Health and disibility final exam prep

Controlling costs – Health expenditures as % of GDP, how much of the gdp are attributed to healht expenditures

how has this changed with time? 2020, 1980, now (2026)

why are these expendatures so high

Health care expenditures are approximately 20% of U.S. GDP [edit: clarified “GDP” means total market value of all goods and services produced in a country in a given year].

Timeline: In 1980: 9.2%,

in 2020: 19.7%.

Projected for 2026: $16,167 per person (vs. ~$1,100 in 1980s).

Why are expendatures so high: Growth due to..

high prices,

lack of standardization,

lack of transparency,

low-value care,

minimal government regulation,

high physician wages,

complex patient care,

and paying for social determinants of health.

Why U.S. health care costs have increased over time

High prices, no universal standardization, lack of care coordination, limited transparency, use of low-value services, minimal regulation, high wages for physicians, expensive complex care, and costs from addressing social determinants of health.

Health costs and outcomes model

• Healthcare costs and outcomes model

  • Use? - 

    • Provides a framework for discussion, analysis, and decision making

      • The relevant outcome of interest is the overall population vs an individual

      • Results that spending more money does not improve outcomes

Strategies for cost control – Painless methods

Control provider fees/incomes,

cut drug/supply prices ([edit: U.S. prescription drugs ~50% higher than other countries]),

reduce administrative waste,

unnecessary interventions/technologies,

increase preventive services to lower hospitalizations.

Where U.S. health care money goes

~⅔ from rising prices faster than other sectors,

~¼ from increased quantity of services. More specialists = higher costs.

Financing vs. reimbursement controls

Financing: flow of money from individuals/employers to health plans.

Reimbursement: money flowing from health plans to providers.

Stratagies for cost control: Financing controls – regulatory vs. competitive

• Financing controls

  • Regulatory: limits on taxes or premiumas

  • Competitive

Stratagies for cost control: Reimbursement controls –

• uses price controls

  • regulatory or competative

Price controls (regulatory or competitive), quantity controls (aggregate payment units, patient cost sharing, utilization management, supply limits), and mixed controls.

Stratagies for cost controls: utilization

• defined as quantity controls

  • aggregating units of payment

  • payment cost sharing

  • utalization management

  • supply limits

Use and Drawbacks of financing controls: regulatory and competative stratages

• Regulatory

  • The government’s regulation of taxes = control over public expenditures

  • Drawback: increasing taxes is a political process + inadequate support = larger budget deficits

• Competitive strategies

  • Health insurance plans compete based on price and are rewarded for lower costs

  • Drawbacks: us is not very good at controlling costs = higher premium plans

Cost containment – controlling quantity. How do you do it? what polcicies should we focus on? hint ther are 5

• Changing the unit of payment (global cost containment tools)

  • More aggregated units of payment to counter cost inflation due to provider pressure to increase quanity

  • More risk shifted to the provider- fee schedules or expenditure caps 

• Paintent cost sharing

  • Point of service” utalization

    • Individuals with cost sharing plans ⅓ fewer office visits and hospitalized ⅓ less times - leads to a reduction of preventative services

    • Us has one of the highest leves of cost sharing of any nation but hte highest overall costs

• utilization management

  • Insururser examine physician behaior and use of services and apply a micromanagement approach .

  • Looking more at the entire practice 

• supply limits

  • puts a limit on the number of providers + material resouces

  • requires physccicans to prioritze services on the approprieatents and urgency of patient need

• controling supply limits

  • control the number of genralists vs specialsits

• overgenralization

  • Micromanagement of capacity and budgets

  • Global cost containment tools - paying by capitation or aggregated methods, limiting size and speciality mix of providers, concentrating high-tech services regionally

Global cost containment tools to use (similar to quantity controls)

Capitation or aggregated payments, limiting provider numbers/specialty mix, regionalizing high-cost services.

Main reasons U.S. health care is expensive

High prices, lack of standardization, lack of care coordination, lack of transparency, low-value care, minimal regulation, high physician wages, costly complex care, and paying for social determinants of health.

Affordable Care Act – 4 main components

1) Insurance market reforms (no preexisting condition denials, no lifetime/annual caps, coverage until age 26, essential benefits)

• cannot deny based on preexisting conditions

• ended lifteime/anual caps

• standardized essential bennefits.

2) Public program expansion (Medicaid up to 138% FPL).

