Unit I Flashcards
(216 cards)
1
Q
What is a health system according to the World Health Report?
A
All the activities whose primary purposes is to promote, restore, or maintain health
2
Q
What are examples of depts in the Executive Branch of govt?
A
- President/White House
- Cabinet depts (e.g. HHS)
3
Q
Why do some criticize the concept of health care consumers?
A
Because the role/conceptions of rights of a patient and his/her identity don’t match
4
Q
What are the 3 dimensions of health?
A
1) Physical
2) Mental
3) Social Well-being
5
Q
What health care right does the ACA grant?
A
access health insurance
6
Q
Who is the current secretary of HHS?
A
Sylvia Mathews Burwell
7
Q
What government power from the US Constitution allowed many federally funded programs to exist?
A
power to tax and spend for the general welfare
8
Q
What is tertiary care?
A
Specialized consultative care (e.g. trauma center, Smilow)
9
Q
What is the first category of views on a right to Health Care?
A
Basic security when it comes to their health care - Obama
10
Q
What health care right does the Emergency Medical Tx and Active Labor (EMTLA) (1986) grant?
A
Right to screening/stabilization on presentation to ED
11
Q
What is the fifth category of views on a right to Health Care?
A
Right to standard of living adequate for health and well-being (encompassing total health). - UN Declaration of Human Rights
12
Q
What is primary care?
A
Basic/general health care: family practice, pediatrics, internal medicine, sometimes GYN
13
Q
What are examples of depts in the Judicial Branch of govt?
A
Courts
14
Q
What are the three aims of a health system?
A
1) Improve the health of the popl’n they serve
2) respond to people’s expectations
3) provide financial protection against costs of ill health
15
Q
What is the second category of views on a right to Health Care?
A
Health care is a right, not a privilege - Pope Francis
16
Q
What is the role of the Legislative Branch?
A
1) Debate and pass bills
2) Exec branch oversight
17
Q
What are examples of depts in the Legislative Branch of govt?
A
Congress = House, Senate, committees/subcommittees
18
Q
What is the fourth category of views on a right to Health Care?
A
Health care not a right or privilege; service provided by doctors and others who wish to purchase it - RM Sade, NEJM
19
Q
What are 3 determinants of health?
A
1) Physical environment
2) Social environment
3) Personal traits
20
Q
What is an example of vertical integration?
A
Yale Health, Kaiser
21
Q
What is a proposal to achieve the Triple Aim?
A
Integrated care
22
Q
What is integrated care?
A
Providers/organization accept responsibility for all three aims (CARE, HEALTH, COST) and are held accountable (fiscally & clinically) for health outcomes of popl’ns they serve
23
Q
What health care right does the Medicare program (1965) grant?
A
Health care for:
1) 65+
2) <65 with disabilities:
End-stage renal disease, ALS
24
Q
What health care right does the Medicaid program (1965) grant?
A
Health care for:
some individuals + families with low income
25
What are some examples of health policy trade-offs?
NIH funding priorities, cost-quality in health care, insurance plan coverages, screening recommendations
26
Name 4 possible explanations why healthcare/health reform is so controversial in the US.
1. Special interests
2. National values
3. Complexity
4. Trust (or lack thereof)
27
What is the definition of Health according to the WHO?
A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.
28
What health care right does the Children's Health Insurance Program (CHIP) grant?
Health care for:
| uninsured children in low income families + do not qualify for Medicaid
29
What are the activities of an integrator?
1) Culture of transparency and education
| 2) View technologies with skepticism and require strong burden of proof from proponents
30
What are the 5 principal features of US Health Policy?
1) Dominant role of private sector
2) fragmented/incremental/piecemeal policies
3) powerful interest groups
4) many sources of policy creation
5) impact of presidential leadership
31
What is the role of the Judicial Branch?
1) constitutionality of laws
| 2) review exec branch activities
32
What is the role of the Executive Branch?
1) Policy developing & advocacy
2) Rule making/regulation
3) enforcement
4) funding
33
What is the Triple Aim?
1) Improve individual experience of care
2) improve health of popl'ns
3) reduce per capita costs of care for popl'ns
CARE, HEALTH, COST
34
Which group does NOT have a legal right to health care under current US law?
