American Healthcare Final

HMO vs ACO So, what's the difference between HMO and ACO?

An HMO is a medical insurance organization that provides health care to anyone who is a member for a certain annual fee. On the other hand, an ACO is a group of networked healthcare professionals who are supposed to make sure that quality health care is provided to a set number of members. In an HMO, a primary care physician (PCP) is selected to act as a gatekeeper to other pre-selected health care providers. A member can only get additional access to treatment through a referral from a PCP, a cost-cutting feature HMOs are known for. With ACOs, PCPs are in charge of a member's care team where the member can choose any health care provider. Health care providers are reimbursed in relation to quality metrics already in place. It is clear that in an HMO environment, medical cost is a heavy factor, compared to ACOs where the reimbursement system relies on improving medical care

Sources of New Physicians

Applicants from U.S. Trained in U.S. Medical Schools (Small Number of Non-U.S. Residents) Applicants from U.S. Trained in Non-U.S. Medical Schools (Many from Caribbean Medical Schools) Must Received Graduate Training (Interns and Residents) at U.S. Hospitals Non-U.S. Applicants Trained in Non-U.S. Medical Schools Even if Practiced in Other Countries Must Go Through Graduate Training in U.S. and Pass a Test Three Groups Compete for Residency Slots

Techniques to control health spending

Change incentives for providers Change incentives for patients Government regulation

FDA approval process

Compares a medication to a placebo for narrow outcomes Safety and Efficacy for a narrow set of diagnoses Clinical trials for efficacy Specific population by age and sex Specific protocol No comparative effectiveness or cost-effectiveness Difficult to balance access with established clinical benefit

Donabedian Framework versus the NQMC Domain framework for clinical quality measures

Donabedian Clinical Quality Measure: process, outcome, structure NQMC Domain Clinical Quality Measures: process, access, outcome, structure, patient experience

What does the term "downstream" mean in terms of social determinants of health?

Downstream: medical care, environmental factors, health behaviors

List the types of reimbursement

Global budget: fixed payment over entire year for all care (ACOs) Capitation: payment per person per month (managed care organizations Budled/Episode Payment: payment per episode of care Free-fore-service: payment per service

Examples of a health disparities versus a healthcare disparities

Health disparity: black women are more likely to die from ovarian cancer than white women Healthcare Disparities: Black women were less likely than white women to receive guideline recommended care for advanced epithelial ovarian cancer (54% compared with 68% P<0.01)

How do Drugs and technology contribute to US Healthcare spending?

High prices of drugs & technology US uses higher proportion of new drugs & technology

Reports of Early Signs of Physician Shortage Today

Longer waiting times for patients Longer referral times for physicians Practicing physicians report burn-out Policy change from shortage to surplus by AAMC, AMA, COGME Finding a primary care physician has become difficult—even in physician "rich" areas, like Massachusetts The largest demand according to recruitment firms is for primary care physicians Hospitals are becoming a major employer of physicians

Why is it important to control health spending?

Money spent on healthcare is money not spent on other things Individual patients - have to spend a high proportion of their income on healthcare (premiums, out-of-pocket costs, high medical bills that can lead to medical bankruptcy) and can't pay for other things in their lives Employers - have to spend more money on health insurance for their employees, which means less money for employee salaries; high spending on health insurance means limits on other spending by employers State government - Medicaid is the second highest expense for states, and it takes up money that they could otherwise spend on other things (states have to balance their budgets) Federal government - health spending is a major reason for high public debt

What is it important to control health spending?

Money spent on healthcare is money not spent on other things: Individual patients - have to spend a high proportion of their income on healthcare (premiums, out-of-pocket costs, high medical bills that can lead to medical bankruptcy) and can't pay for other things in their lives Employers - have to spend more money on health insurance for their employees, which means less money for employee salaries; high spending on health insurance means limits on other spending by employers State government - Medicaid is the second highest expense for states, and it takes up money that they could otherwise spend on other things (states have to balance their budgets) Federal government - health spending is a major reason for high public debt

How do we define quality?

On the basis of several definitions in the literature, the WHO definition of quality of care is "the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centred." Quality must be.... Safe: Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors. Effective: Providing services based on scientific knowledge and evidence-based guidelines. Timely: Reducing delays in providing and receiving health care. Efficient: Delivering health care in a manner that maximizes resource use and avoids waste. Equitable: Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status. People-centered: Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community.

Explain QALY and how it is calculated (in relation to NICE)

One QALY is equal to 1 year of life in perfect health.QALYs are calculated by estimating the years of life remaining for a patient following a particular treatment or intervention and weighting each year with a quality-of-life score (on a 0 to 1 scale). It is often measured in terms of the person's ability to carry out the activities of daily life, and freedom from pain and mental disturbance.