• if you are up to that level of the fedral poverty line

3) Health insurance marketplaces (buy plans if 138–400% FPL with subsidies).

• you can buy your own plan if you do not qualify for any of those meausres

• if you are between 138-400% of the income line the govnerment subsitizes some of this for you

4) Individual mandate ([edit: repealed in 2017]).

• you have to have insurance or else you pay a fine

What are some of the levels of the health insurance market places

• Do not qualify above? You can buy your won plan if you make between 138-400% of the fpl (government will substidise part of it for you)

  • Bronze – you receive minimal credible coverage. The plan covers 60% of the benefit costs of your plan.

  • Silver – covers 70% of the benefit costs of your plan

  • Gold – covers 80% of the benefit costs of your plan

  • Platinum – covers 90% of the benefit costs of your plan. \

ACA – Key coverage measuresy

High-risk pools for uninsured with preexisting conditions;

dependent coverage to age 26;

no lifetime caps;

no denial for children with preexisting conditions;

Medicare Part D coverage gap reduction;

Medicaid expansion to 133–138% FPL;

insurance exchanges; employer mandate (>50 employees must provide insurance).

Employer “Pay or Play” mandate

• - employers with more than 50 employees have an approximately $2000/ employee penalty if they do not offer an employer sponsored plan to atleast 95% of full time employees

ACA financing reforms

• Higher-income individuals pay more into Medicare; excise tax on high-cost employer plans;

• fees on pharma/insurance companies;

• more generic drugs;

• reduced Medicare payments to hospitals with excess readmissions.

private insurance

• no refusals for coverage due to preexisting conditions

• no mor elife tieme limits

• children now covered until 26

state responsiblity

• states are responsible for enrolling newly eligable medicare beneficiaries

• medicare payments were reduced to hospitals that had excess admisssions

• the approval of more generic drugs

ACA quality improvement measures

• Bundled Medicare payments;

• performance-based Medicare payments to hospitals;

• reduced malpractice litigation;

• funding for preventive services with no copays.

  • for screenigns for gestational diabees, cervical cancer, breastfeeding support, domestic violence, contraceptives, or chekcups

4 ways to get insurance under ACA

• Employment-based – for those who work for an employer that has more than 50 employees, your employer must offer you health insurance

• Medicare – If you are over 65, have chronic renal disease, ALS, or are disabled, you qualify for Medicare

• Medicaid – when the ACA was signed into law, you qualified for Medicaid if your income was below 133% of the FPL. Now the income qualification is up to 138% of the FPL.

• Health Insurance Marketplace Exchanges - If you do not qualify for any of the above, you may buy your own health insurance plan. In all but 19 states if you make between 138-400% of the FPL the government will subsidize part of the premium for your health insurance. It was up to each individual state to decide if they wanted to expand Medicaid up to 400% of the FPL. Some decided to and some did not.

National health insurance – common features of the ACA

• Benefit package includes hospital, doctor visits, imaging, rehab, prescriptions ([edit: excludes long-term care and dental]);

  • covers baseline needs

• minimal patient cost sharing;

  • a single payer system (national heaht insurance plan would minimize patient cost sharing. helps minimize people bing underinsure

• cost containment via global budgets and fee regulation.

  • global budget and have regulation on fees

Primary reasons why quality is lacking in U.S. health care

• Lack of access to care, (these are the primary causes

  • not all people have acces to the same services

• practice variations and defects, (primary causes

  • overuse of services,

  • underuse of effective care,

    • underuse of generic drugs= things costing too much

  • and misuse/errors.

• inefficiecny and wastes

  • long delays and waits for services

  • lack of communication between different hospitals

Misuse and errors in healthcare

Adverse events during Medicare patient hospital stays cause many deaths; frequent miscommunication and equipment failures.

Never events (serious hospital errors not reimbursed)

• Surgery on the wrong body part or wrong patient

• Wrong surgery on a patient

• Foreign object left in a patient after surgery

• Death/disability associated with intravascular air embolism, incompatible blood, or hypoglycemia

• Stage 3 or 4 pressure ulcers after admission (these occur when a patient is left in one position for an extended period— the skin breaks down and an ulcer develops).

• Death/disability associated with electric shock, a burn incurred within a facility, or a fall within a facility.

Inefficiency and waste in health care

Long waits, delays, and poor communication between hospitals reduce efficiency.