Patients with HIV/AIDS
35
What are some examples of priorities and agenda-setting?
Mismatch between disease prevalence and funding priorities (e.g. vitamin D deficiency + rickets vs. UV exposure and skin cancer)
36
What is the third category of views on a right to Health Care?
Health care is not a right, but a service (commodity) provided through voluntary and mutually beneficial market exchanges - John Mackey, cofounder of Whole Foods
37
What is secondary care?
neuro, cardio, rheumatology, dermatology, oncology, ortho, opthalmology
38
Which health profession has the largest number of active practitioners in the US?
RNs
39
What are the key characteristics (4) of primary care?
1) First contact care
2) Longitudinality (continuity)
3) Comprehensiveness
4) Coordination
40
What doesn't health system imply?
1) any particular degree of integration
| 2) anyone in charge of it
41
What are the 10 components of the US Health System?
1) Gov't
2) Hospitals, medical practices, health systems
3) health professionals
4) industries
5) biomedical research
6) Insurers
7) Patients & patient advocacy orgs
8) Employers
9) Non-Profit, NGOs
10) Others?
42
Name 4 themes/major challenges for Health Policy
1. Context and contingency
2. Priorities and Agenda-setting
3. Trade-offs
4. Remembering Patients and Individuals
43
What are the differences among those who support a right to health care?
1) Same level of care
| 2) Some minimum level or care
44
What are the three big questions in health policy?
1. Is healthcare a right?
2. What is the role of the gov't?
3. How would the responsibility of gov't function?
45
How much did the US spend on health care in 2014?
3 trillion, 17.5 % GDP
46
How much did the US spend on health care in 2016?
$3.3 trillion
47
How much is the US expected to spend on health care in 2025?
$5.6 trilion, 20.1% GDP
48
What is the consumer perspective of "cost" in health care?
price (bills, insurance premiums, etc)
49
What is the National (Health System) perspective of "cost" in health care?
Health care expenditures or health care spending
50
What is the equation for health care expenditures/spending?
product of all health care services delivered x price of those services
51
What is the provider perspective of "cost" in health care?
Staff salaries, facility costs, supplies, technology, etc.
52
What category is the largest component of health care spending in the US?
Hospital care
53
What is the second largest component of health care spending in the US?
Physician services
54
Prescription drugs account for what percentage of US health care spending?
10%
55
What is thought to be the largest contributor to growth of health care costs?
Technologies
56
What does "skin in the game" mean?
When people are more responsible for their health costs, they are supposedly more likely to consider cost or shop around for the best deal on medical tx
57
Why are provider incentives a reason for escalating health care costs?
Fee-for-service models: providers charge fees for specific services (make more money the more tests and procedures they perform- volume>value)
58
What are alternatives for Fee-for-Service care?
1) Pay for performance
2) ACO's = shared savings
3) bundled payments, capitation, etc
59
How does a growing elderly popl'n escalate health care costs?
They need more care + long term, more people qualify for medicare
60
Name 6 reasons for escalating health care costs.
1) Medical Model of health care delivery
2) Admin costs
3) Fraud and abuse
4) Defensive medicine
5) practice variations (hence EBM)
6) Rising prices for same services (e.g. epipen)
61
What does it mean to bend the cost curve?
To shift the curve to a more efficient relationship between costs and health outcomes (lower cost, better health)
62
What is the Ubel/Jagsi "financial stewardship" model for physicians?
Opting at times not to pursue interventions that they believe might provide some benefit for a particular patient because of concern over total health care costs and its societal consequences.
63
What is a premium?
The amount paid for a health insurance plan (for employment based plans, usu shared between employee and employer).
64
What is a deductible?
An amount that the insured person must pay out of pocket for covered health services before the insurance begins to pay.
65
What is copay?
A fixed amount paid by the insured person for covered health services.
66
What is coinsurance?
A percentage paid by the insured person for covered health services (after any deductible, if applicable).
67
What is usually referred to when people talk about "cost-sharing"?
Deductible, copay, coinsurance
68
What is the simple definition of access to health care?
