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Flashcards in Health Care Systems Deck (81):
0

Objective of health care delivery system (2)

Enable all citizens to receive health care services

Deliver services that are cost effective and meet standards of quality

1

Complexity of health care delivery (components)

Education/research
Suppliers
Insurers
Providers
Payers
Government

2

General facts about US health care

16% of GDP - highest of all countries
Per capita spending ~$8000 - also highest
Per capita spending projected to continue to rise.
Life expectancy and mortality measurements worse than most other countries

3

Who finances health care?

Private - employer based or patient purchases individually

Public - Medicaid, Medicare, other (VA, IHS, etc)

4

Medicaid

For the impoverished poor diasbiled

Joint venture between federal and state govt
States choose how to run them
Some federal requirements

5

Medicare

For the elderly

6

External forces affecting health care delivery

Social values and culture
Global influences
Population characteristics
Physical environment
Technology development
Economic conditions
Political climate

7

Description of US health care delivery

Large and complex
Fragmented
Many organizations and individuals

8

Major characteristics of US health care delivery (10)

No central agency governs
Access is based on insurance coverage
Under imperfect market conditions
3rd party insurers act as intermediary between finance and delivery function
Multiple payers makes cumbersome
Balance of power between all players - no single dominant entity
Legal risks influence physician behavior
New technology creates automatic demand
New service settings over continuum
Quality not seen as unachievable

9

No central agency

Mostly private financing and delivery
Hospitals and physicians independent of govt
No monitor of budget or utilization
(Exception is Medicare and Medicaid)
Govt sets standards thru policy and regulation
Minimum standards of quality

10

Partial access

Access restricted to:
1-have health insurance thru employer
2-are covered by govt plan
3-can afford insurance out of pocket
4-can pay for services at time of delivery

Emergency room - catastrophic insurance

Primary care access is lacking - reason for deficit in US health

11

Imperfect market

Consolidation and alliances

Quasi-market
1-patients and providers are not independent
2-prices not set by interaction of supply and demand
3-not unrestrained competition
4-patients lack info on different services
5-patients lack info on prices and quality
6-patients don't bear full cost of services
7-patients don't make decisions

12

Types of pricing

Item pricing

Package pricing

Capitation

13

Capitation

All services include one set fee per person

14

Package pricing

Bundled fee for group of related services

15

Phantom provider

All services billed separately; pathologist, anesthesiologist, supplies, hospital facility use

16

Third party insurers and payers

Wall is separation between financing and delivery

Quality of care is secondary

17

Multiple payers

Many different plan options available
Cumbersome

18

Power balancing

Multiple players
Fragmented self-interests

19

Legal risks

Litigious society
Defensive medicine

20

High technology

Creates demand despite cost
Need utilization of capital investments
Legal risk if don't provide

21

Continuum of services

3 broad categories
Curative
Restorative
Preventative

22

Quest for quality

Continuous improvement
Higher expectations
Compliance standards

23

Quad function model

By shi and Singh
4 functional components of healthcare delivery
FIDP
financing
Insurance
Delivery
Payment

24

Types of financing

Employers
Government (Medicare and Medicaid)
Self funding

25

Types of insurance

Insurance companies
Blue cross/blue shield
Self-insurance

26

Types of payment

Insurance companies
BCBS
third party claim processors

27

Type of delivery

Physicians
Hospitals
Nursing homes
Diagnostic centers
Vendors medical equipment
Health centers

28

What is managed care?

System to improve efficiencies by integrating basic functions, control utilization, and set prices for services

Integrates the 4 functions of healthcare delivery to better deliver care

29

Financing mechanisms (for MCO)

Capitation - for one set fee per month per member, MCO delivers all needed healthcare

Discounted fees


1-insurance- MCO assumes risks
2-delivery-MCO arranges services and controls utilization
3-payment-MCO is payer and pays providers based on capitation or discounted fees

30

Evolution of health services - 3 periods

Pre-industrial era 1700 1800
Post industrial era late 1800s to mid 1900s
Corporate era

31

Characteristics of pre industrial era of health service

Open entry into medical practice
Primitive medical procedures
No institutional core - almshouses, mental asylums, penthouses, dispensaries
Family based care
Substandard medical education

32

Characteristics of post- industrial era in health service

Physicians gained professional sovereignty
Scientific basis for medicine
Hospitals
Formal medical training
Licensing
Development of public health
Workers compensation starts
Private insurance
Medicare and Medicaid
Prototypes of managed care

33

What changed health services in 1900s?