Donabedian’s quality assessment model

• hree central things influence outcomes

  • Structure, process, are influencing outcomes

    • Structure (source inputs)

      • Facilities

        • Must be licenced and accredited to make sure standards are met

          • Joint commissions accredits hospitals

          • The commission on accreditation of rehabilitation facilities (CARF) accredits rehab

      • Equipment

        • Equipment in hospitals and rehab facilies needs to be up to date 

      • Staffing levels

        • Proper staff and adiquae levels

      • Staff qualifications

        • Qualified staff

      • Delivery system 

        • Distribution of beds and staff

    • Process (actual delivery of services)

      • Interpersonal aspects of care (how patients are treated. How things are communitcated. Empathy and wahtnot)

  • To improve you much touch upon all aspects

Health Care Effectiveness Data and Information Set (HEDIS)

Used to compare and publicize provider performance to improve care quality.

Common HEDIS indicators? definition

• healthcare effectiveness data and information set

• What indicators does it includ

  • Children immuninized

  • Mammograms 

  • Pap smears

  • Prenatal exams

  • Eye exams for diabetic patients

  • Osteroperosis screaning

  • bmi

Methods to achieve malpractice reform

Tort reform (limits on awards to patients for malpractice),

alternative dispute resolution (mediation/arbitration),

• substituting mediation and arbatrition for jury truals

use of practice guidelines to assess negligence,

no-fault reform (compensation without proving negligence),

• providing copensation to paitens suffering medical injury regardless of negligance or not

enterprise liability (institutions responsible for compensation).

• making institutions responsible for cpomensations to improve quality of care need

What are some Proposals to improve quality of healhtcare outside of cost? who does this

Continuous Quality Improvement (CQI) that allows providers to explain mistakes instead of immediate punishment; quality report cards;

Electronic Health Records (EHRs);

Artificial Intelligence (AI).

National commits for quality assurance (NCQA)

• Created healthcare effectiveness data and Information Amset (HEIDS)

  1. Goal = compare performace and publicize that information to help improve clinical care

Role of EHRs and AI in quality improvement

HITECH Act (2009) led to EHR adoption in ~90% of hospitals, streamlining patient care but sometimes reducing interpersonal communication

• takes up more time to doccument too

. AI helps organize large data sets, reads digital images, and can outperform human pathologists.

National Committee for Quality Assurance (NCQA)

Created HEDIS to compare healthcare performance and publicize information to improve clinical care.

Components of high-quality care

• adequate access to care

• Competent healthcare providers

• Adequate scientific knowledge

• Money and quality of care

• Organization of health insitutions (being able to have information transformed easily)

"Being Mortal" – End-of-life care focus

Practitioners must have honest, sometimes blunt conversations about end-of-life care. Discussions can be hard but help patients and families make informed decisions.

Challenges in end-of-life care communication

Doctors may hasten patients to “take time and live” but this can cause fear; coping with death is difficult; patients living longer than expected may increase family stress.

Decisions at end of life

Patients may choose peaceful death or continued aggressive treatment; hard conversations especially around DNR (Do Not Resuscitate) and DNI (Do Not Intubate) orders.

Who would qualify for what: Rehabilitaiton, skilled nursing, nursing home - custodial only, hospice and home care

• Hospital care: used for acute conditions with a one or shorter effects or for chronic conditions

• Rehabilitation facilities: complex medical management or intense rehabilitation services. You have to be able to withstand 3 hours of therapy per day. Ex stroke patient tin recovery to bring them back to normal affairs

• Skilled nursing Facility: offers skilled nursing and rehabilitative services 

  • Used for patients who are not able to withstand 3 hours of therapy but still need therapy (medicare covers 100 days

  • Maintenance care (not covered)- assisting with daily living or activities 

  • Like elderly care homes

• Nursing home

  • Provide only custodial care (maintenance) - just help with daily living. You just live there not expecting to leave

• Hospice: 

  • Covered if you are terminally ill adn have les than 6 monyhs

    • The following things are covered

      • Intermittent nursing care, physical therapy, occupational therapy and speech therapy.

      • Doctors’ services

      • Medications including outpatient drugs for pain relief

      • Home health aide/homemaker

      • Medical social services

      • Medical supplies

      • Counseling

    • Unfortunatley there are significant gaps in coverage

• Home care:

  • When proviers come to your home to provider care to you

  • What do you need for medicare to cover this

    • Patient needs intermittent skilled nursing, physical therapy, occupational therapy or speach therapy

    • Patient is home bound

    • Physician must certify that there is reasonable cause for improvement

Long-Term Care Payment

Medicare does not cover custodial care.