The ability to obtain health services when needed
69
What is the more nuanced definition of access to health care?
The ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner
70
Compared to insured, uninsured are more likely to (6):
1) ^ avoidable hospitalization
2) late diagnoses
3) more seriously ill when hospitalized
4) higher rates of chronic disease
5) lower survival rates from breast cancer
6) higher overall mortality: 40% greater
71
What states have the highest rates of uninsured?
NV, TX, MS, GA, FL
72
Adults with insurance coverage are more likely to be (4):
1) Married
2) Disabled
3) Employed full-time
4) mid-20's
73
How much of the total US. population has coverage?
90.9%
74
Rank the following three age groups from most insured to least insured: age 65, 18-64, under 18
1) Over 65
2) Under 18
3) Age 18-64
75
What level of education do must adults who are insured have?
graduate/professional degree
76
Which ethnicity has the smallest percentage uninsured? highest?
Hispanic - lowest; white - highest
77
What is the total percentage of non-elderly people of color who are uninsured?
55% (whites are 45%)
78
Of the 32.3 million uninsured, what percentage is eligible for financial assistance (2015)?
49%
79
Among the uninsured, what is the most commonly reported barrier to health care?
No usual source of health care
80
What are the financial implications of lacking insurance for patients?
billed at rates higher than insured rates, have to pay upfront and in cash
81
What are the financial implications of lacking insurance for providers and the health care system?
Uncompensated costs of care for the uninsured $84.9 billion
82
What are the three components/measures of quality according to Donabedian?
1) Structure: characteristics of systems (e.g. types of hospitals, qualifications of providers, amenities)
2) Process: interactions between provider and patient (e.g. technical quality of care and interpersonal interactions)
3) Outcomes: patient's health status after an intervention
83
What is the National Quality Strategy?
It is a mandate of the ACA led by Agency for Healthcare Research and Quality (2011)
84
What are the three aims of the National Quality Strategy?
1) Better care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe
2) Healthy People/Healthy Communities: improve the health of the US population by suportung proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care
3) Affordable care: reduce the cost of quality health care for individuals, families, employers, govt
85
What are the 6 priorities of the National Quality Strategy?
1) Make care safer; reduce harm caused in care delivery
2) Person & family engaged as partners in their care
3) Effective communication & coordination of care
4) Effective px and tx practices for leading causes of mortality, starting with CVD
5) work with communities to promote wide use of best practices to enable healthy living
6) Quality care more affordable by developing and spreading new health care delivery models
86
What is Quality Improvement?
prospective and respective; aimed at creating systems to prevent errors from happening
87
What is Quality Assurance?
Retrospective, reactive, policing, and often punitive. Determining who was at fault after something went wrong.
88
What are the four types of medical errors?
1) medication
2) surgical
3) dx inaccuracies
4) systemic factors
89
What is Choosing Wisely?
A website created by the American Board of Internal Medicine an specialty to societies to promote the dialogue on avoiding unnecessary, wasteful tests, tx, procedures
90
What are the potential quality-related negative consequences of a fee for service model?
Overuse of interventions/services
91
What is capitation?
set fee per patient
92
What are the potential quality-related negative consequences of capitation?
underuse of interventions/services
93
What are the potential quality-related negative consequences of a pay for performance?
incentive for providers to avoid high risk patients more likely to have negative outcomes
94
What is pay for performance?
payment linked to quality/efficiency
95
What are clinical practice guidelines?
Systematically developed statements to assist practitioner and patient decision about appropriate health care for specific clinical circumstances
96
What is comparative effectiveness research
Aimed at determining which therapies, care management, delivery models, and public health programs accomplish the most good
97
What information does Comparative effectiveness research provide?
advantages/disadvantages of approaches, can be independent of financial considerations
98
What information does cost effectiveness analyses provide?
benefits of an intervention strategy relative to its cost
99
What does the ACA prohibit Medicare from doing with the results of cost effectiveness analyses ?
Denying coverage
100
Why was the Patient-Centered Outcome Research Instituted established as part of the ACA?
To set priorities and fund comparative effectiveness research
101
What type of insurance do most people have (2013-2015)?
