EXAM Flashcards
(205 cards)
1
Q
What are the three intermediate performance measures considered by Roberts?
A
Efficiency
Access
Quality
2
Q
In the reading by Roberts, are efficiency, access and quality the root cause or problem in health systems?
A
No. They are causally intermediate between root causes and ultimate performance goals.
3
Q
Define the ‘production possibility frontier’
A
The only way to get more of one output is to produce less of another.
I.e. when everything in a system is produced at minimum cost i.e. technically efficient.
4
Q
What are the type types of efficiency in the Roberts reading?
A
Technical and allocative efficiency.
5
Q
Define ‘technical efficiency’.
A
Situations where the good or service is produced at minimum cost.
6
Q
How does technical efficiency relate to health systems and whose primary responsibility is it?
A
Maximum output for money includes questions about the right mix of personnel, equipment, supplies and facilities.
It is mostly the domain of health-care system managers.
7
Q
Define ‘allocative efficiency’
A
Is a nation producing the right collection of outputs to achieve its overall goals?
Is the mix of health services maximising health-status gains?
8
Q
What is the relationship between allocative efficiency and the production possibility frontier?
A
Allocative efficiency asks ‘are we at the right point on the production possibility frontier’ in relation to whether the services (outputs) are achieving the system’s overall goals.
9
Q
Describe ‘diminishing marginal returns’ in relation to health care.
A
Treatment of high needs patients with expensive services can be very cost-effective. However when those services are extended to more of the population, the cost-effectiveness diminishes.
I.e. costs per case increase at the same time case-by-case benefits decline.
10
Q
What do health system managers need to decide when considering diminishing marginal returns?
A
What services should be provided, and to whom.
I.e. how many cardiac bypass surgeries and who gets them.
11
Q
From a political perspective, which is easier to improve: allocative or technical efficiency?
A
Technical.
It is easier to make production more efficient than to move people and plant from producing one thing to producing another. E.g. moving from high-tech tertiary services to primary care.
12
Q
What is the overall combined definition of efficiency (using both allocative and technical efficiency) in the Roberts reading?
A
Each relates to the relationship of inputs to desired results.
Is a health system achieving society’s goals at minimum cost?
13
Q
Are efficiency and equity necessarily in competition according to Roberts?
A
No. Their position is efficiency can advance equity by making it less costly to reach equity objectives.
14
Q
Roberts highlights a type of availability as central to their definition of access. What is this?
A
Effective availability.
15
Q
Describe physical availability in Roberts definition of access.
A
The physical availability of services. Geographic distribution of resources (beds, doctors, nurses) compared to the population.
16
Q
Describe effective availability in Roberts definition of access.
A
How easy is it for citizens to get care?
Access is a means to reach a country’s goals in the desired distribution of health and satisfaction.
17
Q
What dimension of access is particularly prone to political interference?
A
Physical availability. Regardless of effective availability consideration. E.g. closing a regional hospital that is under-utilised.
18
Q
What are the three dimensions of quality used by Roberts?
A
Quantity
Clinical quality
Service quality
19
Q
What aspect of ‘quality’ is the Amercian health system praised for?
A
Quantity
20
Q
Describe quantity in reference to quality in the Roberts reading.
A
The quantity of care provided to a patient. I.e. getting ‘lots’ of health care.
21
Q
Describe clinical quality in reference to quality in the Roberts reading.
A
Quality of caregivers and equipment. The combination of the two with the right inputs at personnel and drugs/facilities.
22
Q
Describe service quality in reference to quality in the Roberts reading.
A
Hotel services: food, cleanliness, amenities
Convenience: wait time, travel, appointment delays
Interpersonal relations: care, politeness, respect.
23
Q
What type of ‘quality’ is most often invoked by patients? Why?
A
Service quality. It’s easier for patients to judge than clinical quality.
24
Q
Do assessments of quality tend to look at inputs or evaluating processes or outcomes?
A
Inputs generally are easier to impact. I.e. educational requirements, availability of drugs and facilities.
25
What is the relationship of quality to equity issues?
If quality varies across a population (for e.g. urban vs rural) some groups will be disadvantaged compared to others.
