pubh 402
Why Study the Medical Care System?
Studying the medical care system is considered "Big News!".
This is due to ongoing significant events such as the endorsement of "Medicare for All" by the second-largest doctors group in the United States.
Additionally, the system is currently facing strains from overlapping emergencies that impact the nation’s health workforce and threaten critical vaccination campaigns.
There are also significant policy debates occurring, like Congress acting on drug price reform.
What Services Does the Healthcare System Encompass?
The sources list a wide range of services that are part of the healthcare system:
Preventive and wellness healthcare services
Health screenings
Counseling on individual behaviors
Vaccines and medicines
Acute care
Care for chronic disease management
Reproductive health, prenatal care and childbirth
Emergency care
Surgery
Medicines for infectious illnesses
Medicines for chronic disease management
Intensive care
Mental health care services
Long term care services
Major Challenges Facing the US Healthcare System
The sources explicitly identify key challenges:
Cost
Quality
Access
Equity
Other challenges mentioned include disparities in care and efficiency.
Understanding the Cost Challenge
According to the sources, US health care costs are the highest in the world.
In terms of per capita spending, it was approximately $12,500 per capita.
As a proportion of the national economy, healthcare spending was about 18+% of Gross Domestic Product (GDP) in 2022.
Cost vs. Performance
Despite the high spending, the sources raise questions about whether this translates into better performance.
They ask, "Doesn’t higher spending mean better performance?" and "Isn’t US healthcare the best in the world?". This suggests that high cost does not automatically guarantee superior performance or being the best system globally.
Evaluating performance itself is complex, leading to questions like "What do we even mean by performance?" and "What is a 'high performing' health care system?".
Other System Characteristics and Questions
The sources describe the US healthcare system as characterized by a "Paradox of Excess and Deprivation".
Fundamental questions about the system that need consideration include:
How do we get access to care?
Is it good quality?
What does our healthcare system cost and is this sustainable?
1. Organization of US Healthcare
The US healthcare system is not a single, centrally planned system.
It is a mix of private and public systems that evolved with little to no central planning.
No one central agency governs the system as a whole. Instead, multiple subsystems developed based on market forces or the need to care for specific populations.
Numerous agencies at federal, state, and local levels have roles in administration, regulation, oversight, and financing.
Examples of different systems include:
Private, non-governmental (for-profit & non-profit) hospitals and outpatient care.
Local government public hospitals and clinics (mainly for the poor).
State government systems (mainly mental hospitals).
Federal government systems (Veterans' hospitals, clinics, nursing homes).
Separate systems for active duty military, Indian Health Service, and prison systems.
The US healthcare industry is large, stated as over $3 trillion.
The number of uninsured Americans was significantly higher (41-44 million) before healthcare reform efforts (ACA) compared to around 28 million currently.
The system faces challenges like high costs, barriers to access, and variable quality.
The US is described as the only major industrialized nation without a truly comprehensive, national healthcare or health insurance system. The system is like a "patchwork quilt" built with gradual additions, making it complex and somewhat fragile.
2. Evolution of Organization and Financing
Originally, the US healthcare system focused on acute illness management.
1850-1900:
Main health issues were public health concerns like epidemics (cholera, yellow fever) and problems with food, water, and sewage. Injuries were also an issue, but treatment options were limited.
Medical technology was minimal, and treatments were described as "anything goes" or "wild west".
Medical training was highly variable and rudimentary; physicians often apprenticed without science training.
Nurses were often poor/displaced or from religious orders.
The medical profession was not professionalized or well-paid.
Care was primarily by families, charities, and churches.
Hospitals functioned similarly to "poor houses".
1900 – Pre-WWII:
The Flexner report (1910) provided a critique of American physician education, revealing variations in training and effectiveness. It recommended standards for scientific training, licensure, and practice.
Physicians began to professionalize, seeking higher status, pay, authority, and autonomy, and excluding others.
Medical science and technology increased.
Hospitals evolved into institutions of science; private hospitals emerged for those who could pay, diverging from local public hospitals for the poor.
Payment was still largely out-of-pocket (cash, barter) or free care from charities.
1930s (Great Depression):
Health issues still largely focused on acute care like infectious diseases (e.g., pneumonia).
The Great Depression made the concept of public assistance more socially acceptable.
The concept of health insurance emerged to help individuals pay for care and help providers get paid. This saw the rise of "the Blues" (Blue Cross/Blue Shield).
World War II:
The government implemented wage freezes, allowing health insurance as a popular fringe benefit.
Health insurance became tax deductible for employers and pre-tax for workers, making it government-subsidized. This was very popular.
By the 1960s, the majority of patients no longer paid for care directly themselves.
WWII – Present (~1945-2000s):
Infectious diseases decreased due to antibiotics, vaccines, and sanitation.
Chronic illness increased.
There was an explosion in medical technology.
Employment-based insurance became widespread, leading to rising prices for care. Providers had significant power to set prices.
Many uninsured people still couldn't afford care.
The national government began two public insurance programs in the 1960s.
Healthcare costs began rising faster than inflation.
The idea of healthcare as a "right" gained traction.
The government became a major payer.
Various health insurance reform proposals were considered over the decades, leading to reforms being passed under President Obama.
3. Health Insurance Overview
Financing is how healthcare is paid for. Health insurance is key to the US system.
Financing in the US is largely market-based, unlike most other developed countries where it's mainly government-financed. It's paid for by employers, individuals, and government funds for safety net programs.
Healthcare needs are unpredictable in timing and cost.
In the insurance world, "risk" refers to a threat causing financial losses covered by insurance; this is different from the epidemiological definition of "risk".
The concept of "spreading risk" or a "risk pool" allows the higher costs of the less healthy to be offset by the lower costs of the healthy. A larger risk pool generally leads to more predictable and stable premiums.
Insurance helps increase the affordability of care for patients and the predictability of expenditures for the payer.
Health insurance is considered an important factor in medical inflation.
Moral hazard occurs when someone increases their exposure to risk because they are insured and someone else (the insurer) bears the cost.
Agency in health economics refers to the information imbalance between patient and doctor, potentially leading to physician-induced demand (doctors suggesting more services because they benefit).
Key terminology:
Premium: What you pay regularly (e.g., monthly) for your plan.
Deductible: The amount you pay before your plan starts covering anything.
Co-Pay: A fixed dollar amount paid when you use a service (e.g., doctor visit).
Co-insurance: A percentage of the total fee you pay after meeting your deductible (e.g., plan pays 80%, you pay 20%).
Types of health insurance include out-of-pocket, employer-based, individual private, workers' compensation, and governmental programs (Medicare, Medicaid, military).
4. Insurance Rating: Community vs. Experience
Early non-profit plans like Blue Cross/Shield used community rating.
Community rating: Premiums are based on risk factors for everyone in the market, not varied by individual health status or claims history.
As health insurance became lucrative, for-profit companies used experience rating to compete.
Experience rating: Premiums are based on risk factors specific to the individual or group purchasing the insurance.
Experience rating allows insurers to raise premiums on the sickest persons. It also allows insurers to select only the healthiest patients ("cherry-picking", "cream-skimming").
Community rating can potentially lead to adverse selection, where sickest people are more likely to buy insurance.
5. Government-Based Health Insurance
Government programs cover populations with "holes" in the employer-based system, such as the elderly, unemployed, poor, disabled, and employed without benefits.
Medicare:
Passed into law in 1965.
A federal "Social Insurance" program.
Payment is based on contributions (everyone pays, everyone gets paid after eligibility).
Has broad political support.
Eligibility: Primarily age 65+ who have paid into social security for 10 years (or spouse), disabled, or chronic dialysis patients.
Coverage:
Part A: Hospital acute care, psychiatric hospital care, post-hospital skilled nursing, post-hospital home health.
Part B: (Voluntary, monthly premium) Physician services, clinical lab, home health, medical equipment.
Part C: Allows enrollment in private plans (HMOs, PPOs), often managed care, sometimes with comprehensive benefits.
Part D: Prescription drug benefits.
Holes/Challenges: Does not cover long-term nursing home or in-home care. Generally doesn't cover hearing aids, dental, vision. Can have large deductibles for long hospital stays. Physicians can choose not to participate.