Private plan
102
What comprises most of the private insurance plans?
Employment-based plans
103
What government plan insures the most people (2013-2015)?
Medicaid
104
What year were Medicare and Medicaid made laws?
1965
105
Who played an important role in getting Medicare passed?
Rep. Wilbur Mills (Lyndon B Johnson signed)
106
How much of the population does Medicare cover?
~55 million Americans (~17% total popl'n)
107
What is the annual cost of the Medicare program?
$586 billion
108
What was the legislation for creating Medicare?
"Prohibition against any federal interference with the practice of medicine or the way medical services were provided."
109
Who is eligible for Medicare?
1) People 65+ (US citizens or 5+ yrs as permanent residents)
~85% of all benificiaries
2) Under age 65 with permanent disabilities
110
What diseases are eligible for medicare?
1) end-stage renal disease
| 2) Amyotrophic lateral sclerosis (ALS) - Lou Gehrig's disease
111
What is the main treatment for people with end stage renal disease?
Dialysis - and its expensive!
112
How much does ESRD cost Medicare?
$29.03 billion; per patient, it costs $30,000 - $85,000
113
What is included in Medicare Part A?
HOSPITAL INSURANCE PROGRAM.
1) inpatient hospital
2) skilled nursing facility
3) some home health visits
4) hospice care
114
What is included in Medicare Part B?
SUPPLEMENTARY MEDICAL INSURANCE PROGRAM.
1) Physician
2) Outpatient
3) Home health
4) Preventive
115
What is included in Medicare Part C?
MEDICARE ADVANTAGE.
Allows beneficiaries to enroll in a private plan (e.g. HMO or PPO) as alternative to traditional Medicare.
116
What is included in Medicare Part D?
OUTPATIENT PRESCRIPTION DRUG BENEFIT.
Voluntary benefit delivered through private plans contracted with Medicare: Prescription drug plans or Medicare Advantage prescription drug plans
Pay a monthly premium + cost sharing for prescriptions
117
What established Medicare Part D?
The Medicare Modernization Act (2003) implemented in 2006
118
What is not covered by Medicare?
1) Long-term care (e.g. nursing home, assisted-living facility)
2) Hearing exams/aids
3) Eyeglasses/vision care
4) Routine dental/dentures
119
What is the services most used by Medicare beneficiaries?
Prescription drugs
120
What is the "Doughnut Hole"?
The doughnut hole refers to the coverage gap in Medicare Part D, the prescription drug benefit, that occurred due to two set coverage limits: 1) the initial coverage limit and 2) the catastrophic coverage limit.
With the initial coverage limit, the enrollee pays 25% of total drug costs past the deductible up to $2,960. Past this limit, there is no coverage until the Catastrophic Coverage limit.
Once a patient hits the Catastrophic Coverage limit (~$7062), then the enrollee pays 5% out of pocket, while Part D and Medicare pays the remaining cost of coverage.
Between $2,960 - $7,062 past the deductible, there is a coverage gap where enrollees must cover most of the cost ("manufacturer discount"). = Donut Hole
121
What are the caveats of Medicare Advantage?
The amount Medicare pays is a capitation structure based on bidding. Plans must cover Parts A & B, and most cover D, but there are out-of-pocket limits.
- can req. additional premiums from patients
- COSTS TO MEDICARE > TRADITIONAL MEDICARE
122
How much does Medicare actually cover a beneficiary's actual health care expenses?
<50%, ~$5000/yr
123
What are some solutions intended to reduce out-of-pocket costs for medicare beneficiaries?
1) Medicare Advantage
2) Employer insurance
3) Medicaid (dual-eligibility)
4) Medigap plans
124
What is a Medigap plan?
Separate, private insurance policies offered to Medicare enrollees to cover uncovered expenses
125
Prior to 1982, how were hospitals reimbursed?
Based on "customary and reasonable" charges?
126
What were customary and reasonable charges replaced with?
The "Prospective Payment System" based on Diagnosis-Related Groups
127
What are the two main things medicare benefits pay for?