Most pay out-of-pocket until Medicaid eligible.

• have to run out of a good portion of life savings

Private LTC insurance exists but is expensive/high deductible; ~13% of costs out-of-pocket.

PACE Program (On Lok Model)? when was it started? who finances it? what does it manage/ who does it help? purpose

Community-based care for 55+ to avoid nursing homes. Financed by Medicare/Medicaid. Manages multiple chronic conditions and ADL dependencies to keep elders in community.

• Combines all the necessary care needs for an elderly person

• started in the 70s

• assumes financial risk for frail individuals

• These programs try to keep people out of nursing homes and hospital facilites

Money Follows the Person (MFP)? How does it work?

Medicaid program helping nursing home residents transition to community living with flexible service funding and home modifications.

• How does mfp work

  • Allows for flexible funding helping states develop the infrastructure and process needs for transitions

  • Provides financial assistance for particiipatns

Medical Home

Primary care model with coordinated team managing all aspects of patient care to improve quality and outcomes.

• it is an apporach to providng comprehensive primary care… not an actual place lol. it extends outside of the hospital

Nurse Staffing in Nursing Homes

Required: 3.48 hrs care/resident/day (2.45 aide + 0.55 nurse); RN on duty 24/7. Only ~20% meet standard; efforts ongoing to increase staffing.

Health Promotion

Enabling people to control/improve health via social/environmental interventions beyond individual behavior.

History of Public Health in US

Early 1900s: state sanitary inspections/disease control → federal involvement → grants for mental health, substance abuse, prevention programs.

Assurance-Assessment-Policy Cycle

Continuous process: assess community needs → develop policy → assure services → reassess.

1. ASSURANCE GOES TO ASSESMENT WHICH INFLUENCE PPOLICY DEVELOPMENT AND IT GOES INTO A CIRCLE

2. How is this working

   1. Public health officials begin with assessing community nees

   2. Passing initiates should be next to promote teofrm

      1. Ex food pyramid to base nutrition 

   3. Prevention (two components)

      1. Primary prevention

         1. Preventing the first occursnde (ex immunizations)

      2. Secondary prevention

         1. Early detection of sisease (ex mammogram)

   4. 5 levels of intervention (bottom to top)

      1. Socioeconomic factors (baseline needs)

      2. Indiciduality

      3. Long lasting preventing conditions. 

      4. Clinical interventions

      5. Counseling and intervention (topeteor needs like malows hierarchy of needs)

Primary Prevention

Prevents disease before it occurs (e.g., immunizations, safety education).

Secondary Prevention

Early disease detection (e.g., mammograms, screenings) to improve outcomes.

Levels of Intervention (triangle graph:hint)

Socioeconomic factors → Changing context (policy/environment) → Long-lasting protections (vaccines) → Clinical interventions → Counseling/education. Population impact decreases from broad to individual.

COVID-19 & Public Health

Public health agencies assessed system weaknesses, underfunding, and inconsistent responses. Policies reduced transmission; applied assurance-assessment-policy model.

UK (NHS)

How is the NHS funded? How do hospitals and doctors get paied

• Funded by taxes (single-payer).

• uses a single payer (hospital) for healthcare

What does it cover?

• coveres nearly all care

• no cost for transport or seeing a doctor for the country

Who has access

• everyon regarlesss of profession through a pcp

How does the cost of care and outcomes compare to the Us

• better life expectancy and lower the costs than the us

• Covers nearly all care. Universal access via PCP. Better life expectancy & lower costs than US. Weakness: long waits for disability/chronic care.

Switzerland

Avg 16% income on premiums, high copays. Insurance not tied to jobs. Government regulates prices, mandates coverage. Everyone required to have insurance.

Australia

Public insurance (Medicare) funded by taxes, for citizens/permanent residents. Private insurance offers faster care/perks

• note private care may be better for those with chronic conditions or non urgent conditions

. Government sets drug/treatment prices. Strain from people dropping insurance → rising costs.

Canada

Universal healthcare system with no public/private split.

Strengths: coordinated resources, hospitals not overwhelmed during COVID.

Gaps: LTC, mental health, financial aid, tech delays.