26
When citizens bypass local health services for national health services (i.e. urban hospitals), what aspect of health system performance is this related to?
Clinical quality.
27
What are the three considerations regarding quality that need to be taken into account,
Is each service being produced in a way that results in the highest possible quality given the costs being incurred?
Even if a service is operating on the quality possibility frontier, are the producers offering an appropriate mix of qualities?
What level of resources should we devote to each service?
28
What is the quality possibility frontier?
The point at which, within a given budget, service and clinical quality are of the highest possible quality given the costs being incurred.
This accounts for the fact that spending on one aspect of quality takes resources away from the other.
29
What is the impact of different philosophical perspectives on assessment of quality in health care systems?
Differences in opinion over where resources should be concentrated.
I.e. objective utilitarians interested in health maximisation would want tho produce the maximum clinical quality for any given budget.
30
What are the four worlds of the general hospital?
Community (trustees)
Control (managers)
Cure (doctors)
Care (nurses)
31
How is the quadrant of 'cure' (doctors) oriented?
Manage down, into operations and out because they don't report into the hospital's hierarchy.
Functions through an arrangement of chiefs and committees.
32
How is the quadrant of 'care' (nurses) oriented?
Manage down, into operations and in because they report into the hospital administration.
NB: nurses and other care management.
33
How is the quadrant of 'control' (managers) oriented?
In because they're involved in hospital administration, and up because they are removed from operational day to day matters.
34
How is the quadrant of 'community' (trustees) oriented?
Not directly connected to the hospital's operation or personally beholden to it's hierarchy. Therefore oriented up and out.
NB: represented by the trustees of the hospital and informally by those who volunteer their time to it.
35
When applied to the health system in general, what occupies the four quadrants of the Glouberman and Mintzberg model?
```
Cure = acute cute (acute hospitals)
Care = community care (primary care, long term care facilities, alternative health services)
Control = public control (public health authorities, regulatory agencies, insurance companies)
Community = community involvement (elected officials, advocacy groups)
```
36
What is represented in the 'cure' quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Cure = acute cute (acute hospitals)
37
What is represented in the 'care' quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Care = community care (primary care, long term care facilities, alternative health services)
38
What is represented in the 'control' quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Control = public control (public health authorities, regulatory agencies, insurance companies)
39
What is represented in the 'community' quadrant of the Glouberman and Mintzberg model applied to the health system as a whole?
Community = community involvement (elected officials, advocacy groups)
40
What is the main contention of the Glouberman and Mintzberg article?
No matter how necessary the divisions of labour inherent in the four quadrants might be, the associated divisions of organisation and of attitude or mindset render the system unmanageable.
41
What is the difference between doctors' and nurses' orientations and behaviour?
Down and out versus down and in.
| Doctors intervene and leave the care to the nurses.
42
What are the four elements of medical intervention from intrusive to interpretive?
Incursion (cutting)
Ingestion (feeding)
Manipulation (touching)
Mediation (talking)
43
In medical practice, whose domain is 'touch' and why?
Seen as less scientific and therefore less the domain of the doctors (cure) and more of the nurses and associated care practitioners (care).
44
What is different about the degree of specialisation for physicians versus nurses and managers?
While nurses and managers are increasingly specialised, they can retrain relatively easily whereas physicians tend to focus on one area and lose the ability to appreciate other specialisations in medicine let alone the work of nurses and managers.
45
How is the acute hospital similar to doctors?
It has a highly specialised, interventionist approach which leaves much of the 'care' aspect to others.
46
Which professional role comes closest to being responsible for the complex coordination of the workflows in a hospital?
Nobody is formally responsible, but nurses come the closest.
47
How does the nurse's informal role as coordinator come into conflict with doctors and managers?
Doctors claim responsibility for patients, despite their absence and managers claim responsibility fro control, despite their distance.
48
Where does the distinction between 'cure' and 'care' become less useful?
As interventions become less invasive and tend more towards interpretive measures of cure, the distinction is less useful.
E.g. in geriatric hospitals there is less professional demarkation between doctors and nurses.
49
What is a consequence of the division and hierarchy associated with 'cure' versus 'care'?