1) Medicare Advantage
| 2) Hospital Inpatient Services
128
What are the alternatives to fee-for-service currently being tested by the Center for Medicare and Medicaid Innovation?
ACO's, bundled payments
129
What does the public support most in terms of potential Medicare Reforms?
Better deals/discounts on pharmaceuticals
130
What issue does Medicaid create?
An issue between the insured poor and uninsured poor
131
How many people are covered by Medicaid?
~72 million people (~23% of total population)
132
How much does Medicaid cost annually?
$450 billion
133
Who funds Medicaid?
Federal-state
134
Prior to 2014, who was eligible for Medicaid?
Low income +
1) young child (CHIP)
2) parent of young child, pregnan
3) elderly
4) disabled
135
After ACA, who is eligible for Medicaid?
All individuals with incomes up to 138% of federal poverty guideline.
136
What ethnicity is predominantly covered by Medicaid?
Alaska Indian/Alaska Native (38%) then Hispanic (35%)
137
What percent of Medicaid beneficiaries are disabled?
15%
138
What person of Medicaid Beneficiaries are dual-eligible?
9%
139
Because Medicaid is funded by the federal budget, what does it become for state budgets?
A spending item and a source of federal revenue in state budgets.
140
What is the cost of Medicaid to patients/beneficiaries?
No to trivial out-of-pocket costs; some cost-sharing permitted for select groups (e.g. copay)
141
How are reimbursement rates for Medicaid set?
They are set by state and they are typically lower than Medicare
142
How much less are the Medicaid reimbursement rates, on average?
~34
143
What happened in NFIB vs. Sebelius?
Mandated Medicaid expansion by the states was ruled unconstitutional, making expansion optional. Only 31 states plus DC have expanded.
144
How was the ACA Medicaid expansion going to be funded?
The states would need to expand in order to receive matching funds from the federal gov't. BUT federal gov't would pay 100% until 2020, and then 90% thereafter.
145
What race/ethniciy with uninsured status has the lowest income and is eligible for the Medicaid expansion?
1) American Indian (63%)
| 2) Black (62%)
146
Policy-for-politics
policies driven by political consideration
147
Federally funded quality improvement organizations (QIOs)
develop and enforce standards re: appropriate care in Medicare
148
Distributive policy
spread benefits throughout society
149
Redistributive policy
designed to benefit only certain groups of people by taking money from one group and using it for benefit of another; often creates visible beneficiaries and payers = point of contention
150
Medicaid maximization
states took advantage of federal matching grants for Medicaid by including a number of formerly state-funded services under an “expanded” Medicaid program; allowed states to gain increased federal funding, while providing the same level of services they had provided before
151
Ways and Means Committees (House)
all bills involving taxation – power to tax
- Sole jurisdiction over Medicare Part A, Social Security, unemployment, public welfare, and health care reform
- Shares jurisdiction over Medicare Part B w/ House Energy & Commerce Committee
152
Energy & Commerce Committee (House)
Sole jurisdiction over: Medicaid, Medicare Part B, public health, mental health, health personnel, HMOs, food and drugs, air pollution, consumer product safety, health planning, biomedical research, health protection
153
Triple Aim
1) improving the individual experience of care
2) improving the health of populations
3) reducing the per capita costs of care for populations
154
Tragedy of the commons by Garrett Harden
great task in policy is not to claim that stakeholders are acting irrationally, but rather to change what is rational for them to do
155
Integrator
entity that accepts responsibility for all three components of the Triple Aim for a specified population
- cannot exclude members or subgroups of the population which it is responsible
- will link health care organizations whose missions overlap across the spectrum of delivery
156
How much is the U.S. spending on health (2010)?
2.6 trillion total = 17.9% GDP
157
National Health Expenditures
1) Hospital Care
2) Physician/Clinical Services
5) Prescription drugs
158
Why are health care costs growing faster than the economy overall?
1) Wealthier countries can afford to spend more on health care technologies
2) US population is getting older and disease prevalence has changed
3) Insurance coverage has increased
4) Americans pay a lower share of health expenses than they used
• lower cost sharing at the point of service = use more health care = expenditure growth
5) Unnecessary spending in the US health care system
• Health care waste >20% from overtx, failures of care coordination, failures of care delivery, admin complexity, pricing failures and fraud and abuse
6) recent slow-down in health spending
159
What are two main issues with health care costs?
