revenues by increasing utilization or charging higher prices in other areas free of controls
Two successful cost-containment periods in US History 1. 1983-4 DRG Implementation 2. 1995-8 Balanced Budget Act & other major managed care penetration into HC
Cost containment regulatory approach- All-Payer (Single-Payer) System Top-down control (global budgets) US doesn't have an all-paer system (bottom-up cost control, cost shifting occurs)
Cost containment regulatory approach- Health Planning Thinking more about community & prevention Govt's efforts to align & distribute HC resources to achieve health outcomes No system-wide planning & controls in US
Containment- Price Controls Important event to control price for IP hospital care was converting hospital Medicare reimbursement from retro- to prospective system
Utilization Controls- Peer Review Orgs (PROs) State-wide private orgs composed of practicing physicians & HC providers employed by managed care orgs (MCOs) Can deny payments if care not medically necessary Each state has its own PRO Now called Quality Improvement Orgs (QIOs)
Cost containment Competitive Approach- Demand-Side incentives Cost sharing by consumers Self-rationing mechanism RAND experiment- lower HC costs with cost-sharing mechanisms in place Ex: Co-pays, deductibles, sharing premium costs
Cost containment Competitive Approach- Supply-Side incentives- Anti-Trust Laws Prohibit business practices that stifle competition among providers Ex: Price fixing, price discrimination, exclusive contracting arrangement, mergers Forces HC orgs to be cost-efficient
Cost containment Competitive Approach- Payer-Driven Competition Pt's not customers- they pay little out of packet & lack technical info Payer-driven competition occurs at 2 levels- employers shop for value in insurance plans; managed care shops for best value from providers
Access to Care Ability to obtain needed, affordable, convenient, acceptable, & effective personal health services timely Implications: determinant of health, benchmark in assessing effectiveness, equity, quality & efficient use of needed services
Access concepts Does pt have a source of care (PCP)? Use of HC- availability, convenience, referral Acceptability of services- pt's preference & values
Dimension of Access- Accessibility Fit b/t locations of providers & pts i.e. transportation, convenience
Dimension of Access- Affordability Ability to pay
Dimension of Access- Accommodation How resources are organized to provide services & the pt's ability to use the services i.e. timely appts, quick service, walk-ins, etc.
Dimension of Access- Acceptability Compatibility (waiting time; race, culture, gender, etc)
Potential Access Capacity Organization Financing
Realized Access Type Site Purpose of health services
Equitable/inequitable Access Distribution of HC to pt's perceived need
Effective & Efficient access Links realized access to health outcomes
Microview of quality Clinical (technical) aspects Interpersonal aspects Quality of life- General HRQL, Disease-specific HRQL, Institution-related QoL
Macroview of Quality Mortality Incidence & Prevalence
Institute of Medicine definition of quality Degree to which health services for individuals & populations increase the likelihood of desired health outcomes & are consistent with current professional knowledge *Leaves out roles of cost & access in the eval of quality
Institute of Medicine definition has implications Quality occurs on a continuum Focus is on services provided by the system Quality may be evaluated from individual or population's perspective Emphasis on desired health outcomes Professional consensus used to develop measures of quality
Donabedian's 3 domains in which HC quality should be examined Structure Process Outcomes All are important in measuring quality & are complementary, so should be used collectively
Donabedian Model- Structure Facilities: license, accreditation Equipment Staffing levels Staff qualifications Staff training Distribution of hospital beds, physicians, etc. in a given population
Donabedian Model- Process Clinical practice guidelines- EBP, professional consensus when scientific evidence lacking Critical pathways- timeline, ID's planned medical interventions, with expected pt outcomes for a diagnosis
Average in Quality- Process Specific way in which care is provided Ex: correct dx test & prescriptions, accurate drug admin Main developments: clinical practice guidelines, critical pathways, risk mgmt
Donabedian Model- Processes- Cost Efficiency Benefits>Costs? Under-utilization & over-utilization based on cost efficiency
Donabedian Model- Processes- Risk Mgmt Proactive Efforts to prevent adverse events related to clinical care & facility operations- focused on avoiding medical mal-practice
Average in Quality- Outcomes Effects/final results obtained from utilizing structure & processes of HC delivery Measure of effectiveness of HC delivery system Suggests overall improvement in health status Measures include: infection rates, rates of rehospitalization, pt satisfacti
Developments in Process Improvement- Clinical Practice Guidelines aka Medical practice guidelines- they're preferred clinical processes Constitutes a plan for managing a clinical problem based on evidence Provide protocols to guide physicians' clinical devisions Intention: Lower costs, get better outcomes
Developments in Process Improvement- Cost-Efficiency aka cost effectiveness Cost efficient when benefits received > cost incurred Point is optimal quality- demarcation b/t underutilization & overutilization
Developments in Process Improvement- Critical Pathways Outcome-based & pt-centered case mgmt tools that are interdisciplinary & facilitate coordination of care among multi clinical depts & caregivers Time-line that ID's planned med interventions w/ expected pt outcomes for a dx
Developments in Process Improvement- Risk Mgmt Pro-active efforts to prevent adverse events related to clinical care & facilities operations, focusing on avoiding medical malpractice
Quality Initiative- Accountable Care Orgs Designed to help increase cooperation b/t providers across various HC settings to improve Medicare pt outcomes
Greatest challenges to HC delivery Increasing costs, lack of access, concerns about quality HC costs in US are highest in the world Access is a determinant of health status
Created by: 1190550002



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