HC exam 2

who are the major payers in the U.S.?

Medicare, Medicaid, The government taxpayers, & private and public insurers

Which program is the single largest federal healthcare expenditure? Explain what makes it so large.

Medicare.

It is a federal health insurance program that primarily covers adults aged 65 and older, as well as younger individuals with specific disabilities or conditions

spending on Medicare exceeds Medicaid.

Describe the uninsured population in the U.S. List three different reasons someone might be uninsured.

• High Cost and Affordability: The primary reason people are uninsured is that health coverage is too expensive.

• Lack of Employer-Sponsored Coverage: Many individuals lack access to health benefits through their jobs.

• State-Level Medicaid Expansion Differences: Public program eligibility varies significantly by state. Many low-income adults fall into a "coverage gap" where they earn too much for traditional Medicaid but too little to qualify for marketplace subsidies

 Single Payer

One public or government-backed agency acts as the sole insurer, collecting funds (primarily through taxes) and paying for all essential medical services for the entire population.

Multi-payer

where multiple public and private organizations like commercial and employer insurance pays for plans including government paying for Medicare. 

Universal Coverage

all people and communities in a country can access the full range of quality health services they need without facing financial hardship.

Non-universal coverage

a health insurance or healthcare system where not every resident is guaranteed coverage

What type of HC is the US & is it universal coverage?

Multi-payer & No

What type of HC is the Canada & is it universal coverage?

Single payer & yes

What type of HC is the UK & is it universal coverage?

Single payer & yes

What type of HC is the US Medicare & is it universal coverage?

Single payer & no

What type of HC is the US VA & is it universal coverage?

Single payer & no

What type of HC is the US Indian Health Service & is it universal coverage?

Single payer & No

How is Healthcare Funded

government taxpayers

People sometimes refer to “free healthcare.” In your own words, what does “free” usually mean in this context, and who ultimately pays for the care?

There is no such thing as “free,” and something that is considered so usually just falls back on people’s taxes.

The patient receiving the care does not have to pay out of pocket.

 Across the globe, the most common source of healthcare funding is

general taxes (taxpayers)

Why might a country primarily fund healthcare through taxes while still allowing people to purchase private insurance?

To guarantee a baseline of universal coverage for all residents, while still allowing private insurance to exist as a complementary, supplementary, or parallel option to offer extra choice and speed.

UK does this

main drivers of higher healthcare costs in the U.S.

High Prices for Inpatient/Outpatient Care, High Prescription Drug Prices, & Volume/utilization

Volume of Services (Utilization)

the quantity or frequency of healthcare services consumed by a population. 

-EX: total number of MRIs performed

Volume might be helped by reducing the numbers of unnecessary services and procedures

Unit Price (The Cost per Service)

the actual dollar amount paid to a healthcare provider or manufacturer for a single, discrete service or item.

-EX: the price of one MRI scan

unit price could be negotiated with different suppliers and companies.

Name at least four measures used to compare healthcare systems across countries.

Worse health outcomes even with the most amount of money spent and the most advanced technology and research, cost of care, payer systems, Quality, & Access to Care

List three reasons the U.S. may experience worse health outcomes than peer countries.

 Lack of Universal Health Coverage: The United States is the only major high-income nation without universal health coverage

Incentivizes volume over value, which directly leads to worse chronic disease outcomes compared to nations that reward efficiency and long-term health. A larger percentage of the population suffers from chronic illness than in any other country

Fragmented Primary Care: The lack of universal coverage and high out-of-pocket costs prevent patients from accessing routine preventive care.

The US also has worse health behaviors in general, contributing to severe illness later in life,

Compared with other countries, how do U.S. public-sector and private-sector healthcare spending differ?

The U.S. healthcare system differs because it relies heavily on private financing and has a much smaller public share of total health expenditures.

US uses a mix of public and private sectors as a multi-payer system for things like insurance

Other countries all have a single-payer system.

Why does spending more on healthcare not necessarily produce better health outcomes?

Medical care is only a small piece of a person's overall well-being, and high spending is often driven by system inefficiencies rather than effective treatment.

Price Control

Governments or single-payer national health authorities directly regulate, negotiate, or cap the prices of medical services, procedures, and prescription drugs.

Reference Pricing

The practice of using the prices of prescription drugs or medical treatments in one or more foreign countries to help set or negotiate the price in a home country.

Planned Rationing

The intentional, government- or system-level restriction of medical services, technologies, or medications to stay within a fixed public budget.

Vertical integration

different services joining together

-EX: 2 or more hospitals merging to form a single organization

Horizontal integration

organizations providing similar services are joined together.

-EX: a hospital and a long-term care facility merging

How could vertical integration affect healthcare cost, access, or competition? Consider both a potential benefit and concern.

 Significantly alters costs, access, and market competition.

 Benefits: Improved Care Coordination & Workflow

Concerns: Higher Costs and Reduced Competition

Teaching hospital

Provide American Medical Association-approved graduate medical education programs for physicians & education for other medical professionals.

-serve as recipient sites for clinical experience during trainings

-” Academic medical centers”

For-profit hospital

Primarily owned by shareholders to make a profit from the facility’s operations.

-Operated to produce income for individuals, partners, or shareholders of a corporation.

-Do not receive tax-exempt status

-Privately funded and subject to income taxes.

Non-profit hospital

Nonprofit hospitals are charitable organizations that reinvest all excess revenues back into operations, facilities, and community health

Rural hospital

Often have a disproportionate # of poor and elderly patients, have difficulty keeping up with demographic changes, cannot afford to purchase special equipment, or are unable to attract the speciality medical staff their communities demand.