Financing Challenges: Expected increase in enrollment (Baby Boomers retiring) with fewer younger workers paying into the fund. This may shift more costs to patients.
Medicaid:
A "Public Assistance" program.
Financed by a Federal-State partnership and administered by states.
Eligibility is generally based on low income, with criteria varying by state. Also covers poor elderly, disabled, and blind on SSI (who may have both Medicare and Medicaid).
Most important payer for long-term care, paying for 60% of these services. A substantial portion of the Medicaid budget goes to long-term care for the poor elderly.
Challenges: Lengthy application, frequent reapplication. Low payments to healthcare providers often limit participation and access for beneficiaries. Strict rules on coverage. Can carry a stigma of "welfare". Costly for states. Has a weaker political support base than Medicare. Significant state-to-state variation.
Individual Insurance Market: For those not covered by employer plans, Medicare, or Medicaid, they must shop for insurance individually.
6. Medical Inflation and Managed Care
The 1970s and early 80s saw significant healthcare inflation.
The concept emerged of managing how doctors practiced to control costs and quality. This led to Health Maintenance Organizations (HMOs).
Managed Care is the integration of delivery and finance of healthcare.
It involves different provider reimbursement models and management of physician practice style to control costs and (in theory) quality.
Managed care became popular in both private and public sectors.
Examples include HMOs (set network, lower costs) and PPOs (more choice, often higher costs).
Trends in reimbursement are moving away from older models:
Hospitals used to charge "Usual, Customary, Reasonable" (UCR) – insurers paid whatever was demanded.
Physicians used to be paid "Fee for Service" – the more they did, the more they got paid.
Now, trends are towards new payment models that don't simply reward doing more things, aiming instead to reward value.
Despite patient suspicion and physician frustration (erosion of autonomy), almost all care is now managed care. The private and public sectors continue experimenting with payment models that reward value.
Study Guide: Access to Healthcare and Barriers
1. Defining Access to Healthcare
Access is defined as the ability to enter or get into AND use the healthcare system.
This includes:
Potential access: The ability to pay for care, having health insurance, and personal factors like acceptability.
Realized access: The actual amount of entry and use of healthcare services (e.g., how many services were used last year).
Researchers study and measure barriers to access.
2. Broad Categories of Barriers
Financial barriers
Non-financial barriers
3. Financial Barriers
Include issues like lack of insurance or inadequate insurance. Holes exist in the insurance system.
Major programs like the Affordable Care Act (ACA) and Medicaid expansion have helped, but access issues remain for large numbers of uninsured and underinsured populations.
An estimated 30 million people under age 65 remain uninsured in the U.S..
Higher rates of being uninsured (>20%) are seen among the poor, minorities, non-citizens (especially undocumented), and those without a high school diploma.
Financial barriers are strongly linked to receiving recommended care.
Studies like the RAND Health Insurance Experiment (a randomized trial) showed that as out-of-pocket costs go up, the use of care goes down, affecting both unnecessary and necessary care.
Medical debt is a significant issue even among people with health insurance.
24% of U.S. adults have unpaid, past-due medical bills.
Medical debt is cited in two-thirds of bankruptcies.
People with medical debt are more likely to show other signs of financial vulnerability and are more likely to skip or delay needed medical care.
Being uninsured also creates structural access issues.
Limited choice of healthcare providers willing to work with the uninsured.
Often rely on city/county safety-net providers (clinics and hospitals).
Less likely to have a regular source of care (a place they usually go for care).
Less likely to have a regular doctor.
Uninsured or publicly insured adults and children are more likely than the privately insured to have trouble finding a general doctor or be told a doctor won't accept them.
Less likely to receive needed specialty care.
4. Non-Financial Barriers
Categorized into:
Patient factors:
Culture
Communication
Language
Truth-telling
Individual vs. family decision making
Health literacy
Mistrust (of the system)
Knowledge
Fear
Structural factors:
Distance / travel time to facilities
Hours of availability
Wait times
Language availability at the facility level
Specialist availability
Stigmatization/discrimination
Policy barriers
The right mix of types and characteristics of personnel
Language Access is a specific non-financial barrier.
Access to trained medical interpreters is mandated but often not sufficient.
Reliance on "ad hoc" interpreters can lead to significant misunderstandings of medical instructions (e.g., "medicine IN the ear" vs. "medicine by mouth FOR the ear").
Non-financial barriers have a significant impact on the use of services. They can make it difficult for patients to maintain a regular doctor over time, potentially leading to quality problems.
5. Impact on Health Outcomes
Barriers to access DO affect health outcomes.
People facing these barriers are likely to receive:
Fewer health screenings
Less health education/counseling
Less prompt care
This can lead to being diagnosed later with illnesses.
Resulting in:
More avoidable hospitalizations
Greater illness severity and risk of complications
Lack of insurance is linked to a higher risk of overall mortality, even when controlling for other factors.
While medical care is not the only determinant of health status, access to care does have a significant impact.
Lack of insurance and underinsurance affects getting the right services within the right time frame, continuity of care, and ultimately, health outcomes.
6. The Healthcare Safety Net
Safety net providers are those who by mandate or mission offer access to care regardless of a patient's ability to pay and serve a substantial share of uninsured, Medicaid, and other vulnerable patients.
Types of safety net providers include:
Hospitals: Public (city/county) and private non-profit hospitals that care for a certain proportion of needy people. These can receive "disproportionate share" (DSH) funds.
Outpatient care clinics: Federal, State, and locally supported community health centers and Federally Qualified Health Centers (FQHCs).
Special service providers: Family planning clinics, school-based health programs, Ryan White AIDS programs, etc..
EMTALA (Emergency Medical Treatment And Labor Act) is a federal law requiring hospital emergency departments to screen and stabilize patients with medical emergencies regardless of insurance or ability to pay. This law has been an unfunded mandate since 1986.
The safety net varies widely by location.
However, the safety net system faces many problems:
Demand exceeds supply.
Financial challenges.
Administrative challenges.
Suboptimal Health Information Technology (HIT).
Patient challenges.
Challenges accessing specialty care.
7. Disparities
Health Disparities refer to variations in rates of disease, complications, and disability between defined populations (geographic, income, gender, racial/ethnic).
It is important to distinguish between disparities in health conditions/outcomes (patient health needs) and disparities in health services delivery (what the healthcare system does for patients).
These may overlap, but the distinction is important because each may require different solutions. For example, addressing equitable food access versus equitable access to specific medical exams.
Healthcare Provider Payment Methods: Study Guide
This study guide covers the key concepts and payment methods discussed in the sources, focusing on why different methods emerged, the incentives they create, and who bears the financial risk.
Introduction: The Role of Insurance and Challenges
Why Insurance? Insurance is considered a good way to pay for healthcare due to the unpredictability of both healthcare needs and the cost of care. Health insurance helps people pay for costly and unexpected medical expenses.
New Challenges: While helpful, insurance also contributed to new challenges, specifically medical inflation.
Early System: In the past, healthcare providers (doctors and hospitals) charged based on "Usual, Customary, and Reasonable" (UCR) charges. Insurance companies would basically pay whatever price was demanded.
Problem with UCR: This system was blamed for increasing costs because it reimbursed providers for basically anything they asked for. The incentive in this system was to raise prices.
Emergence of New Systems: To change this cycle, many health insurers started trying new ways to pay providers to change incentives and make providers "share the risk".
Complex Interactions in Healthcare Payment
Understanding healthcare payment involves a complex interaction between several factors:
Quality vs. Responsibility
Risk (payment) vs. Reward (profit)
Organizational Design
Healthcare Goals A change in one factor creates changes in the other two. This interaction is often unpredictable.
Reimbursement Creates Incentives
A core concept is that reimbursement (how providers get paid) creates incentives for healthcare providers. Different payment methods lead to different provider behaviors. When thinking about payment systems, it is always important to ask, "what are the incentives?".
Who is at Risk?
Another key concept is who bears the risk, meaning who bears the burden of or responsibility for excess costs. This also means understanding who is in a position to make money or lose money and under what circumstances. Payment systems are increasingly about incentives and who bears the risk. It is important to ask, "who bears the risk?".
Physician Payment Methods
Different payment methods for physicians create different incentives and shift risk differently:
Fee for Service (FFS)
Description: Providers are paid for each service provided.
Incentive: The more you do, the more you get paid, so the incentive is to do more.