Care can be relegated to poorly resourced and supported areas of the health system.
Patients are less able to/less attracted to access alternate care services like dietary care.
50
What is problematic about the relationship between doctors and managers?
Managers purportedly control the administration of the institution in which the doctors work, but the doctors respect their own professional medical hierarchy far more.
Unless managers have clinical training of their own, it is difficult to establish authority in the operational setting. It follows that, if a manager can't control the operational aspect of the hospital, in what sense are they controlling the hospital at all?
51
How are managers supposed to manage? What does this mean?
Through measurement.
| The problem is measurement is hard to define and differs depending on who you talk to.
52
How do the problems of hospital managers compared to those of public managers of health systems?
They are very similar. Managing disparate and competing hierarchies. They are removed from the institutions they manage in a similar way that the managers are removed from the clinical operations they manage.
53
Intervention occurs in the cure quadrant, where else does it occur?
In the control quadrant. Managers frequently intervene in operational matters.
54
Where does the smallest amount of differentiation relating to task occur in the four quadrants?
Community. Among the Board the hierarchy is least pronounced.
55
Which of the four quadrants has the least direct ability to 'do' anything in the health system or hospital?
Community. All members of the other quadrants can physically effect change.
56
Because of their inability to effect change directly, upon who do the 'community' bring their influence to bear?
Managers
57
When 'community' does intervene, what often occurs? What is problematic about this?
They behave in a way similar to physicians - intervening to fire a manager, fund a new piece of equipment.
It can be problematic because idiosyncrasy often plays a part i.e. trustees get their information selectively and have their own biases and personal preferences.
58
What are the key words associated with each domain in the Glouberman and Mintzberg framework?
Cure: professional chimneys (intervention)
Care: operating workflow (coordination)
Control: administrative hierarchy (containment)
Community: formal board (oversight)
59
What type of coalition exists between care and control?
Insider coalition
60
What type of coalition exists between control and community?
Containment coalition
61
What type of coalition exists between community and cure?
Status coalition
62
Why type of coalition exists between cure and care?
Clinical coalition
63
What dictates an increasing need for integration?
Increasing differentiation of the units of an organisation as to its goals, structures and interpersonal orientations.
64
What are the forces driving integration across the four quadrants?
Commitment to purpose.
Desire to advance knowledge.
Urgency.
65
What can government intervention involve in health care 'market'?
Purchasing care on behalf of consumers or providing such care.
66
What is the basic reason underlying extensive government intervention in health care?
That none of the ideal assumptions of perfect markets works in the case of health care.
67
What are the characteristics (and consequences) of the health care market which lead to the requirement of extensive government intervention?
Risk and uncertainty of contracting illness (in an unregulated market leads to diseconomies of small scale, moral hazard and adverse selection)
Externalities
Asymmetrical distribution of information about health care between providers and consumers combined with problems of professional licensure.
68
Do other markets exhibit similar characteristics to health care?
Yes but Donaldson's contention is that none exhibit all these characteristics simultaneously.
69
Why is health care versus the impact of adverse events (i.e. psychological problems, anxiety and stress) more likely to be insured?
It is more easily quantified by the insurance company.
70
What is the distinction between 'health' insurance and 'health care insurance' (though the former is usually how the latter is referred to)?
Health insurance would cover everything related to health whereas health care insurance only covers impact of an adverse health event in terms of paying for quantifiable services accessed.
71
What do people typically insure against?
Large unpredictable losses.
72
Describe 'diseconomies of small scale'
When there are a number of small providers in a competitive market.
Each provider only services a small number of clients therefore limiting their ability to spread fixed and administrative costs across their clients.
73
Describe 'economies of scale'
The relationship between fixed cost and output.
The more goods produced, the lower the cost per unit to produce.
This occurs by distributing fixed costs across the products thus reducing both the fixed and total cost per unit produced.
74
When do economies of scale fail?
When an organisation becomes to large or too small.
75
Why do diseconomies of small scale produce market failure in insurance?
People are less likely to pay premiums inflated by high administrative costs caused by too many small providers. Equally they are unlikely to pay premiums to a large, exploitative monopoly.
