Chapter 13: Stakeholders, Costs, and Patients’ Rights

Learning Outcomes

• Identify expectations of major stakeholders in U.S. health care system.
• Describe major factors influencing health care costs.
• Examine components of access and quality in health care.
• Summarize mechanisms for Americans to pay for health care.
• Examine status of patients’ rights to health care.

Stakeholders in the Health Care System

• Consumers: Patients and their families.
• Employers: Provide health insurance plans for employees.
• Health care facilities and practitioners: Included hospitals, clinics, etc.
• Governments: Federal, state, local.
• Private insurers: Offer various health insurance plans.
• Voluntary facilities and agencies: Affect policies and provide services.
• Health care training institutions: Educate future practitioners.
• Professional associations: Advocate for health care professionals.
• Biotech and pharmaceutical companies: Develop and produce health products.

Cost, Access, and Quality Definitions

• Cost: Total expenditure on health care by individuals, employers, and various agencies.
• Access: Availability and affordability of health care services.
• Quality: Degree of excellence in health care service delivery.

Sources of Revenue for Health Care

• Dominance of health insurance, accounting for 68% of funding.

Where Is the Health Care Dollar Spent?

• In 2020, the U.S. spent approximately $4.1 trillion on health care.

Rising Cost of Health Care Factors

• Fee-for-service reimbursement: Encourages higher service quantity.
• Fragmentation in payment and care delivery: Disconnected patient care.
• Administrative burden: Excessive paperwork for providers and patients.
• Aging population and chronic diseases: Increased health service demand.
• Medical technology advances: Innovation drives higher costs.
• Market consolidation and competition: Effect on pricing and access.

Access to Health Care

• Essential services should be:
  • Available and reachable.
  • Affordable and culturally sensitive.
  • Continuous and comprehensive.

Agency for Healthcare Research and Quality (AHRQ)

• Federal agency improving health care systems.
• Publishes National Healthcare Quality and Disparities Report showcasing strategies for better care, health promotion, and affordable care.

National Quality Strategy Aims

1. Better care: Enhanced quality through patient-centered approaches.
2. Healthy communities: Foster population health by addressing determinants of health.
3. Affordable care: Reduce overall health care costs.

National Quality Strategy Priorities

1. Safety and harm reduction during care.
2. Patient and family engagement.
3. Care communication and coordination.
4. Effective prevention and treatment.
5. Community health promotion.
6. Affordable care initiatives.

Population Changes Affecting Health Care Dynamics

• Decline in fertility and birth rates impacting workforce.
• Fluctuations in life expectancy trends.
• Shift from infectious diseases to chronic conditions as leading health concerns.
• The U.S. has the highest per capita health care expenditure globally.

Paying for Health Care: Insurance Models

• Private Insurance: Employer-based, with employee contributions.
• Medicare: For individuals 65 and over, funded by specific taxes.
• Medicaid: For low-income individuals, funded by federal and state governments.

Additional Coverage Programs

• TRICARE and CHAMPVA: Military families' coverage.
• CHIP: Health coverage for children from working families with incomes too high for Medicaid.
• Workers' Compensation Insurance: Covers job-related injuries, varies by state.

Patient Protection and Affordable Care Act (ACA)

• Enacted in 2010, significant reforms in health coverage.
  • No exclusions for preexisting conditions.
  • Dependents up to age 26 can remain on parents' plans.
  • Preventive health services mandated in plans.
  • Lifetime dollar limits removed.
  • Penalties for not obtaining insurance eliminated in 2017.
  • Established a Health Insurance Marketplace for plan comparisons and enrollment.

Patients’ Bill of Rights Overview

• HIPAA: Rights regarding personal health information.
• ACA initiatives to enhance patient protections, coverage assurances, and support family involvement in health care decisions.
• American Hospital Association: Promotes patient rights through the Patient Care Partnership and state-specific bills.