Risk Bearing: More risk is borne by the insurance company (payer), less by the physician or practice. This is illustrated in Scenario #1 where PrimeCare is paid per physical exam and per electrocardiogram.
Salary
Description: Doctors are paid a set amount for working a certain amount of time or a specific job, regardless of the time it takes, number of patients, or services performed.
Incentive: Do less, go slow, go home early.
Risk Bearing: The individual doctors do not bear financial risk associated with patient care (they get paid the same regardless of what they do). This is illustrated in Scenario #4 where doctors are paid a set monthly amount regardless of patients seen or procedures done. (Note: How the group practice is reimbursed is not specified in this scenario, so the overall risk for the group is unknown).
Capitation
Description: Paid a flat rate per patient per month regardless of the cost or effort involved. Literally means "per head".
Incentives: Do less, attract healthier patients / shed sicker patients, or prevent trouble.
Risk Bearing: More risk is shifted from the payer (insurance) to the doctors' group practice. If a patient needs a lot of care, they might be more expensive than the monthly capitated payment, causing the practice to lose money for that patient. If the patient needs little or no care, the practice profits. This is illustrated in Scenario #2 where LeanCare receives a flat $25 per month per patient regardless of services provided.
Risk Adjustment: Some payers introduced risk adjustment to account for differences in how "sick" patients are, adjusting payments upward for sicker patients requiring more complex care. This requires significant data.
Episode of Illness or Care (Bundled Payment)
Description: A single fee is paid for a package of services related to a specific episode of illness or care, such as a surgical procedure and associated pre- and post-operative visits.
Incentives: Reduce errors and complications, increase efficiency. There can also be an incentive to refuse sicker patients who might require more complex or costly care.
Risk Bearing: More risk is shifted from the payer (insurance) to the provider (e.g., the surgeon). The provider could lose money if the patient's needs are more costly than the bundled fee. This is illustrated in Scenario #3 where Dr. Hernandez receives a flat fee for a gallbladder removal including surgery and visits. Bundled payments can aggregate across provider types, longer time periods, and different service types.
Hospital Payment Methods
Hospitals can also be reimbursed in different ways:
Per Diem
Description: The hospital is paid by the day.
Incentive: Keep patients more days, leading to longer hospital stays.
Risk Bearing: The payer (insurance) bears the greater risk. If the patient has a longer length of stay, it costs the insurance company more. This is illustrated in Scenario #5 where Happy Hospital is paid based on the number of days the patient is in the hospital.
Diagnosis-Related Group (DRG)
Description: A system developed in the 1980s to pay a set amount for all the care associated with a hospital stay for a specific diagnosis. This is another type of "bundled payment" for a hospital episode of illness. The set amount is based on the diagnosis, regardless of the actual length of stay or exact services provided.
Incentives: The sources ask what the hope and expected effect were. Based on the risk shift, the incentives would likely be to increase efficiency and potentially reduce the length of stay.
Risk Bearing: This shifts the risk from the payer (insurance) to the hospital. The hospital could lose money if a patient's care is more expensive than the fixed DRG payment (e.g., due to complications or inefficiency). If the hospital can provide care for less than the DRG payment, they make a profit. This is illustrated in Scenario #6 where In N’ Out Hospital is paid a set amount based on the acute MI diagnosis, regardless of the length of stay or exact care.
Global Budget
Description: The hospital is paid a set annual operating budget for all services.
Incentives: The source asks what the incentives are. Based on the risk shift, potential incentives could include careful management of resources and prioritizing cost-effective care.
Risk Bearing: The provider (hospital) bears more risk compared to systems like FFS or Per Diem.
Organizing Payment Systems by Aggregation and Risk
Payment systems can be organized based on the amount of aggregation (grouping of services) and who bears the risk.
Less Aggregated: Payment is broken down into smaller units (e.g., per procedure, per day). The Payer (insurance company) has more risk in these systems because they pay based on the volume or duration of services provided.
Examples: Physician Fee for Service, Hospital Fee for Service, Hospital Per Diem.
More Aggregated: Payment is for larger units (e.g., episode of illness, per patient, per time period). The Provider (doctor or hospital) has more risk in these systems because they receive a fixed payment for potentially variable costs.
Examples: Physician Bundle/Episode of Illness, Physician Capitation, Physician Salary, Hospital DRG, Hospital Capitation, Hospital Global Budget.
General Rule: As a general rule, the more aggregated the payment, the more risk is shifted from the payer (insurance company) to the healthcare provider (either the doctor or the hospital).
Towards Value-Based Payment
Old School: Paid more for merely doing more (volume), which incentivized doing more, potentially regardless of appropriateness.
Next Phase: Attempts to control costs with systems like capitation, which incentivized doing less, potentially regardless of appropriateness.
Current/Future Challenge: The goal is now to figure out how to incentivize the best quality care AND control costs.
Incentivizing Quality: Methods include Pay-for-Performance, Bundled Payments (can aggregate across providers/time/services), and "Accountable Care".
Accountable Care: Involves shared risks (losses) and benefits (profits), shared responsibility for quality, and shared responsibility for organizational design.
Value over Volume: Payment systems are still experimenting with ways to reward the value, rather than the volume (amount) of healthcare services.
Balancing Goals: There is a need to control costs to improve access, but simultaneously, a need to maintain and improve quality.
Summary Points
Historically, providers were paid Fee-for-Service at "usual, customary, reasonable" prices, which contributed to medical inflation and rising costs.
Significant medical inflation led to the creation of newer provider payment systems, including capitation and various forms of bundling.
A key way to understand the effects of these systems is to consider who bears the financial risk.
Payment systems continue to experiment with ways to reward value rather than the volume of services.
Healthcare faces the challenge of controlling costs to improve access while maintaining and improving quality.
PUBH 402: US Healthcare System Organization (Chs 5 – 6)
I. Organization of Healthcare in the US
The US Healthcare system(s) evolved with little to no central planning.
It evolved to be focused on a biomedical approach to acute illness management.
NO CENTRAL AGENCY GOVERNS THE SYSTEM as a whole.
The system includes both private and public systems.
Many different agencies have roles in administration, regulation, oversight, and financing.
II. Levels of Care
Medical care is generally categorized into three broad levels.
Primary care involves preventive services and treatment of common problems.
Accounts for 80-90% of healthcare visits.
Understanding the functions and importance of primary care providers is noted as important (with more detail coming later).
Secondary care involves problems that require more specialized clinical expertise.
Tertiary care involves treatment of more rare problems.
Requires the highest degree of specialized and intensive care.
III. Major Models of Organizing Care
Generally, two different approaches or models can be used to organize a healthcare system to deliver the three levels of care in a given region or geographic area.
1. Planned Model:
A more planned, structured model.
Organizes care to meet population needs for the three levels of care in a region.
"Planned" implies that someone or some agency has responsibility for the health of the population.
This entity has some level of authority (to say "yes" or "no").
Also has budgetary control.
Example given: The UK.
2. Dispersed Model:
A less planned, less structured model.
Numbers and locations of providers and technological resources are not so tightly planned.
Patients may have more freedom to enter and move about the levels of care as they and their personal healthcare providers see fit.
This model implies that other forces direct the allocation of scarce resources.
In the US, this force is usually the Market.
The Market includes: Competition among sellers, Consumer choice, Willingness to pay.
These forces are seen as deciding the "winners and losers".
IV. The U.S. as a Dispersed Model
The U.S. exemplifies a more Dispersed Model.
Characterized by less centralized planning and a preference for market forces.
There is a strong role for MD professionalism & autonomy.
Patients generally able to refer themselves to any level of care (if they have access).
Competition incentivizes providers to offer what patients want (even if it leads to "overuse").
Hospitals often compete on specialization and technology, instead of these resources being distributed by regional needs.
V. Summary Points
The US healthcare systems evolved with little to no central planning.
Medical care services can be categorized as primary, secondary, or tertiary care.
A country’s healthcare system may be organized using the planned or a more dispersed model.
Earlier structures evolved into more complex systems, including HMO’s (which may be vertically integrated, or virtually integrated). (More on this is noted for the following week).
Based on the sources you provided and our conversation history, here is a study guide covering the organization, models, and evolving structures of the US healthcare system:
This study guide summarizes key information from the provided source material regarding the structure and evolution of the US healthcare system.
