Critical Issues In Healthcare Quick Reference Guide #1 - Soraya Ghebleh

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This is a basic table defining some of the major terms and issues in healthcare today. Great for someone who wants some basic definitions and a quick reference guide.

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Critical Issues In Healthcare Quick Reference Guide #1 - Soraya Ghebleh

  1. 1. Critical  Issues  Final  Review  Sheet     Topic   Details   Medicare   -­‐  Federal  health  insurance,  65  and  over,  eligible   for  ss  disability  payment  and  indiv  who  need   kidney  transplants  or  dialysis   -­‐Part  A  –  (hospital  insurance)-­‐>  inpatient  care,   skilled  nursing  facility,  hospice,  home  health  care,   no  premium  required   -­‐Part  B-­‐  (medical  insurance)-­‐>  covers  medically-­‐ necessary  services  like  doctors’  services  and   outpatient  care/preventive  services   -­‐Part  C-­‐  (Medicare  Advantage  Plans)  –  combines  A,   B  and  D  -­‐>  managed  by  priv  ins  companies   approved  by  Medicare   -­‐Part  D-­‐  (Medicare  Prescription  Drug  Coverage)   helps  cover  prescription  drugs   Medicaid   -­‐  Federally  aided,  state-­‐operated  and  administered   program  -­‐>  low-­‐income  families  with  children,   elderly,  disabled,  blind  individuals  who  are  covered   by  SSI,  pregnant  women  whose  family  income   under  133%  of  poverty  level   Two  Models  of  Government  Health   Plans   Social  Insurance  =  Medicare  (only  those  who  have   paid  are  eligible)   Public  Assistance  =  Medicaid  (criteria  based  on   income  and/or  medical  condition)  -­‐>  those  who   contribute  may  not  be  eligible   SCHIP   -­‐  Cover  uninsured  children  up  to  age  19  from   families  who  made  too  much  $  to  qualify  for   Medicaid   Socioeconomic  Status   -­‐  Social  standing  or  class  of  an  individual  or  group   -­‐  Measured  as  a  combination  of  education,  income,   occupation   -­‐  Often  reveal  inequities  in  access  to  resources,  plus   issues  related  to  privilege,  power,  and  control   Gradient/Gap   -­‐  gradient  isn’t  just  about  “poor”   -­‐  every  rung  up  SE  ladder  people  w/in  society  tend   to  be  healthier  and  live  longer  the  higher  up  you  go   -­‐person-­‐level  unit  of  analysis  –  rigorous  evidence  of   a  strong  and  positive  association  between  absolute   SES  and  health   -­‐  health  is  affected  by  social  position  and  scale  of   soc/econ  diff  among  the  population   -­‐  in  terms  of  income,  relationship  is  with  relative   rather  than  absolute  income  levels  
  2. 2. Epidemiologic  Transition   -­‐  poor  places  suffer  with  poorer  health  and  lower   life  expectancy   -­‐  economic  improvement  leads  to  improvements  in   health  and  life  expectancy,  but  only  to  a  point   Gini  Index   -­‐  “measurement  of  the  income  distribution  of  a   country’s  residents.  Number  ranges  from  0  to  1  and   is  based  on  residents’  net  inome,  helps  define  the   gap  between  the  rich  and  the  poor,  with  0   representing  perfect  equality  and  1  representing   perfect  inequality.   Pathways  for  SES  Relationship  to   Health   Social  Mobility-­‐  people  in  poor  social/econ   condition  because  of  poor  health  -­‐>  has  impact  on   social  mobility  but  too  small  to  account  for  health   diff   Behav/Cultural-­‐  Lack  of  self-­‐regulation,  poorly   developed  coping  skills,  external  locus  of  control,   discount  rates,  collection  of  learned  behaviors  w/in   a  community   Materialistic-­‐  Higher  income  affords  better  shelter,   food,  clothing,  more  education  -­‐>  safer,  less  phys   demanding  jobs,  wealthier  places  have  better   schools,  hospitals,  transportation   Pyschosocial  Mechanisms-­‐  Stress  of  trying  to  keep   up,  humans  well  designed  to  deal  w/  immediate,   short-­‐term,  actionable  stress     Policies  to  Decrease  SES  Health   Inequalities   -­‐  Income  redistribution   -­‐  Education  Promotion   -­‐  Social  Cohesion   PPACA   ****Refer  to  the  document  Gardent  posted  that   describes  all  the  different  features  in  detail     1. Providing  Health  Care  to  All  Americans   2. Role  of  Public  Programs   3. Improving  quality  and  efficiency  of  health   care   4. Prevention  of  chronic  disease  &  public   health   5. Health  care  workforce   6. Transparency  &  program  integrity   7. Improving  access  to  innovative  therapies   8. Community  living  assistance  services  &   supports   9. Revenue  provisions   Individual  Mandate   Employer  Requirements     Health  Insurance  Exchanges  