In the classic framework for clinical quality measures, define outcomes

Outcomes answers the question, "What is quality? Clinical outcome Adverse outcome Functional status Health risk state or behavior Quality of life measure

process and outcome measure generally expressed as rates. Give examples of how this is measured

Rate = (care meets the criterion / number of people eligible for care) Immunization rate = (children immunized / total children) Mammography rate = (women with annual exam / eligible women)

Define quality of life measure

Refers to "health-related quality of life based on those aspects of a person's overall well-being that are affected by health status or health care."

Solutions to our inefficient healthcare delivery system

Reform the delivery and reimbursement system for increased coordination (ACOs, bundled payment) Have prepaid group practices (like Kaiser) that can provide the same amount of care with fewer physicians

In the classic framework for clinical quality measures, define structure

Structure answers the question, "What facilitates quality?" How care is configured (facilities, supplies, personnel, EHR, availability of board certified specialists, nurse staffing levels)

The ACA established innovation center in order to do what?

To study new forms of payment and delivery systems under medicare supported creation of Accountable Care Organizations (ACO's) and bundled payment demonstrations

Bundled Payment Pilot Models 1-3

In Model 1, the episode of care is defined as the inpatient stay in the acute care hospital. Medicare pays the hospital a discounted amount based on the payment rates established under the Inpatient Prospective Payment System used in the original Medicare program. Medicare continues to pay physicians separately for their services under the Medicare Physician Fee Schedule. The first cohort of Awardees in Model 1 began in April 2013 and concluded on March 31, 2016. The remaining Awardee concluded their participation on December 31, 2016. Models 2 and Model 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care. In Model 2, the episode includes the inpatient stay in an acute care hospital plus the post-acute care and all related services up to 90 days after hospital discharge. In Model 3, the episode of care is triggered by an acute care hospital stay but begins at initiation of post-acute care services with a skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency. Under these retrospective payment models, Medicare continues to make fee-for-service (FFS) payments; the total expenditures for the episode is later reconciled against a bundled payment amount (the target price) determined by CMS. A payment or recoupment amount is then made by Medicare reflecting the aggregate expenditures compared to the target price.

What needs to happen to achieve higher quality?

Increased demand for higher quality— from individuals, organizations, and purchasers Value-focused financial incentives Public leadership at federal and state levels Medical education reforms Delivery system behavior-- leadership, effective solutions and shared commitment to improving quality

What is the trend for the demand for physicians?

Increasing demand for physicians (due to the baby boom generation) met with decreasing supply of physicians

Summarize the overall definition of healthcare disparities

"...racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention"

What does moral hazard refer to?

"Moral hazard" refers to the additional health care that is purchased when persons become insured. Under conventional theory, health economists regard these additional health care purchases as inefficient because they represent care that is worth less to consumers than it costs to produce.

How can health disparities effect people? (definition)

"are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by social disadvantaged populations"

Quotes about Social determinants

"health starts in our homes, schools, workplaces, neighborhoods, and communities" "social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.: "A key social determinant of health is education"

U.S. technology policy: Market approach

Lots of individual insurers Fewer administrative controls on spending widely used elsewhere No fixed national budget for health care overall, hospitals or doctors Limited use of technology assessment to judge cost-effectiveness of new drugs and devices Few incentives for doctors and patients to take cost into account when considering high-tech treatment options Overuse of high-tech services encouraged by design of insurance products

Is it possible to provide quality care with fewer physicians?

Low intensity U.S. regions achieve equal or better results with fewer physicians

Increasing role of non-physician practitioners

Many argue there is a substantial and worsening shortage of primary care providers Increasing supply of nurse practitioners (NPs) and physician assistants (PAs) can fill some of the gap Evidence of their role has been positive Similar quality as compared to physicians Can practice in multiple settings and situations Primary care, urgent care, chronic dis mgmt, pediatrics, etc. Emphasize more "patient-centered" care Communication, prevention & wellness, longer visits, patient satisfaction Still, resistance to an expanded role remains due to: Lagging capacity to train adequate numbers of NPs and PAs Provider resistance to expanded roles Restrictive state scope of practice laws

Who is spending all of this money in the american health care system?

Medicare (federal government) Medicaid (state government + federal government) Individual insurance companies (private businesses) Individual patients - premiums, out-of- pocket costs

How does health reform bill encourage more primary care?

New scholarships for medical students who choose primary care as a specialty and support for those entities training primary care doctors. Support those delivery models that focus on primary care models, such as medical homes, team management of chronic disease, those that integrated physical and mental health services, and accountable care organizations. Going forward medical systems will need physicians taking on a broader clinical responsibilities.