I. Organization of Healthcare in the US
The US healthcare system(s) are described as having evolved with little to no central planning.
The system is primarily focused on a biomedical approach to acute illness management.
There is NO CENTRAL AGENCY that governs the system as a whole.
It comprises both private and public systems.
Numerous agencies play roles in administration, regulation, oversight, and financing.
There is a complex interaction between factors such as quality vs. responsibility, risk vs. reward, organizational design, and healthcare goals.
II. Levels of Care
Medical care is generally categorized into three broad levels:
Primary care: Involves preventive services and the treatment of common problems that account for 80-90% of healthcare visits.
Secondary care: Involves problems that require more specialized clinical expertise.
Tertiary care: Involves the treatment of more rare problems that require the highest degree of specialized and intensive care.
III. Major Models of Organizing Care
Healthcare systems can be organized using two general approaches to deliver these levels of care:
Planned Model:
A more structured model that organizes care to meet the population's needs for all three levels of care within a given region or geographic area.
Implies that "someone" or some agency has responsibility for the health of the population and possesses a level of authority and budgetary control.
The UK is given as an example of this model.
Dispersed Model:
A less planned, less structured, and more free-flowing model.
The numbers and locations of providers and technological resources at different levels are not tightly planned.
Patients may have more freedom to enter and move between levels of care as they and their personal healthcare providers deem appropriate.
The allocation of scarce resources is often directed by other forces, primarily the Market in the US. Key market forces include competition among sellers, consumer choice, and willingness to pay.
The U.S. exemplifies a More Dispersed Model.
Features less centralized planning and a preference for market forces.
Characterized by a strong role for MD professionalism & autonomy.
Patients (assuming they have access) are generally able to refer themselves to any level of care.
Competition incentivizes providers to offer what patients want, potentially leading to "overuse".
Hospitals often compete on specialization and technology, rather than these resources being distributed based on regional needs.
IV. Structures of Medical Care Delivery
Traditional structures (around the 1970s):
Physicians commonly practiced in solo or small group practices, generally paid on a Fee-For-Service (FFS) basis.
Hospitals were commonly non-profit, sometimes affiliated with religious orders or medical schools, and often had a board of trustees.
Crucially, physicians were not employed by hospitals but joined the hospital "staff" with "admitting privileges". This structure gave physicians dominant power in the hospital because the hospital's business depended on physician referrals.
Seeds of Modern Structures: Historically, other structures existed that formed the basis for newer structures emerging today:
Multi-specialty group practice.
Community health center.
Pre-paid group practice/HMO.
V. Early Models
The Multi-Specialty Group Practice:
The Mayo Clinic is given as an early example.
This was a physician-owned and operated group practice that employed physicians from multiple specialties and support staff.
Staff physicians were paid a salary, but the group began accepting and billing insurance on an FFS basis.
Benefitted from close collaboration among different specialty types.
Criticism included the potential for large groups to be impersonal with no single MD accountable for the patient.
This model was attacked by the AMA for threatening MD autonomy.
Community Health Center (CHC):
An early example is the Greater Community Association in Creston, IA.
Civic, religious, education, and healthcare groups collaborated to provide care, primarily in a rural area.
Focused on preventive and primary care and utilized a system of public health nurses.
Hospitalization was viewed as a last resort where prevention had failed.
The CHC model was revived and brought to urban areas in the 1960s with the federal neighborhood health center program, having roots in the civil rights movement and the War on Poverty.
Pre-Paid Group Practice / HMO:
Early examples include Group Health Cooperative of Puget Sound and Kaiser Health Plan.
Original principles were group practice, pre-payment, and prevention.
This structure combined medical care and financing.
Instead of paying a premium to a third party who then reimburses providers, the premium is paid directly to pre-purchase the healthcare itself.
In the 1970s, these organizations began to be called "Health Maintenance Organizations (HMOs)" and were promoted by legislation hoping to contain medical inflation.
The "Health Maintenance Organization" Act of 1973 was significant, requiring employers with 25 or more employees to offer federally certified "HMO" options if they offered traditional healthcare options.
VI. Flavors of HMOs
HMOs evolved into different forms:
Vertical Integration:
Considered the "First generation" or "HMO with walls".
The supply chain of the organization is owned by that company.
Kaiser is given as an example, consolidating ownership under one roof, including the Health Plan (insurer functions), the Hospital corporation, and the Permanente Medical Group (physician organization). Kaiser also has its own integrated IT system.
Virtual Integration:
Considered the "Second generation" or "HMO without walls".
Also known as the "Network-Model HMO".
Achieves similar benefits and added flexibility through contractual links, rather than requiring ownership of everything "under one roof".
In the network model HMO, physician organizations have contracts with multiple health insurance plans, each with their own payment arrangements.
The source poses the question of whether the health insurance plan can influence provider behavior in this "without walls" model as effectively as in the vertically integrated "with walls" model.
VII. How HMOs Achieve Savings
They utilize payment mechanisms that shift away from FFS, employing types that do not solely incentivize a sheer volume of services.
These mechanisms shift risk to providers (at least to the organization).
The theoretical ideal was that provider organizations bearing risk would have an incentive to keep patients healthy (and thus lower costs).
In the vertically integrated HMO, the organization can improve efficiency through economies of scale, achieve better care coordination, and promote a specific organizational culture and practice style.
Research into how HMOs achieve savings found that the most impactful differences in practice, in terms of cost reduction, were linked to a strong role for primary care.
VIII. Primary Care: Functions and Value
Research highlighting primary care's importance in HMO savings leads to a focus on its value:
Definition (U.S. Institute of Medicine, 1996): "The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community".
Key Tasks:
First contact.
"Longitudinality" (continuity) – Building and sustaining a relationship over time.
Comprehensiveness – Ability to manage a wide range of needs.
Coordination – Of services delivered by multiple caregivers.
The “Gatekeeping”/Coordination function has been identified as crucial in successfully helping patients navigate the healthcare system and plays a key role in well-functioning HMO/managed care organizations.
Healthcare providers who commonly fulfill these roles include General Practitioners (common in the UK), Family Practice, Internal Medicine, Obstetrics/Gynecology (for women), and Pediatrics (for children).
IX. Even More New Models Are Evolving!
These newer models seek to leverage the benefits of primary care:
Patient-Centered Medical Home (PCMH) Model:
Builds on a strong foundation of primary care.
Takes a population-based view of the patients under its care, meaning the practice is responsible for the whole registered population it serves, not just the patient currently present.
Coordination is key.
Payment is often a blend of capitation and FFS, sometimes using bundled payments.
Reimbursement for coordination of care is built into the bundled payment system.
Compared to the traditional model where care is visit-dependent and patient-coordinated, the PCMH uses a proactive plan to meet health needs, standardizes care based on evidence-based guidelines, and employs a prepared team of professionals to coordinate care for all patients, including tracking tests, consultations, and follow-up.
Accountable Care Organization (ACO):
Another new approach aimed at improving coordination and incentives.
It is physician-led, formed by a group of physicians (primary care and specialists) along with hospitals and other necessary providers.
The mission is for the payer and providers to take responsibility for all the care of a defined group of patients and to share the financial risk.
They operate within a global budget target for the care of those patients.
X. Summary
The US healthcare systems evolved with little to no central planning.
Medical care services can be categorized as primary, secondary, or tertiary care.
A country’s healthcare system can be organized using a planned or a more dispersed model.
Earlier structures evolved into more complex systems like HMOs, which can be vertically integrated or virtually integrated.
Understanding the functions and importance of primary care providers is crucial.
A significant goal for the US system is to find ways to deliver (and pay for) healthcare services that reward quality services, not just the amount of services.
Okay, here is a study guide based on the provided source material regarding the healthcare workforce.
Study Guide: The Healthcare Workforce
This guide summarizes key concepts and data points from the provided session materials on the healthcare workforce. Focus on understanding the different professions, their education, numbers, and the broader issues of supply, demand, and diversity.
1. The Nation's Major Health Professions
Know the main categories of health professionals discussed:
Nurses (Registered Nurses, Licensed Practical/Vocational Nurses, Nurse Anesthetists, Nurse Midwives, Nurse Practitioners).
Physicians & Surgeons.