76
What is one reason for the increased costs of administration observed in the US after more competition was introduced to the market in the 1980s?
Spending on advertising and hospital utilisation reviews.
77
What are the two types of moral hazard?
Consumer moral hazard and provider moral hazard.
78
Describe consumer moral hazard.
When the act of being insured reduces the (financial) costs of treatment at the point of consumption. This makes being sick less undesirable and consequently less is done on the part of the consumer to actively avoid becoming unwell.
79
What are the implications of moral hazard in terms of the quantity of services accessed when illness occurs?
Potentially more services are accessed than is truly necessary because the consumer incurs no financial cost due to being fully insured.
80
Describe provider moral hazard.
This can arise from a lack of awareness of costs or in a fee-for-service system when doctors are incentivised to provide more care than is necessary by a system which pays them per-service.
81
What is provider moral hazard also known as?
Supplier-induced demand.
82
What are the dangers of a fee-for-service model?
If the fee is a truly competitive price then it operates fine.
If the fee is beyond what would normally be obtained, doctors are incentivised to over-provide.
If the fee is below what would normally be obtained, doctors are incentivised to under-provide.
83
Who are the two third parties to whom costs can be passed by consumers and providers in the US?
Employers and insurance companies.
84
How can provider moral hazard/supplier induced demand occur in taxation-funded systems?
Because health care providers themselves don't incur the full opportunity cost f provision of many aspects of care (i.e. diagnostic tests) they are prone to moral hazard through lack of awareness of costs.
85
How can a 'gateway' policy limit moral hazard?
By utilising primary care doctors as the 'gateway' to secondary and tertiary services, the over-utilisation of these services is limited.
86
How can moral hazard be countered financially?
Co-payments
87
What are the four ways in which provider moral hazard/supplier induced demand have been countered in the past?
1. Non-pecuniary incentives i.e. peer review
2. Use of a salaried service to cap payments to providers of care.
3. Financial limitations imposed.
4. Direct government regulation with financial penalties for non-compliance.
88
What does adverse selection result from?
Asymmetry of information in the insurance market.
| Buyers of insurance tend to have more of an idea of their risk status than sellers of health care insurance.
89
What is the process for adverse selection?
An average premium is set, to cover those across the spectrum of low to high risk.
Low risk individuals will perceive the premium to be too high, and opt to not obtain insurance.
This shifts the mean risk/cost ratio higher and causes the premiums to increase.
90
Describe 'cream skimming'
The process by which low-risk individuals are drawn into low-premium plans. Can be a consequence of adverse selection when companies realise there is a group of uninsured low-risk individuals available.
91
What is the impact of cream skimming on high risk groups?
They pay higher premiums.
92
How does adverse selection constitute market failure?
Out of the two groups who remain uninsured, it is the low risk individuals who keep pulling out of insurance schemes as premiums rise for whom the market has failed.
This is because both the insurer and customer would be willing to enter into a contract, but the necessary information required for such a transaction to be entered into is not transmitted from one party to the other via the market.
93
The high risk individuals who cannot afford experience-rated premiums which arise as a result of adverse selection are not failed by the market. Why is this?
The market does not fail, simply their financial resources cannot cover the cost of insurance.
94
What has caused the market failure resulting from adverse selection in low risk individuals who remain uninsured?
Asymmetry of information about risk status.
95
What determines people's response to the problem of un - and under-insured people in society?
Adverse selection and externalities.
96
Describe externalities
How much members of society care about the exclusion of others from access to needed health care. (altruistic)
How much members of society are willing to pay to obtain a related but external benefit. (selfish)
97
What is the consequence of unregulated markets failure to account for individuals to pay for external benefits?
These markets lead to the underproduction of health care.
98
What is the most effective and efficient way to account for externalities in health care?
By a form of taxation or public health insurance.
99
What is the problem with subsiding those in need versus responding to externalities through publicly financed health care systems?
Identifying who is in need and estimating their treatment expenses in advance.
The issue that people may not spend the money on what it was intended.
100
What issue is ignored when consumers are subsidised to pay for health care?