  3. 3. Changes  to  Private  Insurance   Paying  for  PPACA   Societal  Approaches  to  Changing   Behavior   Individual  (medical  model)     -­‐  Convince  individuals  not  to  smoke,  drink,  eat,  ect   -­‐  Counseling   -­‐  Education   Population  (public  health  model)   -­‐  Broad  public  health  efforts  might  be  a  better  use  of   funds   -­‐  Change  social  structure   • Education  Campaign  (knowledge)   • Marketing/Advertising  (Fear/Promote)   • Social  Change  (make  it  socially  negative)   • Ban/Restrict  (limit  access)   • Tax  (make  it  more  costly)       Pauly  Article  –  Disruptive   Innovation   -­‐Using  cheaper,  simpler,  more  convenient  products   or  services  that  meet  needs  of  less  demanding   customers   -­‐  dominant  players  focused  on  improving   products/services  miss  more  convenient  and  less   costly  offerings   -­‐  A  little  less  quality  for  a  lot  less  money     -­‐  (think  of  the  flat  curve  of  spending  Hansen   referred  to  in  his  lecture)   Role  of  Pricing  in  HC  Costs   -­‐  is  supply  inducing  demand  or  is  demand  inducing   supply?   Economics  of  Employer  Mandate   -­‐  Making  employers  provide  costly  insurance   reduces  the  demand  for  labor   -­‐  If  insurance  is  part  of  the  package-­‐  the  supply  of   labor  also  increases   Consumer  Choice  and  Moral   Hazard   -­‐How  much  healthcare  will  people  demand  with   marginal  price  close  to  zero   -­‐  How  does  that  compare  to  what  we  would  demand   in  a  world  with  “perfect  insurance”   Hospital  Consolidation   -­‐  Increases  in  hospital  market  concentration  lead  to   increases  in  price  of  hospital  care   -­‐  Hospital  mergers  in  concentrated  markets  lead  to   significant  price  increases   -­‐  for  some  procedures  -­‐>  hospital  concentration   reduces  quality   -­‐  Hospital  competition  improves  quality  under  an   administered  pricing  system   -­‐  Competition  improves  quality  where  prices  are  
  4. 4. market  determined,  although  the  evidence  is  mixed   Healthcare  Ethics  –  General   Principles   -­‐  Health  care  ethics  relates  to  national   policy/reform:   -­‐  access,  quality,  safety,  effective,  and  value   -­‐  Ethics  is  a  driver  for  health  care  change   Healthcare  Ethics-­‐  Healthcare   Organizations   -­‐  Ethics  defines  what  and  who  organization  is  at  its   core   -­‐  Serves  as  how  organization  will  fulfill  that   foundation  in  practice/culture  and  how  it  will   address  ethical  conflicts   Common  Morality   Respect  for  patients  (autonomy)  –  Promoting  self-­‐ determination  through  shared  decision-­‐making,   confidentiality,  truthful  communication,  promise-­‐ keeping   Promote  patients’  best  interests  (beneficience,   nonmaleficence)-­‐  promoting  beneficial,  evidence-­‐ based  care  w/in  rel  and  avoiding  actions  that  cause   harm   Distributive  &  Social  Justice  –  Allocating   resources  failry  and  providing  value  for  services   rendered   Ethical  Conflicts  in  Medicine   -­‐  Occurs  w/  uncertainty/conflict/question   regarding  competing  ethical  principles,  values,  or   professional/organizational  ethical  standards  of   practice   -­‐  When  one  considers  violating  an  ethical  principal,   personal  value,  or  organizational  standard  of   practice  =  an  ethical  conflict   -­‐  clinical  ethics  =  application  of  ethical  framework   to  individual  patient  care  issues   Research  Ethics   -­‐  Application  of  an  ethical  framework  to  the  design,   sponsorship,  review,  conduct,  and  dissemination  of   research   -­‐  Voluntary  consent  of  human  subject  =  essential  for   research   -­‐  Research  Ethics  Framework  =  social/sci  value,   scientifically  valid  design,  fair  subject  selection,   favorable  risk-­‐benefit  ratio,  independent  review,   informed  consent,  respect  for  enrolled  subjects   Quality  Improvement  Ethics   -­‐application  of  an  ethical  framework  to  the  design,   review,  conduct,  and  dissemination  of  QI   Organizational  Impact  of  Ethics   Conflicts   -­‐  Organizational  ethics  =  application  of  ethical   framework  to  system  of  care,  including  its  missions,   values,  structure,  culture,  and  practices   -­‐  Ethics  conflicts  have  impact  on  health  care  org  