Pharmacists.
Other important clinical health professions:
Physical/Occupational Therapists.
Dentists.
Respiratory Therapists.
Physician Assistants.
Social Workers.
Psychologists.
Etc.
Be familiar with the overarching questions: Who are they? What are their educational pathways? How many are there?.
2. Numbers of Healthcare Jobs (as of 2018, Bureau of Labor Statistics)
Be aware of the approximate numbers for major professions as listed:
Registered Nurses (RN): 3,059,800
Nurse Anesthetists, Nurse Midwives, Nurse Practitioners: 240,700
Licensed Practical/Vocational Nurses (LPN/LVN): 728,900
Physicians & Surgeons: 756,800, roughly 750,000 in practice.
Physical Therapists & Occupational Therapists: 380,700. Physical Therapists (PT): 247,000 / Occupational Therapists (OT): 133,000 (these numbers add up to ~380k).
Pharmacists: 314,300.
Dentists: 155,000.
Respiratory Therapists: 134,000.
Physician Assistants (PAs): 118,800. Note: About 120,000 PA grads annually is mentioned, suggesting growth beyond the 2018 job number.
Social Workers: 707,400. >700,000 practitioners, described as a growing profession.
Psychologists: 181,700.
3. Educational Pathways & Training Details
Physicians:
Education requires a Bachelor's degree first.
Followed by Medical School, a 4-year, science-based curriculum. The Flexner Report standardized training and led to the closure of some schools historically.
Requires Postdoctoral training (internship + residency). At least one year (internship), but most complete more (3 to 5-7 years for specialization, plus potential fellowships for sub-specialty).
State licensure requires certification of graduation from medical school, passing a licensure exam, and completion of 1 year of residency (in most states).
Residency Training (More Details):
Accredited by ACGME for allopathic (and osteopathic) programs.
Many programs are affiliated with academic medical centers or sponsored by community hospitals.
Residency is an important source of workforce for hospitals.
Board certification in a specialty requires completing an accredited residency and passing a specialty board exam. While not required for state license, it is de facto required for admitting privileges and joining HMO networks.
Only about 70% of residency spots are filled by US medical school grads. Foreign Medical Graduates (FMGs) fill the rest.
FMGs must complete a US residency to get a US medical license, regardless of prior training/experience abroad. FMGs can be US citizens who studied abroad or non-US citizens (almost half from India, Philippines, Mexico, Pakistan). They typically receive temporary educational visas for residency, which may be extended if they agree to practice in a physician shortage area.
Medical education financing: Students pay high tuition for med school. The Federal government plays a major role in financing residency programs via Medicare Graduate Medical Education funds to sponsoring hospitals. Funding is based on Medicare patients, trainees, and indirect costs, and Medicare limits the total number of funded slots.
Physician Assistant (PA):
Licensed to practice medicine with physician supervision.
Originated in 1965, providing a pathway for Vietnam War medics.
Must graduate from an accredited program and pass a licensure exam.
Most programs require a Bachelor's degree and last 20-36 months, described as a "condensed version of med school".
Historically, most worked in primary care, but now only about 28% practice in primary care.
Registered Nurse (RN):
Largest health profession in the US.
Education historically was in hospital-based diploma programs but has shifted to academic training (2-3 year Associate Degree RN or 4-year BS Degree RN). Research suggests potential better patient outcomes in hospitals with more BS RNs.
Requires passing a national licensing exam administered by the National Council of State Boards of Nursing.
Foreign-trained nurses have helped fill shortages. They do not need US training for licensure eligibility and can sit for the exam and apply for an occupational visa. About 1/3 historically were from the Philippines.
Nurse Practitioner (NP):
An "Advanced Practice" nurse.
Education typically a 2-year Master's after a BSN; may involve a Doctorate (DNP).
Primary care NPs may perform about 80% of physician tasks with equivalent quality.
Pharmacist:
Education historically a Bachelor's, now requires longer training for a Doctor of Pharmacy (6-8 years total). Fellowships available for specialization.
Physical & Occupational Therapists (PT/OT):
Require a Doctor of Physical Therapy (DPT) degree for PT, and a Master's degree for OT.
All require a state license.
Social Worker:
Most health care-related positions require a Master's degree and state licensure.
4. Supply, Demand, Shortages, and Surpluses
The overall supply (numbers and ratios to population) of most health professionals has been rising in past decades.
However, health services analysts have had concerns about both shortages and surpluses at different times.
Example: Concerns shifted from physician surplus (1980s/90s) to shortage (early 21st century).
Example: Concerns shifted from nurse oversupply (1990s) to shortages (late 1990s), which many declared ended by 2010.
Why are perceived shortages discussed when supply increased?
Overall supply trends don't equal labor force participation (e.g., licensed but not working or not full-time).
Supply is only one measure; having the needed workforce also depends on the judgment of what is required to meet needs.
Specialty mix and geographic distribution (where they are working vs. where needed) impact perceived need.
5. Judging Workforce Needs (Schools of Thought)
Approach 1: Market Factors & Indicators of Demand
Many vacant positions/unfilled job openings indicate a possible shortage.
Unemployment/underemployment for trained workers indicates a possible surplus.
Approach 2: Population Needs & Outcomes Data
Look at what staffing levels lead to the best health outcomes.
Examples: Staffing patterns associated with lower medication errors, hospital-acquired infections, nursing home falls/dementia care, or primary care ratios per capita associated with better population health.
A combination of these approaches has been used, e.g., for analyzing nursing shortages. Wage increases and legislation (like CA minimum RN staffing) also play a role.
Challenges in judging "needs" precisely: Americans seek both necessary and unnecessary care.
6. Healthcare Workforce Supply and Mix Issues
Specialty Mix: We seem to have more specialists and fewer primary care doctors than needed.
Distribution: Where professionals are located versus where they are most needed. Healthcare provider shortage areas can mean barriers to access in rural and urban areas.
Diversity: Important for the workforce to reflect the diversity of the population.
7. Workforce Diversity (Gender & Ethnic)
Gender Diversity:
Historically, physicians and pharmacists were predominantly men, and nurses women. This is changing.
Currently, about half of pharmacists and 35% of MDs are women.
Over half of pharmacy students and about half of medical students are women. More men are becoming nurses.
Women MDs are more likely to spend more time talking with patients and sharing decision-making.
Ethnic Diversity:
As the US population diversifies, the health professions are lagging.
African Americans, Latinos, and American Indians are underrepresented in many professions compared to their population share. Examples: 10% of pharmacists and MDs, 19% of PAs, 16% of nurses, 9% of dentists. (Specifically, African Americans account for 5.7% of MDs).
Improvement has been better in nursing, but less so in other professions. Recent research suggests representation of Black and Latino medical school students has stagnated. One analysis found no increase in Black male medical school applicants since 1978.
Why is ethnic diversity important?
Minority communities often have worse health status and access to care.
Underrepresented minority physicians are more likely to serve in underserved communities.
Ethnic "concordance" (match) between provider and patient is associated with:
Better doctor-patient communication.
More shared decision-making.
Better cooperation with recommendations.
Better outcomes in language-concordant situations.
8. Summary Points
Many different types of healthcare workers contribute to quality care delivery.
Overall supply has been rising, but has leveled off for some types.
It is difficult to clearly determine if there is a surplus or a shortage, making planning challenging.
Surpluses can lead to overuse and waste.
Healthcare provider shortages can create access barriers.
Better health outcomes are associated with a workforce that reflects the diversity of the population.
Based on the sources provided, here is a study guide covering the key concepts discussed regarding cost containment in the US healthcare system:
PUBH 402: Cost Containment in the US Healthcare System
The Problem: Rising Costs
Costs in the US healthcare system continue to rise.
Employers and employees are paying more and more.
There is a constant effort by different parties to shift costs.
Payers are shifting costs to employers.
Employers are shifting costs to employees.
Everyone is shifting costs to patients.
Data shows that the combined employee premium contribution and deductible as a percent of median household income increased between 2006, 2010, and 2015.
Thinking About the Problem: Defining "Too High" Costs and Value
A key question is what makes a certain amount of spending "too high"? How would one define this?
It's important to consider "Value for Money" – what do all those dollars spent get you?
Value can be thought of by considering what it costs to achieve a given outcome.
