Critical Issues in
Healthcare
A QuickGuide to Pertinent
Healthcare Topics in the United States
What is public
health?
•  Mission: fulfilling society’s interest in assuring conditions in which
people can be healthy; pr...
How is health
measured?
•  WHO defines health as a state of complete physical, mental and social
wellbeing and not merely ...
Determinants of
Health
Evans & Stoddard Field Model of Health and Well-Being
Public Health
strategies
•  Primary: Seek to prevent occurrence of disease or
injury by reducing risk factors (i.e. laws f...
Health Services/
Clinical strategies
•  Primary: Clinical preventative services & basic care;
i.e. vaccines
•  Secondary: ...
misplaced priorities in
healthcare
•  Woolf, et al
•  Put resources toward interventions that maximize
health benefits to ...
Woolf’s solutions to
misplaced priorites
•  Choosing Effective Services: Most effective services don’t always
get priority...
How is health care
organized?
•  Primary Care – Common health problems and
preventive measures (sore throat, diabetes,
hyp...
Regionalized vs. Dispersed
model of care
•  Regionalized
•  Primary Care is the main focus, most physicians are GPs
•  Sec...
Structure of healthcare
services marketplace
Challenges in
healthcare
Major Trends
•  Pressure over financing of health care
•  Impact of aging population
•  Rising ac...
Berwick’s triple aim
•  The US healthcare system is
broken (assessed by our health-
expenditure vs. rankings in life
expec...
Risk & Insurance
•  Risk is the chance of something bad happening
•  Patient Perspective: getting sick and not being able ...
Risk & insurance
•  Moral Hazard – “an insulated third party may behave
differently than it would if it were fully exposed...
Risk & insurance
•  Community Rating – Distributes risk “within and
across groups.” => Everyone pays the same rate
•  Expe...
How insurance
works
•  Insurance purchasers pay premiums to insurance companies for
health insurance plans
•  Premiums are...
Types of Health
coverage
•  Out of Pocket: Individual pays provider through
private funds
•  Individual Private Insurance:...
Types of health
coverage
•  Managed Care: Manages healthcare delivery to control
costs, typically relying on PCP as gateke...
Government
Insurance
•  Medicare: Federal, 65 y/o+, disability, dialysis or
kidney transplant
•  Medicaid: Federally aided...
Unwarranted variation
in healthcare
•  Variation not explained on the basis of illness, patient
preference, or evidence-ba...
Accountable care
organizations
•  Network of doctors, hospitals, and other healthcare
organizations that share responsibil...
Accountable care
organizations
Essential Characteristics
•  Provide continuum of
care in integrated system
•  Sufficient s...
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Soraya Ghebleh - Critical Issues In Healthcare Quick Reference Guide #2

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This presentation gives an outline of some of the key issues in US healthcare today in a way that the majority of the population can understand.

Published in: Health & Medicine, Business
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Soraya Ghebleh - Critical Issues In Healthcare Quick Reference Guide #2

