US Healthcare Systems (1 of 3) questions and answers 2022

US Healthcare Systems (1 of 3) questions and answers 2022What are the basic components of a Health Services Delivery System? 1. Financing - how services are paid for 2. Insurance - protects against catastrophic risks 3. Delivery - provision of health care services by various providers 4. Payment - reimbursement to providers for services delivered What are the 4 part of the Quad-Function Model? 1. Financing 2. Insurance 3. Delivery 4. Payment 00:57 01:08 Define health care reform. The expansion of health insurance to cover the insured. What are 5 key components of the Affordable Care Act (ACA)? 1. Individual mandate 2. Insurance plans must cover "essential health benefits" 3. Insurance available for purchase on a web-based exchange 4. Expansion of Medicaid 5. Employer mandate to provide insurance for employees What does managed care seek to achieve? 1. Seeks to achieve efficiencies by integration of the 4 functions of health care. 2. Employs mechanisms to control utilization of medical services. 3. Determines the price at which the services are purchased and how much providers get paid. What is the iron triangle of healthcare delivery? Access, cost, quality Describe health care in the Pre-Industrial Era (Mid-18th to late 19th century) The consumer was sovereign in the market and healthcare was delivered under free market conditions. Medical practice was in disarray, medical procedures were primitive, the institutional core was missing, demand was unstable, and medical education was substandard. Define nosocomial infections. Infections acquired while receiving care. (Subcategory of iatrogenic illness.) Define iatrogenic illness (injury). Illness or injury caused by the process of medical care. What are 5 reasons medical practice was insignificant during the Pre-Industrial Era? 1. Medical practice was in disarray 2. Medical procedures were primitive 3. Institutional core was missing 4. Demand was unstable 5. Medical education was substandard Why was demand for medical care unstable in the Pre-Industrial Era? Opportunity cost of time spent and money spent traveling to the doctor were too high. Demand was limited by economic conditions and the traditional practice of medicine in rural eras. Describe health care during the Post-Industrial Era (late 19th to late 20th century). 1. Growth of professional sovereignty - as tech/meds advanced, status of physicians rose. 2. Physicians succeeded in retaining private practice of medicine and resisting national healthcare. 3. Employers took on a well-defined role in providing health care. 4. Growth of private health insurance. 5. Development of public health 00:02 01:08 Why did physicians rise to positions of power in the 1920s? 1. Urbanization 2. Science and technology / cultural authority 3. Institutionalization / pooling of resources 4. Dependency 5. Autonomy and organization (professional cohesiveness) 6. Licensing 7. Educational reform Define cultural authority. The general acceptance and reliance on the judgement of the members of a profession because of their superior knowledge and expertise. Legitimacy and acceptance of the profession grew. Describe organized medicine. The concerted efforts of physicians through the AMA which equated to professional cohesiveness. What 3 factors prompted the general need for health insurance? 1. Technological - advanced treatments that were desirable but expensive. 2. Social - desirability of medical treatments. 3. Economic - risk of catastrophic loss. What 3 reasons led to the growth of employer-based health insurance? 1. Wage freeze during WWII - employers offered insurance as a benefit in lieu of more money. 2. 1948 Supreme Court ruling - employee benefits were legit part of union-management negotiations. 3. 1954 IRS tax code revision - made employer-paid health insurance tax deductible for employers, tax-exempt for employees. Describe the 4 parts of Medicare. Part A - hospital and limited nursing home coverage (automatic). Part B - Covers physician bills. Pay separate from part A. Part C (1997) - Medicare managed care. Part D (2006) - Prescription drugs. Describe Medicaid. - Helps indigent populations pay for health care. - Eligibility determined via a means test. - A state run program, funded in part by federal government to match state contributions (Kerr-Mills Act). Define medical technology. Application of the scientific body of knowledge for the purpose of improving health and creating efficiencies in the delivery of health care. What is the role of medical technology in health care delivery? A tool to improve the efficiency, effectiveness, safety, and patient health. Excessive use of technology must be balanced with cost - what is the point of diminishing returns? What are some applications of IT and informatics in the delivery of health care? - Decision support systems (Often embedded in EHR) - Clinical information systems (Pharmacy data systems, Radiology & lab reporting systems) - Administrative information systems (Personnel management & scheduling) What factors influence the creation, dissemination, and utilization of technology? 1. Anthro-cultural beliefs and values 2. Medical specialization 3. Financing & payment 4. Technology-driven competition 5. Expenditures on research & development 6. Supply-side controls 7. Government policy What is the government's role in technology diffusion? Government funds 46% of medical technology R&D in the US. Aside from development, they have a responsibility to intervene and ensure safety measures are in place as technology is introduced into the marketplace (via the FDA). Define technology diffusion. The spread of technology into society once it is developed. What are some landmark pieces of legislation in the regulation of drugs and devices? 