An ideal scenario would be to get more for the same costs.
However, there is often a tendency to behave as if higher cost equals better, such as in the example of low back pain.
Value can also be defined as health outcomes achieved divided by dollars spent. This idea was simplified by Porter.
Approaches to Controlling Healthcare System Costs
To control overall healthcare costs, both the price and quantity of healthcare need to be considered.
1. Controlling Healthcare Prices
Prices are high for insurance premiums and what providers charge.
Approaches include:
Financing controls (e.g., prices of premiums).
Payment controls (e.g., prices charged by providers).
Both financing and payment controls can use:
Regulatory strategies.
Competitive strategies (e.g., negotiation).
2. Controlling Healthcare Quantity (Amount of Services Delivered and Used)
Controlling quantity addresses the risk that if prices go down, sellers might try to increase volume to maintain revenue.
"Brute Force" or "Painful" Approaches:
Cost sharing (deductibles, co-pays, etc.).
Utilization review.
Example: prior authorization policies ("Just say no").
Shift risk from payer to provider.
Example: capitation or bundled payment, where providers are at risk.
"More Elegant" or "Painless" Approaches:
Encouraging appropriateness. This requires a definition of what is "appropriate," including clinical input (guidelines) and considering the specific population.
Reducing waste.
Innovation. Case studies mentioned include gastric surgery vs. H2 antagonists and laparoscopic cholecystectomy.
Prevention.
All these approaches aim to improve efficiency in the system.
Waste in the US Healthcare System
Reducing waste is a key "more elegant" approach to controlling quantity.
Estimates of waste in the US healthcare system are significant, ranging from $760 - $935 billion.
Major domains of waste and their estimated costs include:
Failure of care delivery: $102 - $166 billion.
Failure of care coordination: $27 - $78 billion.
Overtreatment or low-value care: $76 - $101 billion.
Pricing failure: $230 - $241 billion.
Fraud and abuse: $59 - $84 billion.
Administrative complexity: $266 billion.
Efficiency and Tradeoffs
Efficiency means doing things better and/or cheaper.
Reducing waste and increasing efficiency is seen as a way to squeeze more benefits out of dollars spent.
The value equation (Value = health outcomes achieved / dollar spent) highlights efficiency.
Efficiency is particularly beneficial in a stable (static) system.
Waste is clearly undesirable; everyone prefers more output for the same cost or the same output for lower costs.
The US healthcare industry has tried to become more efficient by reducing costs using various tools, cutting staffing, and consolidating the industry (e.g., hospital mergers and acquisitions).
However, there are tradeoffs. In a dynamic system where things change, extreme efficiency with minimal resources can increase the risk of other problems:
Reduced adaptability.
Reduced flexibility.
Reduced resources and encouragement for innovation.
For example, tight supply of resources with insufficient reserves increases risk during a sudden shift in needs.
Maximizing one part of the system can have other effects. Increasing efficiency can reduce flexibility and adaptability, leaving no "slack" or "cushion" if needs change.
Summary Key Points
More healthcare is not always better healthcare.
Controlling overall costs requires addressing both price and quantity.
Price controls involve regulatory and payment strategies.
Quantity controls can use "brute force" or "more elegant" approaches.
There are tradeoffs in healthcare systems; increasing efficiency can compromise flexibility and adaptability.
Based on the provided source, here is a study guide covering the key concepts related to Quality Measurement & Improvement in the US Healthcare System:
This study guide draws on the provided slides titled "PUBH402_Session 09_Quality Slides F 2024_25.pptx.pdf" presented by Diana Tisnado, Professor, Department of Public Health.
Quality Measurement & Improvement
Objectives:
Understand why quality matters
Definitions, key components, IOM aims.
How good is quality in the US.
Donabedian’s widely accepted model of quality.
Quality assessment (evaluation)
Know the approaches to assessment and their pros and cons.
Quality improvement
What is it?
Approaches to improvement and pros and cons.
Changing provider and patient behavior.
Malpractice/tort reform
What is it and how do some think it might help?
1. Understanding Quality
Why does it matter?
Quality is a complex interaction affected by quality vs. responsibility, risk vs. reward, organizational design, and HC goals.
To "bend the cost curve," you must know what "better outcomes" look like.
What is quality?
A definition: "The degree of excellence or conformity to established standards and criteria" - Avedis Donabedian.
Key Components of High-Quality Health Care:
Access to care.
Adequate scientific knowledge.
Competent, well-trained health care providers.
Separation of financial and clinical decisions.
Organization of health care institutions to maximize quality.
How good is quality in the US?
Problems with access exist, and no access means no quality.
Much medical care lacks formal scientific evaluation, indicating a lacking knowledge base.
When evaluating "conformity to accepted standards," a high degree of variation in practice is found, including underuse, overuse, and misuse. This is often called "inappropriate care" and can arise from providers, systems failures, or financial incentives.
Donabedian’s Widely Accepted Model of Quality:
Provides an organizing framework.
Quality of care is conceptualized with three components:
Structure: The setting, resources (human and physical), organizational policies. This includes facilities and resources, referrals and coordination, physician support, patient support, continuity, and financial incentives.
Process: What we do to patients (e.g., diagnosis, treatment). This involves timely work-up and treatment delivery, technically appropriate care (no under or overuse), and appropriate communications/shared decision-making.
Outcomes: Mortality/survival, function, symptoms, overall quality of life. Examples include cancer-free survival, Health-Related Quality of Life (physical, emotional, social functioning), patient ratings of care, and preference-concordant care.
Institute of Medicine (IOM) Quality Aims: According to Crossing the Quality Chasm, the aims for a new health system for the 21st century are:
Safe.
Effective.
Patient-Centered.
Timely.
Efficient.
Equitable.
2. Quality Assessment
How can we know what “good” or “better” quality look like? Who should decide and how?
Approaches to Assessment:
Peer Review:
Peers or physician managers review cases and judge based on personal judgment ("implicit review") or adherence to a gold standard ("explicit review").
Can include retrospective peer review or Morbidity & Mortality (M & M) conferences.
But: Primarily based on the judgment of the reviewer(s).
Benchmarking:
Compare performance against others in the professional community (e.g., within a hospital, community, statewide, nationwide).
But: What if everyone else is bad, too?.
Comparing to a “Gold Standard”:
Standards of practice, practice guidelines, or quality indicators can be developed based on professional input/judgment and scientific evidence.
Guidelines may be published by professional societies, government bodies, or private organizations.
But: Can be biased by self-interest and/or funding source.
Reviews by Independent Organizations:
JCAHO (now Joint Commission): Evaluates facilities through onsite reviews, historically emphasizing structure and process.
CMS and other government agencies: Major emphasis on quality measurement, used for pay for performance and public reporting.
NCQA: Evaluates HMOs and other groups, focuses on process and outcomes. Develops the Healthcare Effectiveness Data & Information Set (HEDIS), which creates quality measures or indicators. Publishes "report cards" for consumers.
HEDIS Measure Example: Percentage of adults 50–75 appropriately screened for colorectal cancer. Screening is important because early-stage treatment has a high survival rate, yet over a third of adults 5–75 don't get recommended screenings.
3. Quality Improvement
What is Quality Improvement (QI)?
QI consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.
How do we think about quality problems and improvement?
Proposals include: identifying/sanctioning "bad apples," clinical practice guidelines, measuring practice patterns, continuous quality improvement, computerized information systems, public reporting of quality, pay for public reporting, and pay for performance.
Caution: How we think about quality problems leads us to certain solutions, which may or may not be the best.
Approaches to Improvement:
Traditional “Quality Assurance”: Includes licensure, accreditation, and peer review.
“Bad Apples” Approach: Identifying and getting rid of "bad" individuals – problems?
Identifying deficits in specific knowledge/training, leading to additional professional development/education/training.
Identifying systems-level issues that contribute to quality problems.
System Re-design to support best practices.
Management Science approaches to QI (such as TQM, CQI):
Philosophy: Quality is directly linked to an organization's service delivery approach and underlying systems of care. Improvement requires changing the current system.
Successful programs often incorporate repeated measurements, improvements aimed at below-standard measures, and use data and worker input to improve systems and processes. They also focus on patient needs and teamwork.
Industrial Management QI Models:
Six Sigma: Seeks to improve quality by identifying/removing root causes of errors and minimizing variability; consider if there is wide variability in service.