Not taking into account the asymmetry of information when engaging with a doctor.
101
Why has there never been a free market for doctors' services?
Because this would require no regulation on the supply side.
Consumers would then be able to choose between real doctors and quacks and the consequences on health would be terrible.
These sorts of conflict can exist in other markets because the consequences are less dire.
102
Define licensure.
Whereby a person, in order to practice medicine, has to obtain a minimum qualification.
103
Where does asymmetry exist in health care?
Asymmetry of information between consumers and providers.
The consumer wants to purchase health improvements, but these cannot be purchased directly - they must be mediated through purchase of health care.
104
How does the market fail with respect to the asymmetry of information in health care?
By failing to inform the consumer of the contribution of health care to health status.
105
What is the definition of a doctor as a perfect agent?
The DOCTOR is there to give the PATIENT all the information the PATIENT needs in order that the PATIENT can make a decision, and the DOCTOR should then implement that decision once the PATIENT has made it.
106
What is the idea behind the doctor as a perfect agent?
That the doctors objectively supply information to the patient who can then make a decision which maximises his/her utility.
107
How does Mossialos simplify the provision and financing of health care in the health care triangle?
The providers transfer health care sources to patients and patients or third parties transfer financial resources to the providers.
108
What is the financing equation used by Mossialos?
TF (taxation) + SI (social insurance) + UC (user charges) + PI (private insurance) = P (price) x Q (quantity) of goods and services.
These in turn must be equal to the income of those who provide health care services - the quantity and mix of inputs (W) times the prices of those inputs (Z)
109
What are the three elements into which health care financing is broken down by Mossialos?
Revenue collection
Fund pooling
Purchasing
PROVISION of health care follows from this.
110
What is revenue collection concerned with?
Who pays
What type of payment is made
Who collects it
111
What affects the motivations and incentives of insurers?
Their status as private for-profit, private not-for-profit or public.
I.e. whether they act in the interests of shareholders or members.
112
What are direct taxes?
Those levied on individuals, households or firms.
113
What are indirect taxes?
Those levied on transactions or commodities.
114
Describe the mechanism of social health insurance.
Contributions are usually related to income and shared between the employees and employers.
It is generally earmarked for health and collected by a separate fund.
115
Describe the mechanism of private health insurance.
Contributions are paid by an individual, shared between and employee and employer or paid entirely by an employer.
They can be individually risk rated, community rated (geographic) or group rated (company).
116
Describe medical savings accounts.
Individual savings accounts into which people are either required to, or given incentives to, deposit money. It must be spent on personal medical expenses.
117
What is 'fund pooling'
The accumulation of prepaid health care revenues on behalf of a population.
118
What is the utility of fund pooling?
It facilitates the pooling of financial risk across the population or a defined subgroup.
119
Is revenue collection and fund pooling the same thing?
No.
But they can be done by the same entity. E.g. social insurance schemes and taxes.
Some forms of revenue collection do not enable financial risks to be shared between contributors.
120
What is the rationale for allocating based on risk-adjusted capitation?
To ensure that each pool (insurance fund or territorial health authority) has the 'correct' relative level of resources for the population for which it is responsible.
121
Why are medical savings accounts usually supplemented with catastrophic insurance for very expensive treatments?
Because pooling is prevented by keeping funds in individual accounts.
122
Are user charges pooled?
No.
123
Define purchasing.
The transfer of pooled resource to service providers on behalf of the population for which the funds were polled.
124
What is the trajectory of health care expenditure among OECD countries?
It is rising.
125
In which countries is taxation the predominant source of revenue.
```
UK
Denmark
Italy
Spain
Sweden
```
126
In which countries are social health insurance contributions the predominant source of revenue?
Germany
Croatia
France
127
What are the four factors affect expenditure and revenue outlined in Mossialos?
Situational - transient events like revolutions or internal political change.
Structural - economic base, political institutions, demographic structure.
Environmental - events structures and values that exist outside the boundaries of a political system. Civil war. Technology change. WTO.
Cultural - value commitments within the community.
128
How can direct taxes create horizontal inequity (differential effects on people with the same income)?