1) the amount that is spent in the US per person for health care is high, particularly when compared with the amounts peer nations pay for care
2) health care expenditures grow rapidly relative to the economy overall, and have consistently done so for decades
160
Financial Stewardship
A physician's role in controlling health care costs by trading off small clinical benefits for individual patients in order to promote more general societal welfare
161
How does financial stewardship benefit population health?
1) Benefits the patients who receive less costly care; burden of paying for medical care can cause more distress from patients than clinical effects of tx
2) Increases peoples access to affordable medical care
3) Reduces population health by reducing pressure on health care institutions to cut back on important health care services
5) Allows society to direct its finite resources toward alternative activities that may have greater effect on population health than medical care itself
162
Forms of economic insecurity attributable to health care
1) Medical uninsurability
2) Medical Bankruptcy
3) Job lock
163
Job lock
inability to start a business or leave a job for fear of losing health benefits
164
What are three reasons/arguments for resisting healthcare reform?
1) Moral perceptions: I’m not sick, why should I pay for when you are sick
2) National values: Americans have adopted individual liberty more than any other developed country (i.e. individualism promotes suspicion of the govt)
• Negative liberty: freedom from government
3) Public responsibility = loss of freedom
165
Why does the US have high administrative costs for health care?
Bc diff types of plans and options
166
Who are the Big Five?
1) Aetna
2) Cigna
3) Humana
4) UnitedHealth Group
5) Anthem
167
Grand Bargain
a potential agreement between President Barack Obama and congressional leaders in late 2012 on how to curb spending and reduce the national debt while avoiding steep automatic spending cuts - not endorsed by Big Five
168
What are the two major tenets of the ACA?
1) General framework for expanding coverage
| 2) Timetable for instituting that expansion
169
Center for Medicare and Medicaid Innovation (CMMI)
tests alternative payment models and brings them to scale if they’re successful, as well as permanent ACO program in Medicare
170
Bundled payment models
single payment for all services provided during clinical episode
171
Population-based models
(e.g. accountable care organizations [ACOs]) base payment on results health care organizations and health care professionals achieve for all of their patients’ care
172
Family Glitch
legislative drafting ambiguity that excludes many working families from exchange tax credits
173
Section 1332 of ACA
allows states to apply for waivers from many core features of the ACA, such as the exchanges and the law’s employer and individual mandates, to pursue other ways of meeting the coverage goals while retaining the basic protections of the ACA
174
Non-group health insurance policies
private policies directly purchased on the non-group, or individual market
175
How many people are still ineligible for health insurance and why?
1) 4.9 million (15%) immigration status
| 2) 3.1 million (10%) state’s decision not to expand Medicaid
176
Universal coverage
concept implies that no American should lack access to health care because he or she lacks the ability to pay for it when needed and that no American should suffer serious financial distress or personal bankruptcy as a result of unpaid medical bills
177
Minority Health and Health Disparities Research and Education Act of 2000
created the National Center for Minority Health and Health Disparities and authorized the Agency for Healthcare Research and Quality (AHRQ) to measure the progress on reduction of disparities
178
Culturally and Linguistically Appropriate Services (CLAS)
seeks to ensure that people receive care in a culturally and linguistically appropriate manner
179
Racial and Ethnic Approaches to Community Health (REACH) grants funded by CDC
community-focused interventions to reduce specific neighborhood-based disparities
180
Accountable Health Communities initiative
test delivery approaches that address health-related social needs through clinical-community linkages
181
Donabedian
physicians must recognize that the culture and social systems in which they practice can enhance or detract from the quality of health care
182
Six core aims for 21st century health care system (Donabedian)
Care that is:
1) safe
2) effective
3) patient centered
4) timely
5) efficient
6) equitable
183
Low-value care
no-value care = receiving care that was simply a waste
184
How much of health care spending is hate?