Toyota Production System or “Lean”: Identify processes contributing value, design out burdensome/unnecessary processes to eliminate waste. Frequently used by teams to operationalize process changes.
Quality by Design (Joseph Juran): Quality can be planned; quality crises often relate to how quality was planned. Used in the process planning phase.
Measurement and Analysis:
Flowcharts to document processes and elements to measure.
Data can often be obtained from standard medical records, but poor documentation can be a quality problem itself.
Important to learn about the process firsthand and ask staff doing the work.
Statistical analyses to identify variations (problems and reasons).
“Root cause” analyses to identify sources of variation. Differentiate between Random Variation ("Common Causes") and Assignable Causes. May identify outliers and investigate.
Bottom line: differentiate between clinically appropriate and inappropriate variations.
Example: Central Line Infections
Problem: 28,000 patients/year die from infected central lines.
QI team identified failure to perform important steps.
Introduced a simple 5-point safety checklist prior to line insertion.
Results: 66% reduction in central line infections across 108 hospitals.
Yet: Many institutions still don't use such a checklist.
4. Changing Behavior
How can we make change? Can we change physician culture?
American doctors traditionally have a culture of much professional autonomy & authority.
It's hard to simply tell American doctors what to do, even with data; you have to involve them.
Importance of Involving Physicians:
Physician leadership is key, but not widespread.
Physicians are more comfortable with clinical studies in their specialties than broad QI initiatives.
Physicians are more likely to accept change if they help develop it.
Physician barriers (Shortell): skepticism about organization motives, lack of relevance to their practice, focus on data/problems of little clinical interest, lack of time, fear of policies used against them.
Making Patients “Better Consumers”:
Sharing evidence about risks/benefits can affect patients' decisions.
Patients often choose less-aggressive treatments with similar outcomes and greater satisfaction.
However: It's not clear how many decisions most patients want to make.
Computerized Information Systems:
Can improve documentation, accessibility of data to care team members, coordination, and reduce wasted effort.
Can provide decision-support features and support patient-provider communication.
EHR alone will not improve quality.
Processes for quality must be intentionally designed by health experts (not IT). Poor design leads to wasted time, provider/patient frustration.
Changing Economic Incentives:
Shifting from incentives to do more/less (fee-for-service, capitation) to incentives specifically for quality.
Pay-for-reporting (P4R).
Pay-for-performance (P4P): Rewards good outcomes.
Possible pitfalls: Misalignment with provider motivations can be a turnoff, "studying to the test".
Changing Incentives: “Pathways”:
Program offered oncologists monetary incentives for using recommended guidelines ("pathways") for certain cancers.
Provided education and incentives because pathway treatments were often less lucrative.
Early study found 7% reduction in hospitalizations and 15% reduction in costs.
Public Reporting of Quality:
Public Reporting ("Report Cards") intend to motivate improvement and affect public perception/competition.
Examples: NCQA HEDIS Scorecard, CMS Hospital Compare, Pro Publica surgeon report cards.
5. Tort Reform (Malpractice)
Can we sue our way to better quality? (Review in chapter and recorded lecture).
US Tort and Malpractice System:
Underlying legal principle: the injured deserves compensation if caused by a willful or negligent act.
Twin goals: 1. Financially compensate those suffering medical injuries from negligence; 2. Prevent or deter healthcare personnel from negligently causing harm.
Critiques of the Tort System:
Only a small percentage (2%) of patients affected by medical negligence file malpractice suits.
Studies estimate that a significant percentage (40%) of claims don't involve actual medical errors.
Yet, a quarter of cases without medical errors result in patient compensation.
System is meant to protect quality by punishing "bad apples," but many believe this approach hurts morale, encourages defensive medicine (overuse), may hurt access, and doesn't really improve quality.
System is wasteful.
Assumes jury trial is the best way to assess negligence.
Income bias exists; low-income patients benefit least and are less likely to sue.
Summary Points:
Quality can be viewed in terms of key components.
Donabedian’s model considers structure, process, and outcome.
Assessment includes peer review, benchmarking, comparing to a standard, and review by independent organizations.
There are multiple ways to think about improving quality.
Human behavior (doctors and patients) is difficult to change.
Systems changes are as important as trying to change individual provider practice patterns.
Based on the provided sources, here is a study guide covering the key concepts related to prevention in the US healthcare system:
I. What is Prevention?
Prevention aims to address health conditions before they become severe or to manage existing ones to prevent complications.
There are three levels of prevention:
Primary prevention: Prevents conditions from arising in the first place by addressing root causes.
Secondary prevention: Identifies disease processes at very early stages to prevent progression. An example is most cancer screenings, which aim to find cancer early for intervention.
Tertiary prevention: Manages existing conditions to prevent further progression and complications. Examples include preventing amputation or blindness in diabetics.
II. Strategies of Prevention
There are three major strategies of prevention:
Addressing the social determinants of health: Focuses on improving living standards and social equity. This involves going "upstream" to address factors like food availability, sedentary work/living conditions, alcohol/tobacco/drug advertising, inequality, exercise/sedentary behavior, living conditions, transportation, and advertising.
Public health interventions: Aimed at the community or population level to reduce the incidence of illness in a population. These interventions tend to save the most money, especially primary prevention initiatives. Examples used to address COVID include strategies aimed at reducing incidence in the population. Public health views society as creating conditions that drive lifestyle choices.
Clinical preventive services: Traditionally aimed at individuals and delivered by health care/medical care providers such as doctors, nurses, and physician assistants. These are part of the medical care system's role in prevention. Preventive medical care performed by healthcare providers was also a strategy used to address COVID. Some clinical preventive services interventions save more money than others.
III. Epidemiologic Revolutions
The 1st epidemiologic revolution (1800s – ~1950): Focused on the epidemiology of acute diseases.
During this period, 11 infectious diseases accounted for 40% of deaths.
Prevention of infectious diseases involved sanitation, vaccines, and antibiotics.
Prevention/reduction of injury morbidity and mortality was also a focus.
The 2nd epidemiologic revolution (starting around 1950s): Focused on the recognition of the epidemiology of chronic diseases and their prevention and management.
Reducing the risk of infectious diseases increases the risk of death from other causes.
Lifestyles and exposures changed dramatically during this period, leading to "diseases of development" related to lifestyle changes, diet, and toxic exposures.
Heart disease, cancer, and stroke accounted for 64% of deaths.
IV. Individual vs. Population Focus
Chronic diseases can be viewed from both an individual and a population perspective.
From an individual perspective, individuals play a major role in contributing to their own risk of illness through behaviors. A corollary is that reducing chronic disease mortality could focus on changing individual behaviors.
From a public health perspective, society creates the conditions that influence lifestyle "choices". A corollary is that addressing societal conditions is key.
V. Clinical Preventive Services
Clinical preventive services are a role of the medical care system in prevention.
They fall into 3 categories:
Counseling and educational services: Includes health education on topics like diet, exercise, injury prevention (seat belts, water safety, firearm safety), and diabetes self-management. It also includes counseling for things like weight loss and smoking cessation.
Screening services: Aim for early detection of disease or risk factors for disease. This corresponds to secondary prevention. Examples include screening for cancer (mammogram, Pap smear, colonoscopy), CVD, metabolic/nutritional issues, vision, hearing, prenatal disorders, mental/cognitive disorders, and substance misuse.
Chemoprophylaxis (aka chemo-prevention): Generally refers to vaccinations and drugs/medications. This includes childhood and adult immunizations, post-exposure prophylaxis (Hep B, rabies, tetanus, HIV), and medications like aspirin for heart attack prevention, cholesterol/BP meds, and hormone replacement. The use of medications can fall under different levels of prevention.
VI. Community-Oriented Primary Care Model
Mentioned alongside Wagner's Chronic Care Model.
Systematically defines the target population, determines health needs, and develops community-based interventions.
Works with other community stakeholders and entities like health departments and schools to improve school nutrition, physical activity, implement vape campaigns, and support violence prevention initiatives.
VII. Does Prevention Always Save Money?
Public health interventions, particularly primary prevention initiatives, tend to save the most money.
Some clinical preventive services interventions save more than others.
VIII. Healthy People Initiative
Began in 1979.