- If tax rates vary geographically
- If some forms of income are exempt
- If some forms of expenditure are tax-deductible
129
What is the argument for indirect taxes being regressive?
They are related to consumption, not overall income. Affect vertical equity.
- People with higher incomes save more, and savings are not subject to indirect tax.
- People with lower incomes spend proportionately more of their income on heavily taxed goods such as tobacco.
- Many indirect taxes are set as lump-sum amounts (e.g. vehicle registrations)
130
What are the arguments against local taxation?
- Greater pressure on authorities to keep funding high and maintain status quo.
- Less ability to make trade offs between health and other public policy.
- Can create horizontal inequity by geographic tax differences.
131
What are the main advantages of general tax funding?
- It draws on a broad revenue base.
| - It allows trade offs between health care an dotter areas of public expenditure.
132
What is the main disadvantage of general tax funding?
It is subject to being at the losing end of a trade off between health care and other public policy depending on the quality and strength of the health minister, other priorities and power of lobby groups.
133
Define social health insurance.
Social health insurance contributions are not related to risk, are levied on earned income and collected by a body at arm's length from government.
Contributions are usually compulsory and shared between employee and the employer.
134
What is the predominant attraction of social insurance for countries?
The independence of the insurer from government and perceived greater responsiveness to the patient or consumer.
135
What are the advantages of social insurance?
It is more transparent than hypothecated taxes and usually more acceptable to the public as a result.
It is theoretically better protected from political interference since budgetary and spending decisions are devoted to independent bodies.
It is highly portable for insurers when moving jobs or in and out of the labour force.
It creates a much larger risk pool than does private health insurance - the level of the whole workforce or fund rather than just one fund.
136
What are the disadvantages of social insurance?
Higher labour costs due to employer contributions, could reduce international competitiveness.
Eligibility is sometimes linked to employment or contributions. This can limit access.
If the revenue base (i.e. employed people) is narrow, contributions can fall below the necessary revenue to sustain the system.
137
What is the risk of obligations on social insurance providers to accept all applicants?
The risk that some insurers will be more exposed to high risk individuals than others.
138
How do taxes contribute to social insurance?
They can be used to fund the uninsured and maintain solidarity across the population.
They can also cover the deficits of the insurance funds, this prevents them from becoming insolvent.
However this runs the risk of reducing insurers' incentives to contain costs or operate efficiently.
139
Describe substitutive insurance.
Private insurance available to those not in, or able to opt out of, the social insurance scheme.
140
What are implications of substitutive insurance on social insurance schemes?
Can put the weight of high risk individuals onto the public system alone.
141
Describe supplementary insurance.
This can provide quicker access to services or increase the quality of 'hotel' facilities in the public sector.
142
What are implications of supplementary insurance on social insurance schemes?
They can result in differential access between those and those without private insurance.
143
Describe complementary insurance.
This offers full or partial cover for services that are excluded or not fully covered by the statutory health care system.
144
What are implications of complementary insurance?
It is least affordable to those on low incomes, so they often have to pay the charges for the services not covered by the statutory health care system.
This leads to a disproportionate funding burden on poor people.
145
What is the funnel of doubt?
The area of uncertainty between the lowest and the highest values obtained in projections about private long-term care insurance.
146
Where are medical savings accounts used?
Singapore and China and (to a limited extend) in the US.
147
What are out-of-pocket payments?
They include all costs paid directly by the consumer including direct payments, formal cost sharing and informal payments.
148
Where do direct payments occur?
```
In the private sector:
Dentists
Pharmacists
Physicians for private appointments, hospitals for private treatments.
Laboratories or clinics for tests.
```
149
What is the impact of user charges on health systems?
The higher the proportion of user payments in the total mix of funding for health, the greater the relative share of the funding burden falling on poor people and people in poor health.
150
Why do informal payments exist?
Lack of financial resources in the public system.
Lack of private services.
Desire to exercise consumer leverage over providers.
Cultural tradition.
151
Where do loans, grants and donations form a large part of health revenue?
In low and middle income countries.
152
What is the WHO definition of health?
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease"
153
What are the three aspects of 'health' outlined in module 1? What do most health system focus on most and least?