30%
185
Information asymmetry
severe disadvantages that buyers have when they know less about a good than a seller does
186
Overdiagnosis
correct diagnosis of a disease that is never going to bother you in your lifetime
187
Turtle
abnormality that generally causes no harm
188
means test
a prerequisite for other welfare benefit
189
Sustainable-growth-rate (SGR) formula
mechanism to reduce fees if Medicare spending on Physicians’ services exceeds an aggregate target
190
Meaningful Use program (2009)
uses Medicare and Medicaid incentive payments to and penalties to encourage the electronic reporting of quality data with the use of HER
191
Medicare Shared Savings Program (MSSP)
ACA made it possible for providers who form ACOs within the traditional Medicare program to share responsibility for the quality and cost of care provided to the beneficiaries they treat
192
Medigap plans
supplemental private insurance, offset all/part of patients’ copays under deductibles under parts A & B
193
Fee-for-service model
rewards providers for volume and complexity of services provided
194
value-based purchasing
seeks to promote improved and more efficient care by rewarding providers for better performance or penalizing poor results
195
Hospital Quality Incentive Demonstration (2003)
offered bonus payments to hospitals on the basis of a set of quality measures
196
Blended payment
combination of fee-for-service payment + monthly care-management fee per patient for those served by advanced primary care practice + bonuses for reaching quality targets + shared savings
197
Bundled Payments
intended to support increased coordination and efficiency by setting a single prospective payment covering an inclusive set of services related to a specific medical condition
198
Accountable care organizations
accountable for both the cost and quality of care (ACOs)
199
Medicare Shared Savings Program (MSSP)
groups of providers that meet certain organizational requirements can share in any savings they produce as compared with the predicted cost that would have been accrued by Medicare patients in the ACO if they were treated in the usual system
200
Pioneer ACO
similar to MSSP except that providers in these organizations agree to share not only gains from savings but risks for costs that exceed those in the regular care system
201
Global payment
Providers receive a fixed payment in advance, covering all or most of the health care needs of a group of patients
202
Kerr-Mills Act
provided medical assistance to older persons and became a template for Medicaid
203
Federalism
a defining feature of American government in which power is shared between the federal and state governments
204
Oregon Health Insurance Experiment
RCT of Medicaid coverage on the basis of waiting-list lottery conducted in Oregon 2008
o Compared persons who were randomly selected to be offered Medicaid coverage with those on a waiting list who were not selected for coverage
o Results: evidence of major improvements in the lives of low-income adults who received coverage, with better access to primary care and recommended preventive services, improved mental health, better self-reported physical health, and reduced risk of medical debt
205
Safety net providers
public hospitals, community health centers
206
Delivery System Reform Incentive Payment (DSRIP)
federal government provides supplemental Medicaid funding so that state can reimburse groups of safety-net providers that implement innovative system transformation projects
207
Political culture
Americans are particularly susceptible to claims that the federal government is inept
208
Catalytic Federalism
Medicaid’s intergovernmental partnership encourages state and federal officials to prompt and prod each other to aggressively expand coverage and benefits
209
How many people do Medicare and Medicaid cover?
111 million (1 in 3); 10 million dual-eligible
210
How much do Medicare and Medicaid constitute for national spending?
39% ($1 trillion) or 23% of budget
Total US Budget: 3 trillion
211
How much hospital revenue do Medicare and Medicaid generate?
43%
212
How much of the Medicare population accounts for 59% of the spending?
10%
213
Diagnosis related groups & prospective payments
way to move away from fee-for-service for inpatient hospital care; instead of sending Medicare a bill, a set amount is determined prospectively and you need to treat accordingly to this set amount
214
Dimensions of access to health care
1) Geographic (e.g. transportation)
2) Physical Access (e.g. ADA accessibility)
3) Temporal Access (time)
4) Sociocultural Access (e.g. culturally competent providers)
5) Financial
215
Patient Centered Outcomes Research Insititute (PCORI)
Established as part of ACA to set priorities and fund comparative effectiveness research
216
What are the three components of a comprehensive comparative effectiveness assessment?
1) Clinical comparative effectiveness assessment
- net clinical performance
- clinical outcome heterogeneity
2) Economic costs
3) Broder clinical and nonclinical considerations