Plays a key role in fostering public awareness and health-promoting initiatives.
Set goals to meet and is revised every 10 years.
It sets goals and monitors progress.
Examples of Healthy People Initiative Indicators include Physical Activity, Overweight & obesity, Tobacco and Substance Use, Responsible sexual behavior, Mental health, Injury & violence, Environmental Quality, Immunization rates, and Access to health care.
As of 2020, some objectives were met or exceeded, such as adult physical activity, adolescent tobacco and substance use, maternal and child health indicators, and access to care via health insurance coverage.
Targets not met included diabetes, nutrition and weight status, mental health, and access to care via having a usual source of care.
IX. Summary
Prevention is categorized into primary, secondary, and tertiary levels.
Key prevention strategies include addressing social determinants of health, implementing public health interventions, and providing clinical preventive services.
Historical shifts in public health focus moved from acute diseases (1st epidemiologic revolution) to chronic diseases (2nd epidemiologic revolution).
Clinical preventive services encompass counseling/education, screening, and chemoprophylaxis.
Okay, here is a study guide covering the key information from the provided sources on Long-Term Care, Palliative Care, and Hospice Care.
Study Guide: Long-Term Care, Palliative Care, and Hospice Care
What is Long-Term Care (LTC)?
LTC involves health, social, housing, and other supportive services needed on an ongoing basis.
It is required due to limitations in the ability to perform functions necessary to live independently.
These limitations can stem from mental, cognitive, and/or physical impairment.
Needs are usually determined based on limitations in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).
Who Needs Long-Term Care?
LTC needs are not limited to the elderly.
About 26% of all adults in the US have a disability.
By 2030, projected numbers of individuals >65+ and >85+ years with physical and/or mental/cognitive conditions are more than double the numbers from Year 2000.
Non-elderly populations needing LTC include those with:
Disabilities of various origins, including congenital conditions.
Chronic diseases (physical and mental/cognitive).
Trauma (e.g., spinal cord injury, traumatic brain injury).
Numbers Receiving Long Term Services and Supports (LTSS)
Estimates from 2010/2012 data show about 6.7 million elderly receiving LTSS.
About 15% of these received institution-based care.
About 5+ million received services in the community.
About 5.4 million working-age adults received LTSS.
About 0.6 million children received LTSS.
Just over half of persons receiving LTSS are over 65.
Most LTSS happens in the community (not institutions).
Who Provides Long-Term Care?
"Informal" caregivers are a major provider, often family or loved ones.
66 million served as informal caregivers in 2011.
The majority are women, age 60+, providing >30 hours of care per week.
Community-based & home health services:
Paid in-home care (unskilled & skilled).
Adult day care.
Assisted living facilities.
Board & care.
Community programs.
Institutional long-term care facilities:
Nursing homes: Provide 24-hour care with various services/levels of care (unskilled, skilled).
Skilled nursing facilities (SNF): For nursing/rehab that is time-limited, usually after hospitalization. This is the only kind Medicare pays for.
Most nursing homes are for-profit, chain facilities, staffed by aides, nurses, and other personnel.
Who Pays for Long-Term Care?
Needs and costs vary greatly.
A large proportion of spending is OUT-OF-POCKET.
Public/government funding accounts for a large portion, mostly through Medicaid (about half).
Some funding comes from Medicare and some other state and local sources.
Private long-term care insurance plans have struggled to offer affordable and meaningful coverage.
Some attempts at reform have been made, such as PACE models (using public funds to keep patients in the community with bundled payments).
Congress has struggled to find solutions, with the "CLASS Act" being an example of a law enacted to offer LTC insurance but quickly repealed as unworkable.
Coverage Details (Medicare and Medicaid)
Medicare: Can pay for institutional care for skilled rehabilitative services for 3 weeks when a patient has been discharged from the hospital. It can also pay for some medically necessary home health visits for home-bound patients.
Medicaid: Eligibility and coverage vary state to state.
In California, "Medi-Cal" may cover long-term care for patients >65, blind, or disabled who are also financially needy.
Income and asset criteria are complex. Basics include a limit on "countable" assets (e.g., $2000). Some assets like a primary home may be exempt if certain conditions are met (e.g., equity value < $750,000).
A patient's spouse living in the community may keep part of the institutionalized spouse's income (up to approximately $3,000/month).
Concerns about Nursing Home Quality
Important clinical quality indicators include falls, pressure sores, urinary tract infections, and appropriate medication management.
The Centers for Medicare and Medicaid Services (CMS) issues a "Nursing Home Compare" star rating system, largely based on general measures like staffing ratios.
Critics claim that clinically detailed measures aren't fully reflected in the star ratings, allowing facilities to get good ratings despite problems with key concerns.
Data continue to show lower staffing levels and worse quality scores in for-profit nursing homes.
Persistent Issues in LTC
Financing: Financial incentives often lead to institutional care, although home-based care may be best. A good insurance system for LTC services does not yet exist in the US, and most payers cap their exposure. Working-aged disabled individuals may have to choose between work and spending down assets to qualify for Medicaid.
Regulatory: Despite heavy regulation, quality problems persist, particularly concerning pain control and dementia care.
Workforce: Increasing patient severity and complexity requires more highly trained & skilled caregiving & managerial staff. Sufficient skills are needed to address physical needs, dementia issues, and social/emotional needs. Adequate compensation is needed for quality personnel.
Cultural and linguistic appropriateness.
Challenges Meeting the Needs of a Diverse Elder Population
The older adult population is diversifying; by 2050, elder minorities will significantly increase their share of the elder population.
In California, the elderly population is likely to be "majority minority".
Challenges include:
Finances: Some minority groups may age with fewer resources (wealth, home ownership, pension), impacting housing, nutrition, etc..
Health insurance benefits: Not all immigrants qualify for Medicare, and expenses affect access to medication, aids, and in-home help.
Life course: Earlier life experiences (e.g., chronic stress, discrimination) can impact health in older age.
Preparing a workforce to deliver culturally/linguistically appropriate care is necessary.
What is Palliative Care?
A care approach that improves the quality of life of patients and families facing problems associated with serious and/or life-limiting illness.
Achieved through the prevention and relief of suffering.
Involves early identification, assessment, and treatment of pain and other symptoms, as well as psychological, social, and spiritual needs.
Typically involves a multi-disciplinary care team approach.
The team may include a physician, nurse, social worker, physical and/or occupational therapy, and a chaplain.
What is Hospice Care?
A type and philosophy of care that shares goals and approach with palliative care.
Generally for those close to the end of life.
Medicare covers hospice for beneficiaries when life expectancy is less than 6 months.
Most often delivered in the home, but can be in an institutional setting or include institutional stays for caregiver respite.
Hospice is best viewed as a special case of palliative care.
What is Involved in Hospice Care?
Relief of pain and other symptoms (e.g., shortness of breath, rashes/sores, bowel issues, depression).
Maintenance of nutrition.
Social support, helping the family and patient cope with distress, articulate values, establish goals/preferences, and find assistance.
Spiritual care.
Coordination among multiple disciplines and specialty types involved in care.
Barriers to End-of-Life Care at Home
Most people say they want to die at home, yet many do not.
Reasons include:
Lack of awareness, stigma, misunderstandings: Palliative care is misunderstood as only for end-of-life; hospice is seen as "giving up" or "no care".
Fear of abandonment.
Funding barriers: Hospice funding is often based on restrictive criteria, such as a life expectancy of <6 months and the decision to stop all curative treatments.
Workforce shortages: It's not considered a "sexy" specialty.
To avoid stigma, some have tried to "re-brand" palliative care as "supportive care".
Variations/Disparities in End-of-Life Care
Research shows that non-whites near the end of life are more likely to use "aggressive" care (hospital care, artificial life support).
Non-whites are less likely to have Do Not Resuscitate (DNR) orders.
They use hospice at lower rates than Whites (e.g., 44% of Whites vs. 32% of Blacks).
Summary Points
LTC provides supportive services on an ongoing basis due to limitations determined by ADLs and IADLs.
Just over half of persons receiving LTSS are over 65.
Most LTSS is provided in the community.
Medicaid pays about half of LTSS costs, but there isn't a good insurance system for LTSS in the US.
Palliative and Hospice care address non-curative needs, focusing on symptom relief and quality of life.