1. Absence of illness (negative)
2. Capacity of function (coping)
3. Complete wellbeing (positive)
Health systems most focussed on 1 and least on 3.
154
What is the WHO definition of a health system?
"All activities whose primary purpose is to promote, restore or maintain health"
155
What is the WHO?
The directing and coordinating authority for health within the UN system.
Provides leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.
156
What are the three generic goals of health systems?
To improve health outcomes
Protect us from the financial costs of ill health
Be responsive to our needs and preferences
157
When was the Alma Ata declaration signed and what were its four statements?
1978
- Health care as a human right
- GOAL: Heath for all by 2000
- Participation
- Solidarity
158
What was the Alma Ata definition of PHC?
"Based on practical, scientifically sound and socially acceptable methods and technology made universally accessible through people's full participation and at a cost that the community and country can afford"
159
What are the elements of 'essential health care' outlined by the Alma Ata Declaration 1978?
- Universally accessible
- Acceptable to community
- Affordable
- Supports self-reliance and self-determination
- First level of contact
- Brings health care to where people live and work
- Integral part of the health system
- Main focus of social and economic development
160
What is 'stronger' primary health care according to Starfield?
- First contact and access
- Continuity of care
- Comprehensiveness
- Coordinated care
- Community-oriented care
- Family-oriented care
161
In module 1, what were some proposed measures to strengthen PHC?
- Improving access
- Paying doctors differently
- Moving from individual practitioners to teams
- Increasing involvement of communities
162
What NZ strategies have been developed to re-orient the health system towards primary health care/a population health focus?
- New Zealand Health Strategy 2000
- Primary Health Care Strategy 2001
- Better, Sooner, More Convenient 2009/2011
- He Korowai Oranga: Maori Health Strategy
- Whanau Ora
163
What were the goals of the PHC (2001)?
- Work with local communities
- Identify and remove health inequalities
- Offer access to comprehensive services to IMPROVE, MAINTAIN, RESTORE health.
- Co-ordinate care across service areas
- Develop PHC workforce
- Improve quality using good information
164
When were PHOs set up?
Under PHC (2001)
165
What was the purpose of setting up PHOs?
- Serve whole populations
- Change from FFS to capitation (population based) funding
- Require community governance of PHOs
- Improve access by incentivising PHOs to do so
166
What were the goals of Better Sooner More Convenient?
- Personalised PHC system
- Services closer to home (and IN the home)
- Consolidating structures
- Decreasing bureaucracy
- Reducing pressure on hospital
- Prevention and health promotion
167
When was PHARMAC established?
Under Big Bang 1993 - 1996
168
When was the payer/provider split introduced?
Under Big Bang 1993 - 1996
169
When is a workforce considered to be regulated?
When "access to it and the exercise of it, are subject to the possession of a specific professional qualification"
170
What does the board of a regulated profession do?
- Maintain a register
- Maintain professional standards
- Provide structures for the discipline of individuals
- Approve educational programs
171
What characterised the health workforce in the early 1900s?
Doctor managed and lead, nurses trained on the job by doctors.
172
When were nurses and midwives regulated?
1901 and 1904 respectively
173
What characterised the development of the health workforce in the 20th century?
- High status of doctors
- Specialisation of medical and nursing workforce increase
- Complementary skills acknowledged
- The beginning of the public health workforce
174
What are the six major areas of the 'work' of the health workforce?
- Protecting a health population from becoming at risk
- Developing interventions that target those 'at risk'
- Helping reduce the negative impact of symptoms in early stages
- Helping manage the condition to avoid it leading to other conditions
- Intensive and acute care
- Palliative care
175
What is the economic problem?
Unlimited wants; limited resources
176
Define opportunity cost in relation to health economics
Would it be more efficient to provide for different wants.
The opportunity cost is the thing (or value of the thing) that is the next best alternative to what was chosen.
177
Describe the equilibrium price
At an equilibrium price, all participating buyers and sellers benefit:
- Buyers pay no more than the value of the good given to them
- Sellers receive no less than the cost of the good
- No buyers or sellers who WANT to participate at that price are left on the sidelines
Inefficient sellers leave the market, buyers with low willingness to pay for health don't buy.