1906 Food and Drugs Act 1938 Food, Drug, and Cosmetic Act 1962 Kefauver-Harris Amendments 1976 Medical Devices Amendments 1983 Orphan Drug Act 1990 Safe Medical Devices Act 1992 Prescription Drug User Fee Act 1997 Food and Drug Administration Modernization Act What is the impact of technology on various aspects of domestic and global delivery of health care? - Increased longevity and degreased mortality for people around the world. - Greater effectiveness - Greater costs - Improved diagnosis and treatment (MRI, CT) - New treatments (total artificial organs) - Less invasive and safer procedures (laser surgery) - Molecular and cell biology (genetic research) Describe Health Technology Assessment (HTA). Any process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use, cost, and cost-effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended. What is the current and future directions of HTAs? - Mainly private sector initiatives (VA/DoD in public sector). - Information needs to be shared with providers and policy makers. - Standardization of methods is needed to make results comparable. - Balance between efficacy and economic worth will require a change in the American mindset. What provisions of the ACA pertain to medical technology? 1. The Biologics Price Competition and Innovation Act of 2009 - authorizes FDA to regulate biosimilars (parallel to generic drugs). 2. Biosimilar User Fee Act of 2012 - authorizes the FDA to charge a user fee for the premarketing review of biosimilars 3. A 2.3% excise tax on certain medical devices What are the benefits of the EHR? 1. Interoperability 2. Safety 3. Efficiency What does "meaningful use" describe? Part of HITECH Act - EHR must improve quality, safety, efficiency, and reduce health disparities. What is the HITECH Act of 2009? Provides financial incentives for providers seeing Medicare & Medicaid patients to adopt EHR systems ($19 million earmarked). What are the legal uses of personal medical information per HIPAA (1996)? 1. Health care delivery 2. Operations 3. Reimbursement What does the National Institutes of Health (NIH) do? Conducts and supports basic and applied biomedical research. What does the Agency for Healthcare Research and Quality do? Focus on quality, cost reduction, and better access. Define moral hazard. Consumer behavior that leads to a higher utilization of health care services when the services are covered by insurance. What is the role of health services financing? Payment for health insurance premiums. Can influence the supply and distribution of health services professionals. What are the 4 fundamental principles of insurance? 1. Risk is unpredictable for the individual insured. 2. Risk can be predicted for large groups or populations. 3. Transfer of risk from insured to group. 4. Risk pooling. What are the 10 characteristics that differentiate the US health care system? • No central agency (private systems, poor regulation over all systems) • Partial access (limitations with insurance) • Imperfect market (does not follow traditional supply/demand) • 3rd party insurers (no incentive to advocate for the patient) • Multiple payers (confusion and delayed collection) • Balance of power (variety of interests: providers, admin, insurance, employers, govt...) • Legal risks (malpractice, defensive medicine) • Technology • Continuum of services (curative, restorative, preventative) • Quality is achievable What are the characteristics of the US health care system? 1. Political climate (interest groups, laws and regs) 2. Economic development (general economy, competition) 3. Technological progress 4. Social and cultural values 5. Physical environment (air pollution, sanitation, global warming) 6. Population characteristics (demographics, health trends) 7. Global influences (immigration, trade, travel) Why is health care in the US delivered through an imperfect market? It is only partially governed by free market forces of supply and demand. Prices are set by 3rd party payers who are external to the market. Describe National Health Insurance (NHI). Government controls & coordinates financing, insurance, and payment; delivery of health care is private. Ex: Canada. Describe National Health System (NHS). Government controls all 4 functions of the health care delivery system. Ex: Britain Describe Socialized Health Insurance (SHI). Insurance and payment are integrated. Government mandates contributions to sickness funds by employers/employees. Delivery of health care is privatized. Ex: Israel, Germany, Japan What is the systems framework of US health care services? 1. System foundations 2. Resources (human & non-human) 3. Processes (continuum of care, special populations) 4. Outcomes (issues and concerns, change and reform) 5. Outlook (future of health services delivery) Define health. Per WHO: A complete state of physical, mental, and social well-being, not just merely the absence of disease. Compare illness vs disease. Illness - person's perception or evaluation of their status/feeling. Disease - based on professional evaluation and can be caused by more than one single factor. Describe Blum's model of health determinants. 1. Environment - sociocultural, physical / somatic 2. Lifestyle - attitudes, behaviors, diet, exercise 3. Heredity 4. Medical care What is market justice? Views health care as an economic good and emphasizes the individual. Rationing is based on the individual's ability to pay. What is social justice? Views health care as a social good, emphasizes collective health. Planned rationing of health care. What are the 3 basic health status measures? 1. Morbidity - disease and disability 2. Mortality - death 3. Life expectancy What are 2 crude utilization measures? 1. Access to primary care services = number of persons in a given population who visited a primary care provider in a given year / size of the population 2. Utilization of primary care services = number of primary care visits by people in a given population in a given year / size of the population What are 2 specific utilization measures? 1. Utilization of targeted services = number of people in a specific targeted population using special services / size of the targeted population group 2. Utilization of specific inpatient services = number of inpatient days / size of the population What are 3 institution specific utilization measures? 