  1. 1. Critical Issues in Healthcare A QuickGuide to Pertinent Healthcare Topics in the United States
  2. 2. What is public health? •  Mission: fulfilling society’s interest in assuring conditions in which people can be healthy; promote physical and mental health and prevent disease, injury and disability •  Core functions: Assessment, Policy Development, Assurance •  Vision: Healthy people in healthy communities •  Goals: Prevent epidemics & spread of disease, protect against environmental hazards, prevent injuries, promote & encourage healthy behaviors, respond to disasters & assist communities in recovery, assure the quality and accessibility of health services •  Unique aspects: interdisciplinary approach & methods, emphasis on preventive strategies, linkage with government and political decision making, dynamic adaptation to new problems
  3. 3. How is health measured? •  WHO defines health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity •  Health is measured through mortality and morbidity •  Crude mortality rate= number of deaths in an region divided by total population of the same region (usually mid-year population) multiplied by 100,000 •  Age-adjusted mortality rate = death rate that controls for effects of age distributions in populations (by cause) •  Life expectancy = # of years between age and the average age of death •  Years of Potential Life Lost (YPLL) = Estimate of average years a person would have lived if they hadn’t died prematurely •  Disability-Adjusted Life Year (DALY) = Sum of life years lost due to premature mortality and the years lost due to disability for incident cases •  Quality Adjusted Life Years (QALY) - Change in utility value induced by treatment multiplied by duration of treatment effect (places weight on time in different health states) can be used to determine costs/QALY •  Prevalence = # or rate of cases at a specific time •  Incidence = # or rate of NEW cases occurring during a specific period
  4. 4. Determinants of Health Evans & Stoddard Field Model of Health and Well-Being
  5. 5. Public Health strategies •  Primary: Seek to prevent occurrence of disease or injury by reducing risk factors (i.e. laws for seatbelts or preventing harmful exposures •  Secondary: Preventative screening that seeks to control or reverse disease processes before signs and and symptoms develop (i.e. mammograms) •  Tertiary: Prevention strategies that restore individuals to optimal functioning after a disease or injury is established.
  6. 6. Health Services/ Clinical strategies •  Primary: Clinical preventative services & basic care; i.e. vaccines •  Secondary: Specialized attention once disease is present •  Tertiary: Subspecialty care that is designed to cure or mitigate disease states (i.e. CABG for patients with CHF)
  7. 7. misplaced priorities in healthcare •  Woolf, et al •  Put resources toward interventions that maximize health benefits to lessen disease burden on the public and lower costs- more effective = more attention •  Devote resources to interventions in proportion to their ability to improve outcomes, OR pay extra for healthcare- in lives and dollars
  8. 8. Woolf’s solutions to misplaced priorites •  Choosing Effective Services: Most effective services don’t always get priority (ex: breast cancer screenings (net cost) vs. smoking cessation (net savings)) •  Delivering Care: Focus on restoring quality as much or more than biomedical advances (big investments on medical advances, but most patients can’t access them) •  Preventing Disease: Spend heavily on treatment but little on prevention (ex: chronic diseases- risk reduction and prevention rather than late-stage disease costs) •  Foster Social Change: Alleviate social distress (determinants of health) (ex: put resources toward education, health care access, etc.)
  9. 9. How is health care organized? •  Primary Care – Common health problems and preventive measures (sore throat, diabetes, hypertension, vaccines, mammograms, etc) •  Secondary Care – Problems that require more specialized clinical expertise (usually hospital care) •  Tertiary Care – Management of rare and complex disorders/cases
  10. 10. Regionalized vs. Dispersed model of care •  Regionalized •  Primary Care is the main focus, most physicians are GPs •  Secondary Care – Specialties, hospital-based clinics •  Tertiary Care – Subspecialties located at few tertiary care medical centers •  Patients defer to GP/PCP FIRST and then see specialists •  Dispersed (US) •  Less structure •  Can go directly to a specialist- not everyone has or uses a PCP/GP and there is more freedom of choice •  PCPs provide inpatient and outpatient care •  Competing hospitals because they are not geographically separated as in a regionalized model •  Bulk of hospitals provide secondary and tertiary care
  11. 11. Structure of healthcare services marketplace
  12. 12. Challenges in healthcare Major Trends •  Pressure over financing of health care •  Impact of aging population •  Rising activism among consumers and providers •  Advances in technology •  Unequal distributions of health resources •  Recognition of non-medical determinants of health IOM: Safe, Timely, Efficient, Effective, Patient Centered, Equitable (STEEPE)
  13. 13. Berwick’s triple aim •  The US healthcare system is broken (assessed by our health- expenditure vs. rankings in life expectancy, insured population, and infant mortality” •  The triple aim is: Increase Access, Reduce Cost, and Improve Quality
  14. 14. Risk & Insurance •  Risk is the chance of something bad happening •  Patient Perspective: getting sick and not being able to to pay a provider •  Provider Perspective: providing services to someone who can’t pay you •  Insurance is a contractual agreement used to distribute risk over a large base
  15. 15. Risk & insurance •  Moral Hazard – “an insulated third party may behave differently than it would if it were fully exposed to risk” => Once someone has insurance they may act more recklessly because they do not feel the risk •  Adverse Selection – The tendency of people with poor health to apply for and continue health coverage more than people with good health
  16. 16. Risk & insurance •  Community Rating – Distributes risk “within and across groups.” => Everyone pays the same rate •  Experience Rating – Distributes risk “within” groups. => The amount someone pays is based on their level of risk. Bankers would pay less than coal miners => draws healthy people away from community ratings and is less redistributive
  17. 17. How insurance works •  Insurance purchasers pay premiums to insurance companies for health insurance plans •  Premiums are deposited into financial reserves which pay for covered services (for subscribers), and investments/marketing/ administrative costs (for insurance companies) •  Medical Loss Ratio = % of premiums spent on medical services •  States determine how to enforce laws on MLRs (range is 50-80%) •  Health Reform requires plans in individual/small group markets to maintain a MLR of 80% •  Factors affecting the # of uninsured: Costs of health insurance can be prohibitive, transition in the US economy from industry to service provision, unstable economic conditions, changes in public policy
  18. 18. Types of Health coverage •  Out of Pocket: Individual pays provider through private funds •  Individual Private Insurance: Individual pays premium to health plan, plan reimburses care provider •  Employer-Sponsored Insurance: Employee and employer pay premiums to health plan, plan reimburses care provider
  19. 19. Types of health coverage •  Managed Care: Manages healthcare delivery to control costs, typically relying on PCP as gatekeeper •  HMO: Most restrictive, patients must receive care from specific providers, pain on “per-member, per month” fee •  PPO: Loose-knit, insurers contract with doctors and hospitals to care for patients at a discount with medical/ utilization review (flexible in choice of provider but sometimes at a higher cost) •  Alternative Insurance: Indemnity (deductible & copay), HMO, PPO
  20. 20. Government Insurance •  Medicare: Federal, 65 y/o+, disability, dialysis or kidney transplant •  Medicaid: Federally aided state-operated, for indigent/ low-income •  Reimbursement Methods: Per service, episode of illness, per diem, capitation, global
  21. 21. Unwarranted variation in healthcare •  Variation not explained on the basis of illness, patient preference, or evidence-based medicine •  Estimated 30% of current spending on healthcare is wasted •  Types of Unwarranted Variation: •  Effective Care -> Medically necessary interventions on the basis of clinical outcomes evidence for which benefits outweigh the risks •  Preference-Sensitive Care -> Variation due to patient choice or preference, choice of treatment involves tradeoffs •  Supply-Sensitive Care -> Services where supply of resource has major influence on utilization rates, largely due to differences in local capacity
  22. 22. Accountable care organizations •  Network of doctors, hospitals, and other healthcare organizations that share responsibility for providing care •  Major Principles •  Local Accountability: Providers within a community that can effectively provide/manage full continuum of patient care •  Shared Savings: ACOs that meet quality standards while slowing spending growth will receive a portion of shared savings •  Performance Measurement: Must collect a core set of performance measures that include clinical processes, outcomes, and patient experiences -> measurements are essential to ensure appropriate care is being delivered
  23. 23. Accountable care organizations Essential Characteristics •  Provide continuum of care in integrated system •  Sufficient size to support performance measure •  Capable of planning budgets •  Provider inclusiveness •  Ability to manage risk Challenges •  Critical mass of provider/payer participation •  Adequate financing •  Clinical support infrastructure and technical issues •  Changing provider culture and patient behavior •  Potential to increase provider concentration and market power
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