-Difficult time surviving due to lack of staff and high technology, unable to provide complex care.

Why can hospitals be classified in multiple ways? Name one classification besides tax status.

 They serve diverse functions, have different financial structures, vary widely in physical scale, and fulfill distinct roles within the healthcare system.

Rural and urban are both examples of other classifications of hospitals, vary in financial, operational, and administrative purposes and have different goals.

Define an Accountable Care Organization (ACO). Who participates, and what are they accountable for?

 Come together voluntarily to give coordinated high-quality care to a designated group of patients.

• Preventive care

• Improve patient experience

• Reduce total cost.

How does an ACO try to improve quality and control costs? Give one example strategy.

An ACO tries to improve quality and control costs by shifting providers away from traditional fee for service models toward value-based care.

deliver coordinated, team-based care and sharing in financial savings

Care coordination

Eliminates duplicate services and prevents possible readmissions

Provider networks 

Strategically selecting and managing the physicians and facilities. 

Managing utilization 

Keep from over servicing like running excess test and scans. 

Define a maternity care desert

A county or local area that has no hospitals or birth centers offering obstetric care and no maternity care providers.

What percentage of counties in the U.S. are maternity care deserts, and why might maternity services disappear in some counties?

35% of areas are considered maternal deserts in rural areas.

They might disappear due to lack of specialized providers needed or financial downfall from an administrative standpoint.  

  List two consequences for patients when maternity care is far away.

Increased Risk of pregnancy complications and higher financial and emotional stress.

migration of couples trying to start families to places that can care properly for their new family. 

Propose one realistic policy or system fix that could reduce maternity care deserts.   

Virtual Prenatal and Postpartum Care through Telehealth programs and meetings.

Implement financial incentives for providers to migrate to these rural maternity care deserts like loan repayment of bonuses.

Define outpatient care.

Any HC services that do not involve an overnight stay in a hospital or other institution.

Rank these settings from highest cost to lowest cost: Telehealth, PCP same-day visit, Urgent Care, Emergency Room.

1. Emergency room: Without notice and often comes with many tests, therapies, blood work, procedures, and drugs administered, sometimes it even calls for emergency transportation. 

2. Urgent Care 

3. PCP same day visit 

4. Telehealth visit: often just requires a co-pay and can be very convenient for both providers and patients. 

Define burnout in a healthcare job in 1–2 sentences. What might it look like in the workplace?

Burn out can be losing drive, motivation and feeling purpose in your everyday job.

It might look like anxiety, or dread prior to shifts, it can cause distraction, mistakes and mental health issues. 

-depersonalization, emotional exhaustion, & lack of sense of personal accomplishment

Why might Patient overload stress occur?

Over worked due to understaffing 

Why might Administrative paperwork stress occur?

Overload of paperwork and the inability to keep up with the amount causing a backup in units or operational, financial improvements. 

Why might Staff turnover occur?

Bad staff turnover can occur when communication and preparation and documentation lacks.

What are Advanced Practice Professionals (APPs)? Name two APP roles and briefly describe what they do.

They take on care delivery responsibilities previously performed by physicians, allowing physicians to focus on complex care that requires their expertise.

Nurse practitioners (education follows that of nursing model) and Physician Assistants (education follows that of a physician’s model) are two examples.

Why are APPs increasingly important as the healthcare system faces provider shortages? 

They can provide similar services of a healthcare physician and helps bridge the gaps during these major shortages.

 Why is prescribing authority an important issue when expanding the roles of APPs? How can these rules differ across states?

This is an important issue to allow APPs to work as they need to allow for more quality to care and lower the risks that come with access to care without as many MDs. 

These rules differ as the ability to prescribe certain medications differs across the country and the ability to own their own practices and work without a doctor on staff to work under.

Why is a primary care provider often the first point of contact for routine preventive care and management of common chronic conditions? 

They are generally who you use year to year for checkups so when you go you can bring your concerns up with and they can provide referrals for specialists to work with for chronic conditions and preventative care. 

Blum Model

4 major inputs that contribute to our health & well-being:

-Environment (location & conditions)

-Lifestyle (behavior & situation)

-Heredity (genetic makeup)

-Medical care (what we receive from the HC system)

Lifestyle behaviors are emphasized

CDC Model

Social and structural determinants.  

Things like zip code, financial status, ethnicity 

-Community

-Societal

List at least four key elements of informed consent.

Risks, benefits, procedure overview, alternatives, understanding. 

Why is informed consent important to patient care? Give one ethical and one legal/safety reason. 

 Info on the treatment they are going to do to you, experimental, or big procedure-based

Ethically speaking it respects the patient’s autonomy and boundaries with their bodies. 

Legally speaking, without consent in certain situations it can cause legal backlash on the office/hospital and even cause issues concerning the provider and their license. 

Which populations tend to be higher users of healthcare? Give one reason healthcare needs may vary across different stages of life.

The youngest and oldest patients both need dramatic amounts of very different healthcare.

As a baby you need all your stages of newborn appointments and new baby vaccinations

As a woman in your early 20s you start seeing GYN for family planning or preventing, testing, and pap smears.

In yours 50s-60s you need a colonoscopy and breast cancer screening and in your late stages of life you might need hospice or nursing assistance at home or a facility. 

Define a health disparity. What factors can contribute to differences in health status or access between groups?

the differences in health status between groups. Financial status, zip code, ethnicity, age, sexuality, race.  

Often affect members of minority groups (immigrants, disabled, sexual orientation, etc.)

How could lack of insurance or access to primary care lead someone to use the emergency room as their usual source of care? 

 Because emergency rooms are legally required to treat anyone regardless of ability to pay

might be afraid to pay out of pocket