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Access, quality and cost the three pillars of health policy

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Access, Quality, and Cost: The
Three Pillars of Health Policy
Nancy M. Short DrPH, MBA, FAAN
Associate Professor
Duke Univ...

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What makes a country “developed” ?
International criteria :
Disagreement among authors
Agree on some strong distinguishi...

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Patient care is a highly political endeavor!

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Access, quality and cost the three pillars of health policy

  1. 1. Access, Quality, and Cost: The Three Pillars of Health Policy Nancy M. Short DrPH, MBA, FAAN Associate Professor Duke University School of Nursing
  2. 2. What makes a country “developed” ? International criteria : Disagreement among authors Agree on some strong distinguishing characteristics  High incomes per capita  High GDP per capita  Industrial dominance  U.N. Human Development Index (HDI) ≥ 0.788 o Measures life expectancy and education levels “A country that allows all its citizens to enjoy a free and healthy life in a safe environment.” - Kofi Annan, Secretary General of the United Nations, 2008
  3. 3. Patient care is a highly political endeavor!
  4. 4. Catalysts for Health Policy COST QUALITY ACCESS
  5. 5. ACCESS to healthcare Complex concept • “Having access”: Are services available? Is there an adequate supply of services • “Gaining access/Utilization”: Financial affordability Physical/organizational accessibility Social and cultural acceptability
  6. 6. ACCESS to healthcare • Defining access to care What does “universal” mean? What does “coverage” mean? • Measuring access to care Trends in monitoring access  Demand & Supply • Lack of consistency in terminology
  7. 7. Concepts within “Access” Health supply terms Availability Affordability Health demand terms Utilization Acceptability Access = how much a population can reach health services Coverage = the share of a population eligible (beneficiaries) for a set of interventions
  8. 8. Key points on the concepts : Use the term universal "access" instead or universal "coverage"  Avoid benchmarking "universal" in absolute terms Use of the term "coverage" associated with outcome (intervention) indicators The term "universal access" can be completed by its target expressed in "universal access at 80% of coverage" for a specific intervention
  9. 9. Key points on the concepts (2): Measuring "access" may actually measure just one or a few domains of access (like availability, affordability and/or acceptability), but rarely all of them Define country targets in national context instead of focusing on global targets Define target taking into account the measurability of the targeted entity (e.g. district or population) Overall, the concepts of access, coverage and associated terms are not standardized across programs, so there is room for flexibility.
  10. 10. Concepts within “Access” Universal  Qualitatively, it gives a sense of equality, indivisibility  Quantitatively it can be "all" or "enough for everyone to get a chance" Target  Can be an outcome, prevention, or treatment target  Scopes of target (global, country)  Targeted entity: % of population, population group, group at risk, a group in need, districts, facilities … (measurability) Scaling-up  Expand geographically  diversify Intervention vs. services
  11. 11. ACCESS to healthcare Models for Determining Access: 1. Andersen’s Behavioral Model of Health Services Utilization 2. Health Care Access Barriers (HCAB) Model 3. Eight Factor Model
  12. 12. Andersen’s Behavioral Model of Health Services Utilization
  13. 13. Carrillo JE, Carrillo VA,Perez HR,Salas-Lopez D, Natale-Pereriea A, Byron AT. (2011). Defining and targeting health care access barriers. J Health Care Poor Underserved. May;22(2):562- 75. Healthcare Access Barriers Model
  14. 14. Measuring “true access”: Eight Factor Model “Being able to get to and from services, having the ability to pay for services, and getting your needs met once in the system.” - Margie Lovett-Scott EdD, RN and Faith Prather PhD ACCESS to healthcare
  15. 15. Eight Factor Model
  16. 16. COST of Healthcare Country Health Expenditure per capita in US $$ Health Expenditure as % of GDP United States $8,508 17.7 Switzerland $5,643 11.0 Canada $4,522 11.2 United Kingdom $3,405 9.4 Japan $3,213 9.6 Singapore $2,592 4.5 Argentina $1,321 8.3 Russia $1,277 6.5 Saudi Arabia $ 914 4.0 Cuba $ 414 10.2
  17. 17. Why does it matter how much we spend on sickness and health care? COST of Healthcare
  18. 18. Included Not Included What’s Included in “Cost”?  Fixed costs o Facilities o Utilities  Variable Costs o Labor o Benefits o Risk  Payments for services  Losses from non-payments  Payments for goods o Distribution costs  Opportunity costs o Loss of productivity  Costs of educating health professionals  Bureaucracy o Government o Insurance o Lobbying  Research & Development  “Black market” for health care  Negative externalities o Hospital waste  Expenditures on health determinants