1. Average daily census = Total number of inpatient days in a given time period / Number of days in the same period 2. Occupancy rate = Total number of inpatient days in a given time period / Total number of available beds during the same time period 3. Average length of stay = Total number of inpatient days during a given time period / Total number of patients served during the same time period. Why has the US health care system been resistant to national health insurance reform? 1. No political threats 2. Private infrastructure (physicians, hospitals) 3. Sovereignty of the medical profession (AMA opposition) 4. Opposition from insurance industry, pharmaceutical industry, business (costs) 5. Opposition from labor unions (government was viewed as a usurper of their benefactor's role) 6. Beliefs and values of the American middle class (Market justice, Individualism and self-determination, Distrust of government, Reliance on the private sector to address social concerns) 7. Tax aversion What did the Flexner Report in 1910 achieve? Educational reform in medicine. Proposed higher standards, strict entrance requirements, and better educational facilities. What is the difference between primary care and specialty care? Primary care is the point of first contact for patients. Serve as gatekeepers and provide longitudinal care. Specialty care is sought after primary care, is more episodic and focused, requires a referral from a PCP. What are the different types of health service professionals? - Physicians (MD/DO) - CNM (Certified Nurse Midwives) - Non-physician clinicians (PA/Nurse Practitioner) - Allied health professionals What are the 2 broad categories of allied health professionals? - Therapists/technologists - Technicians/assistants Describe the maldistribution in the physician labor force. Refers to either a surplus or a shortage of the type of physicians needed to maintain the health status of a given population. Geographic and specialty. What is geographic maldistribution? Non-metropolitan areas lack both PCP and specialists, only 9% of physicians practice in rural areas. What is specialty maldistribution? 42% Primary Care/58% specialists. Relates to a rise in costs. Specialists are more prominent in US due to prominence of technology, higher wages, more prestige. What initiatives under the ACA sought to relieve shortages of primary care providers? o Places significant emphasis on preventive care and coordination of services requiring more PCP o Invested $230 million to increase all health professionals in primary care o Invested $12 million to train 300 new primary care residents. What is the role of non-physician providers? o Also referred to as physician extenders because they can in many instances substitute for physicians within primary care. o Receive less training than physicians o NPs work primarily in primary care whereas PAs are evenly divided between PC and Specialty care o NPs are oriented toward health promotion, PAs oriented toward a focus on disease o PAs are licensed to perform medical procedures only under the supervision of a physician o Certified Nurse Midwives are RNs who have training in maternal and fetal procedures. What are the functions and qualifications of health administrators? Provide leadership and strategic direction, responsible for long term success, departmental manager, planning and coordinating functions - Top level: MHA/MBA. Systems level. - Mid level: Bachelors or masters. Functional/departmental level. - Entry level: Bachelors. Team/clinic level. What challenges face the global health workforce? o 57 countries facing health workforce crisis o Shortage of 4.3 million doctor, midwives, nurses, and support workers o Shortage increasing with growing population o U.S has an aging health workforce o Migration of health professionals from developing countries to developed countries What is telemedicine? Distance medicine; employs the use of telecommunications technology for medical diagnosis and patient care when the provider and client are separated. (synchronous=real time/asynchronous=store and forward) What factors influence the creation, dissemination, and utilization of health care technology? 1. Medical specialization 2. Patient demand for latest tech 3. Financing and payment - insurance insulates patients from high costs of tech use 4. Tech driven competition - providers compete for patients by boasting latest tech. 5. Expenditures on research and development 6. Supply side controls - managed care slowed adoption of high-cost tech 7. Gov't policy What is the impact of technology on delivery of health care? 1. Impact on quality of care - more effective, less invasive procedures (lasers) 2. Impact on quality of life - longer, healthier lives 3. Impact on health care costs - primary cause of price increases 4. Impact on access - geography makes it harder to deliver specialty care to rural areas, but tech can help through eHealth/mHealth What impact did the ACA have on medical technology? - Imposed 2.3% excise tax on medical devices - Approved generic biosimilars - Prohibits putting $ value on quality of life for the purpose of determining cost effectiveness. What are the 3 insurance ratings? 1. Experience rating - based on a group's own medical claims experience 2. Community rating - spreads risk among members of a larger population; shifting costs from people in poor health to people in good health, making health insurance less affordable for those who are healthy 3. Adjusted community rating - (modified community rating) overcomes main drawbacks of experience rating and pure community rating by adjusting prices for demographics (age, gender, geography) while ignoring other risk factors; ACA requires adjustment for only age, family composition, geography & tobacco use What are the 4 types of insurance? 1. Group insurance - employer sponsored plan that anticipates a large # of enrollees; better risk sharing = lower costs 2. Self-insurance - large employer acts as its own insurer by budgeting $ to pay for medical claims 3. Individual insurance - usually higher risk people 4. Managed care - cheaper than plans offered by traditional insurance companies; use a selective group of providers to negotiate lower costs