Urbanization
Science and technology
Institutionalizations
Patient dependency
Autonomy and organization
Licensing
Educational reform

34

Concept of urbanization

People away from families
Women enter workforce
Physicians more productive
Less travel reduces opportunity cost

35

Concept of science and technology

Cultural authority
Increased demand for professional services
Decreased reliance on family treatment

Anesthesia
Penicillin
X-rays
Antiseptics
Pasteur and microbiology
Hand washing and sanitation

36

Concept of institutionalization

Pooling of resources needed
Hospital becomes institutional core

Urbanization, technology, and professionalization demand pooling of resources

37

Concept of autonomy and organization

Physicians remain independent from hospitals and corporations
Physicians organize thru AMA

38

Concept of licensure

Medical practice acts of 1870s
Debt vs West Virginia 1888
Need to upgrade medical education
Relieves intense competition in medical practice

39

Timeline of health insurance

1914 - workers compensation
1900- present - voluntary health insurance (disability insurance)
1929 - hospital insurance (prepaid plans)

40

Origins of health insurance

1929 - Baylor university - for school teachers; model for blue cross blue shield

1940s - WWII wage freeze - bargain with unions, becomes permanent part of employee benefits, grows to major medical

41

Federal efforts for national health insurance

1917 - American association of labor legislature
1935 - FDR New Deal
1940s - Roosevelt and Truman
1962 - Medicare and Medicaid
1992 - Clinton and Bush proposals
2009 - patient protection and Affordable Care Act

42

Why no national health insurance?

Political inexpediency
Institutional dissimilarities
Ideological differences
Tax averse

43

Characteristics of Corporate Era of health services

Corporatization
High tech
Comfortable surroundings
No cost control
Managed care - for insurance and delivery
Integrated health care organizations
Consolidation of physicians
Information revolution
Globalization
(Seen as government dominance)

44

Differences between private and public health care systems

Private - focuses on illness, FIDP, markets, biological causes, cure and individuals

Public - focuses on wellness, medical and non- medical interventions, social and govt services, biological and non- biological causes, prevention, and populations

45

4 components of health

Physical
Social
Spiritual
Mental

PMSS

46

Levels of health determinants

Individual
Community
State/national
Global

47

Blum's model of health determinants

ELHM

environmental
Lifestyle/behaviors
Heredity
Medical care

(In order of importance)

48

Determinants of premature death

LEGM

Lifestyle
Environment
Genetic
Medical are

49

Define social cohesion

Hospitable environment in which people trust each other and participate

Linked to lower overall morbidity and better self-rated health

50

Leading cause of death in US

Heart disease
Cancer
Respiratory diseases
Stroke

51

Actual causes of death

Tobacco
Poor diet and physical inactivity
Alcohol consumption

52

Define:
Acute
Subacute
Chronic

Acute - relatively severe, short duration (myocardial infarction, kidney interruption)

Subacute - less severe phase of an acute illness (rehab for hip fracture)

Chronic - less severe, irreversible, long duration but can be controlled (diabetes, -ashrams)

53

Continental poverty divide

Lower usa

54

Measures of health status

Morbidity/mortality
Incidence/prevalence
Disability
Demographic change
Dimensions of health
Utilization

55

Define morbidity

Burden of disease, disability, or sickness

56

Define mortality

Death rate

57

Define at risk community

All people in the same community or group that can acquire a disease or condition

58

Define cases

Number of people acquiring a given negative health condition

59

Define incidence

Number of new cases occurring/population at risk

60

Define prevalence

Total number of cases at specific point in time/specified population at same point in time

61

Define life expectancy

Prediction of how long a person will live

Two types:
Life expectancy at birth
Life expectancy at age 65

62

Activities of Daily Living Scale (ADL)

Used to measure disability in the elderly

6 activities of self care and mobility
Eating
Bathing
Dressing
Toilet
Continence
Transfer from bed to chair

63

Katz Scale

Modified ADL scale

For people in community-dwelling

Added tasks
Grooming
Walking 8 feet

64

Instrumental ADL

For those living independently
Self sufficient

Phone
Driving or public transportation
Shopping
Making meals
Housework
Medications

65

Utilization

Consumption of health care services or extent to which they are used

66

Examples of measures of utilization

# people in given population who visit primary care doctor/#people in study population

Crude, specific, institution specific

67

US cultural beliefs and values (5)

Advancement of science
Capitalism - economic good
Capitalism and health care
Concern for under privileged
Free enterprise/distrust of big govt

68

Distributive justice

Equal distribution of/access to health care

69

Market justice

Capitalism and free markets extends to health care
In United States
Doesn't work when dealing with human problems
Market-based demand
Health care is economic reward
Emphasis on individual
Based on ability to pay

70

Social justice

Govt distributes health care
Assumed more efficient
Central planning and rationing
Equal access is basic right
Community supersedes individual

71

Public health

Ensure conditions in which people can be healthy
Organized community efforts
Maximum positive impact on the health of a population, quality of life, overall satisfaction

72

Roles of public health

Prevent epidemics and spread of disease
Protect against environmental hazards
Prevent injury
Promote healthy behaviors
Respond to disasters
Assure quality and accessibility of health services

73

Sciences behind public health

Biomedical
Environmental
Epidemiology
Social and behavioral
Health policy and management

74

Risk factors and disease

Attributes that increase likelihood of developing a disease or negative health condition

75

Epidemiologic triangle

Host
Agent
Environment

HAE

76

3 types of prevention

Primary - prevent occurrence
Secondary - minimize damage
Tertiary - minimize disability

77

Controversy of public health

Economic impact
Individual liberty
Moral and religious objections

78

Public policy considerations

Scientifically plausible
Politically acceptable
Practical implementation

79

Examples of vulnerable populations

Minorities racial and ethnic
Uninsured children
Women
Homeless
Mentally ill
HIV/AIDS
disabled
Rural populations

80

Three categories of vulnerable populations

Predisposing characteristics
Enabling characteristics
Need characteristics