  19. 19. Life Expectancy at Birth (years) and Health Spending by Country, 2010
  20. 20. Why Can’t We Keep On Spending More and More? Adverse employment effects in United States RAND predicts 10% increase in health care cost = 120,800 jobs lost Loss of Employer Sponsored Health Insurance Shifting costs to employees Employer Health Care Burden Health benefit costs as a share of hourly pay in US = 13%, in Germany = 6.5%, in Japan = 3.7%, Canada = 4.5%
  21. 21. How to Lower Costs? Eliminate care of little to no value o Limit technology acquisition Eliminate redundant tests o Incentivize providers Eliminate medical errors o Greater information technology Improve prevention and coordination Funding innovation (pay for performance?)
  22. 22. Measuring cost of care is easier than measuring the VALUE of that care COST of Healthcare
  23. 23. Quality of Healthcare Measuring “quality”  Health status of a country  Population density  Infant mortality  Death rates  Levels of communicable disease  Ability to respond to health emergencies “Although most of us probably believe that low quality is primarily a reflection of inadequate financial resources, there is good evidence that quality can be enhanced in a number of ways even in the absence of additional resources.” -- Richard Skolnik, Director of International Programs for the Population Reference Bureau
  24. 24. Quality of Healthcare Variation in care: Geography is Destiny  Access to care  Compliance with evidence based guidelines  Monitoring effectiveness of care Types of Errors: Underuse of services Overuse of services Misuse of services
  25. 25. Quality of Healthcare The Institute of Medicine has identified six aims of quality medical care: 1. Safety: ensure that the medical care intended to benefit patients is not causing harm. 2. Effectiveness: Medical treatments must be based on scientific knowledge, and must produce beneficial, measurable results. 3. Patient-centered: Care must be tailored to individual patient preferences, needs and values. Patients should have authority over their own medical care, and their input must guide clinical decision- making. 4. Timeliness: Patients requiring medical attention should have access to timely healthcare and follow-up care to avoid potentially harmful delays in treatment. 5. Efficiency: Quality health care avoids wasting finances, time, equipment, and energy. Efficiency maximizes the impact of global health organizations. 6. Equitability: The quality of medical care must be consistent across all patients, irrespective of gender, ethnicity, socioeconomic status, and other personal characteristics.
  26. 26. Quality of Healthcare Disparities in quality of healthcare  Data collection and reporting varies from country to country  “Racial or ethnic differences in the quality of health care that are not due to access-related factors such as insurance coverage, or clinical needs, preference and appropriateness of intervention.” United States  National Healthcare Quality Report and  National health Disparities Report available at: http://www.ahrq.gov/qual/measurix.htm#quality
  27. 27. Quality of Healthcare Are all disparities in health related to “disparate” health care or access? All people are not born equal. Individual differences in genetic endowment may well control differences in life- expectancy. Even if all individuals are subject to the same environmental influences, they would not flourish, age, and dies at the same rate. -George Orwell
  28. 28. Quality & Safety Institute for Healthcare Improvement in U.S. National Institute for Clinical Excellence in U.K. Joint Commission International International Association of National Public Health Institutes International Society for Quality Health Care (ISQua) WHO, Pan American Health Organization, Canadian Council on Health Services Accreditation , others IOM
  29. 29. What Can Leaders Do?  Shift focus from management to leadership  Decentralize care delivery…greater focus on primary care Strive to level the “playing field” between the impoverished and the affluent ( equal healthcare for all)  Adopt and implement mhGAP (WHO program toward achieving better outcomes in mental health care)  Monitor outcomes including Disability Adjusted Life Years (DALYs) and Years of Life Lost (YLL) measures due to communicable and non- communicable diseases and conditions
  30. 30. What Can Leaders Do?  Promote wise use of antibiotics  Promote appropriate immunization to achieve herd immunity  Support prevention:  methods for preventing HIV/AIDS  control of disease vectors (insects,rodents)  Health in All Policies approach  Promote research and development  Consider unintended consequences related to the interrelatedness of Access/Quality/Cost

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