178
Describe a mutually beneficial trade
When both the buyer and the seller benefit when a trade occurs. The seller gets as least as much as they value the good, the buyer has to pay at most what they value the good at.
179
Where do markets in healthcare exist in NZ?
- Health workforce
- Technologies: consumables, equipment, pharmaceuticals
- Purchase of public healthcare
- Health insurance
180
Why would a government intervene with the price mechanism to stop the market getting to an equilibrium price?
An efficient outcome is not necessarily fair i.e. many people won't be treated in a perfect market.
181
Why are entry and exit to the health care market not 'free'?
Licensure - both of professionals and manufacture of medical devices and pharmaceutical (patents, trademarks and licenses)
182
Are there many buyers and sellers in health care markets?
Not normally - e.g. PHARMA is a single buyer of pharmaceuticals and on-patent drugs have only one possible supplier.
183
Are people only motivated by their own wellbeing in health care markets?
No - externalities and benevolence.
184
Define defensive medicine
The provision of additional goods/services by health professionals based on a fear of litigation.
185
Is there perfect information in health care markets? What are the implications of this?
No.
Can create supplier induced demand.
Can create adverse selection and cream skimming.
186
How can premiums for insurance be defined?
Personal rating
Community rating
Group rating
187
What are some solutions to adverse selection?
- Make participation in a single scheme compulsory
| - Offer several contracts (consequence is coverage differs across groups)
188
What are some solutions to moral hazard?
- Cream skimming (make coverage conditional)
- No claims discounts
- Reduce coverage/deductibles/introduce co-payments thereby making being sick 'hurt' more financially.
189
What are some consequences of an inefficient market?
- Too little is produced (e.g. taxes)
- Too much is produced (e.g. subsidies)
- Something interferes with how values, costs or prices are determined.
- May make allocative efficiency/the balance between the value of health and its cost, very hard to assess.
190
What proportion of US health expenditure is funded by Federal and State governments?
At least half - it has the third highest public health expenditure per person in the world. It spends the most overall.
191
Why do governments intervene in health care markets?
```
Equity
- reduce prices for patients
- provide treatment
- obtain better health/productivity outcomes
Contain health costs
Efficiency
```
192
How can governments intervene in health care markets?
- Collect information
- Regulate and monitor
- Fund health care
- Purchase services
- Provide services
193
Why would governments intervene to collect information in health care markets?
To offset asymmetry of information between consumers and providers.
194
Why would governments intervene to regulate and monitor health care markets?
To offset adverse selection
To discourage moral hazard
To discourage supplier induced demand
To offset monopolies
195
In what ways do governments regulate insurers?
- Enforce community rating of premiums
- Restrictions on use of pre-existing conditions
- Open enrolment (insurers must take all applicants)
- Cover pre-existing conditions
- Require minimum package of services
196
In what ways do governments regulate providers?
Quality: licensure, standards of facilities.
Price: GP fees, DRG payments in USA.
Quantity: number of hospitals, number of medical students, location of GPs, use of clinical guidelines.
197
Why do governments fund health services?
To avoid adverse selection. (NOTE: makes moral hazard worse)
198
Why do governments purchase health services?
To offset the bargaining power of monopolies.
E.g. Sick funds, PHARMAC, DHBs, ACC
199
Why do governments provide health services?
To offset supplier induced demand and potential monopolies.
E.g. public hospitals, community services, public health services.
BUT - can create government monopolies.
200
Historically, why do governments intervene in health care markets?
For equity concerns (as opposed to efficiency concerns)
201
What is an economic evaluation?
The systematic comparison of costs AND benefits of alternative actions.
202
What are the criteria used to score NZ's health system performance?
- Healthy lives (outcomes)
- Quality
- Access
- Efficiency
- Equity
203
What is 'path dependency'?
No high-income country has changed its predominant way of funding health systems for at least 30-40 years. It is extremely difficult for these countries to change, once a path has been established.
204
What have many Asian countries adopted?
A hybrid social insurance/tax system.
205
What type of system are many LMICs moving towards?
SI or taxation based systems.
