Healthcare Systems and Policy: Cost, Access, and Quality

Vocabulary flashcards covering health policy concepts, cost containment, access frameworks, quality dimensions, and healthcare dynamics in Puerto Rico.

Iron Triangle of Healthcare

A conceptual model introduced by Kissick in 1994 stating that cost, access, and quality exist in permanent tension under fixed resources, where steeering one vertex compromises the others.

Healthcare Cost

The total expenditure required for health services, evaluated from macro (national expenditure) and micro (individual/provider expenses) perspectives, where uncontrolled growth limits access and quality.

Healthcare Access

The actual ability of individuals to obtain necessary personal health services in a timely, affordable, convenient, acceptable, and effective manner.

Healthcare Quality

As defined by the IOM, the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and align with current professional knowledge.

Information Asymmetry

A healthcare market failure where patients rely on physicians to make clinical decisions, creating a principal-agent problem that can misalign interests.

Inelastic Demand

An economic condition where healthcare is consumed as a basic necessity, causing patients to pay high prices regardless of cost, particularly during emergencies.

Ley Núm. 26 of 1975

A Puerto Rico statute that created AFASS to administer and operate the hospital facilities of the Department of Health.

Ley Núm. 190 of 1996

A Puerto Rico law establishing the framework for privatizing government health facilities through leasing, sale, or transfer to the private sector.

Quadruple Aim

A healthcare framework consisting of four core dimensions: enhancing patient experience, better health outcomes, lower cost of care, and improved care team experience.

Quintuple Aim

An expanded analytical framework that adds equity and accessibility to the four dimensions of the Quadruple Aim.

National Health Expenditure (NHE)

The macro-level aggregate measure of the total amount spent on health care and health-related services across an entire nation.

Defensive Medicine

The practice of ordering additional diagnostic tests or treatments primarily to protect medical providers from potential malpractice litigation.

Small Area Variations (SAV)

Differences in healthcare utilization and practice patterns across geographic regions or specialties that do not correlate with differences in health outcomes.

Certificate of Need (CON)

A regulatory planning mechanism used by state governments to control capital spending and facility expansion in the healthcare sector.

Diagnosis-Related Groups (DRGs)

A prospective payment classification system used by Medicare to reimburse hospitals fixed amounts based on specific diagnostic categories.

Resource-Based Relative Value Scale (RBRVS)

A schema implemented by Medicare to determine physician reimbursement rates based on the resource inputs required to deliver services.

Quality Improvement Organizations (QIOs)

State-level external organizations contracted by Medicare to review medical utilization and ensure the necessity and quality of care for beneficiaries.

RAND Health Insurance Experiment

A randomized trial (1974–1982) showing that cost-sharing reduced healthcare utilization by 30–40% without harming health outcomes for healthy adults, though it worsened outcomes for poor, chronically ill individuals.

Andersen-Newman Model

A framework for analyzing healthcare utilization based on predisposing factors, enabling resources, and perceived or evaluated need factors.

Availability (Access Dimension)

The fit between the supply and capacity of health services (such as primary care and specialists) and the specific needs of a population.

Affordability (Access Dimension)

The alignment between the actual cost of receiving medical services and a patient's financial ability to pay.

To Err Is Human (2000)

A landmark IOM report estimating that 44,000 to 98,000 Americans die annually due to medical errors, reframing medical errors as systemic flaws rather than individual failures.

STEEEP Dimensions

The six quality aims established by the IOM in 2001: Safe, Timely, Effective, Efficient, Equitable, and Patient-centered.

Underuse

A healthcare quality defect occurring when scientifically proven, effective interventions or services are not provided to patients who need them.

Overuse

A quality problem where medical services or treatments are provided under circumstances where the potential risks exceed the expected clinical benefits.

Misuse

A failure in healthcare delivery where an appropriate clinical process or treatment is executed incorrectly, leading to avoidable injury or preventable complications.

Donabedian Triad

The foundational healthcare quality framework evaluating health services across three connected domains: Structure, Process, and Outcome.

Quality Assessment

The formal measurement of healthcare performance against predefined standards to evaluate current levels of quality.

Quality Assurance

The continuous process of implementing systemic actions and interventions based on measurement data to maintain and elevate healthcare quality.

Federal Medical Assistance Percentage (FMAP)

The statutory formula determining federal Medicaid matching rates, capped at ~55% by statute for Puerto Rico compared to ~83% if calculated using the standard state income formula.