  5. 5. -­‐  Ethical  conflicts  have  sig  cost  implications   -­‐  Theoretical  correlation  between  ethical  conflicts   and  organizational  costs  -­‐>  impact  org  performance,   including  wages,  efficiency,  and  price   IOM  Six  Aims  for  Improvement   1.  Safe  2.  Effective  3.  Patient-­‐centered  4.  Timely  5.   Efficient  6.  Equitable   Health  Workforce  Planning   -­‐  Do  we  have  shortage  of  clinicians?  How  does   regional  supply  of  clinicians  affect  population   utilization  and  outcomes?  How  should  hc  org   rethink  clinician  workforce?   -­‐  “easier  to  add  capacity  than  take  capacity  away”   -­‐  “healthcare  economics  =  imperfect  market  -­‐>   shapes  pattern  of  care”   Physician  Shortage  Concerns   Concerns  1.  Growing  population  (elderly)  2.   Increase  in  age-­‐specific  utilization  rates  3.  Econ   expansion  -­‐>  “GDP  is  destiny”  4.  “demand”   increasing  rapidly  -­‐>  failing  to  anticipate  “demand”   w/  more  phys  =  shortage  5.  Assumes  demand  =   patient  needs  &  preferences   Desirable  Population  Outcomes-­‐   Investing  in  Medical  Workforce   Access  –  to  care  when  it  is  wanted/needed   Quality  –  care  that  is  technically  excellent  and   matches  patients’  preferences   Outcomes  –  care  that  improves  health  and  well   being  of  patients  and  populations   Costs  –  care  that  is  affordable  to  the  patient  and  to   society   ð if  these  outcomes  are  agreed  upon,  what  are   effective/efficient  ways  to  achieve  these   ends?   ð Evidence  that  acces/quality/outcomes  are   sensitive  to  physician  supply?   ð Understand  why  technical  quality/patient   satisfaction  is  not  necessarily  better  with   more  physicians   -­‐  With  similar  outcomes,  must  be  noted  that  many   health  care  systems  deliver  care  w/  far  fewer   physicians  (think  about  WHY  this  is,  what  FACTORS   affect  this,  and  how  to  INCREASE  efficiency)   -­‐  “good  care  trumps  care  &  clinician  quantity”   Clinician  Workforce  Planning  w/in   Health  Care  Organizations   -­‐  Improve  patients  health  &  wellbeing   -­‐  Optimize  organizational  by  strengthening:   1.  Secure  valuable  referrals  (PCP  networks)  2.  Build   capacity  in  high  margin  specialties  3.  Assume  fee-­‐ for-­‐service  revenues  will  flow  unimpeded   -­‐  Current:  Add  clinician  capacity  to  organizations  
  6. 6. does  not  reliably  lead  to  better  outcomes   -­‐  Future:  fee-­‐for-­‐service  will  be  supplanted  by   capitated  payments   Scenarios  in  Organizational   Workforce  Planning   1.  Regional  Per  Capita  Supply  of  Physicians  vs   Proportion  employed  by  a  health  system   -­‐  Evaluate  proportion  of  highly  effective  care   High  Regional  per  capita  supply  +  high  health   syst  proportion  of  regional  supply  =  near   regional  monopoly  within  possible  over  capacity   region,  high  organizational  gain  –  high  risk,   questionable  patient  benefit   High  Regional  per  capita  supply  +  low  health   system  proportion  of  regional  supply   Modest  surgeon  share  w/in  possible  over  capacity   region,  high  organizational  gain  –  moderate  risk,   uncertain  patient  benefit     Direction  of  Workforce  capacity   w/in  organization   Depends  on:  1.  Regional  workforce  environment  2.   Proportion  of  workforce  environment  that  is   “owned”  by  the  organization  3.  Proportion  of   current  care  that  is  highly  effective  in  relation  to   patient  needs  and  preferences     Economics  of  the  Employer   Mandate     **Make  sure  to  review  the  graphs   in  Hansen’s  lecture  and   understand  them     -­‐  Making  employers  provide  costly  insurance   reduces  the  demand  for  labor  but  if  insurance  is   part  of  the  package,  the  supply  of  labor  also   increases   -­‐  With  marginal  price  close  to  zero   -­‐  Flat  of  the  curve  spending  –  if  we  are  near  flat  of   the  curve  and  we  increase  co-­‐pays,  what  should   happen  to  the  health  of  the  insured  population??   NO  CHANGE   -­‐  Expenditure  =  price  x  quantity   -­‐  Understand  the  role  of  prices  and  choice  in   competition  (think  of  chemotherapy  example,   Alaska  colonoscopy  example,  medical  tourism   industry  and  how  that  affects  competition,   insurance  companies  encouraging  patients  to  seek   cheaper  care)   -­‐  lack  of  competition  (market  power)  can  be   destructive   -­‐  consolidation  and  creation  of  market  power  is   happening  (new  york  hospitals  combining  and   forming  giant  hospitals)   -­‐  Insurers  are  able  to  create  demand  elasticity  =>   Demand  elasticity  measures  the  rate  of  response  of   quantity  demanded  due  to  a  price  change,  used  to  
  7. 7. see  how  sensitive  the  demand  for  a  good  is  to  a   price  change  (higher  price  elasticity,  more  sensitive   consumers  are  to  price  changes)      

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