Pros of the contributions of technology to health care

New treatments for previously untreatable conditions Clinical advances in current treatment Development of diagnostic tools/treatments to enhance secondary conditions Expansion of treatment indications over time Incremental improvements in existing capabilities Cumulative effect of incremental treatments (e.g., mental illness) Increased productivity Increased quality of life

Does the US have a physician shortage?

Not necessarily, the US Has More Physicians Per Population Today Than Ever Before Yet--- Many Believe We Have a Growing Shortage of Physicians

Reasons why prices are higher in the US

People earn more in health care jobs Drugs and devices are more expensive Administrative costs of mixed public/private systems Cost of malpractice system Newer/more expensive delivery system Providers have increased price leverage through consolidation and contractual arrangements Health care in the U.S. is big business!

Once available--Individual providers decide when and how to use comparative effectiveness

Physicians can use for specific approval, different level of severity, or off-label Consumer price varies with insurance companies Insurance leverage and pharmacy benefits managers: Pharmacy and therapeutic committees to approve drug for formulary Prior authorization Specialty drug managers and benefit design Off-label use is the use of pharmaceutical drugs for an unapproved indication or in an unapproved age group, dosage, or route of administration.

In Areas with more physicians what are the results?

Physicians use more aggressive treatments Higher costs More physician go to physician "rich" areas For every physician who goes to a low supply region, 4 physicians settle in a high supply region

Changing role of government in Training new physicians

Pre 1965 Number of students not a concern 1965-1975 Medicare/Medicaid Puts Pressure on Feds to Grow Physician Supply Carnegie Commission - 50,000 shortage of physicians 1973 Comprehensive Health Manpower Act-incentives to expand class size 1975-2009 Fed Gov't Does Not Support Undergraduate Med. Ed Medicare Supports Graduate Med Ed 1997---Feds Limit Support for Graduate Medical Education Some States Add New Medical Schools 2010 Affordable Care Act Encourages more primary care through both training grants and higher payments

What is medical technology?

Procedures (medical, surgical) Products (drugs, devices) Support systems (Health IT) Policies (hand washing, insurance expansion) Models of care (ACOs, medical homes) Prevention and treatment

In the classic framework for clinical quality measures, define process

Process answers the question, "What produces quality?" Right health care service provided to the right person at the right time (annual eye exam for diabetic patients, mammography for women over 50)

Structure Measures - Promises and pitfalls

Promises: Easy to measure Easy to identify a problem Can have simple solutions- purchasing more supplies, hiring more staff Pitfalls: Can be difficult to make improvements- need more money allocated Not the full picture- what happens once the patient arrives?

Process Measures Promises and Pitfalls

Promises: Specific helpful for targeting improvement helpful for rare events, diverse populations, can cross conditions Requires a smaller N and thus more practical to collect information Powerful when linked with outcomes Pitfalls: Easy to focus on too many processes or those that don't matter Don't always provide compelling feedback Association with outcomes may be weak, absent, or not studied May be influenced by patient or community factors

Outcome Measures - promises and pitfalls

Promises: appear to be "clean" comprehensive compelling and important in own right, ex: hospital specific death rate from cardiac complications Useful when a broad perspective is needed, ex: infant mortality rates for a population Reflects both measurable and non-measurable aspects, ex: expertise Pitfalls: Reflects many factors (patient, provider or setting) Can be misleading (cause and effect) Not always useful for immediate quality improvement efforts Rare events make measurement more difficult

Why are drug prices so high? (from a public / private payers, patients, and providers point of view)

Public and Private Payers = Medicare: Must cover what is "reasonable and necessary" Structure of Medicare Part D Statutorily prohibited from negotiating prices Medicaid: Payment amounts vary by state Private Insurers: Individual insurers negotiate separately with drug companies Patients: Generous insurance coverage (i.e., moral hazard) Providers Fee-for-service No controls on prescribing

What is public reporting?

Public reporting is data, publicly available or available to a broad audience free of charge or at a nominal cost, about a health care structure, process or outcome at any provider level (individual clinician, group, organization)

Five predictions for 2028

Quality measures are a routine part of doing business - ubiquitous use of quality improvement approaches Information technology has revolutionized approaches to quality measurement through --> More electronic health records Big data approaches to measurement Detailed data allows better risk adjustment Primary focus on outcomes and capturing data on patient-reported info Fundamental changes in the cost equation through value-based purchasing Consolidation of the plethora of measures

What are two strategies to control costs? Describe them

Regulation: Quality: Certificate of need laws; set limits/criteria on how services will be covered and utilized (ex: utilization review, gatekeeping) Price: Price controls; state rate review boards Market Based: Quality: Copay insurance; Payment mechanisms(bundled payment, global budgets (i.e. ACOs) Price: high-deductible health plans; premium support

Stages of Drug Innovation

Step 1: Discovery and development = research begins in laboratory; target is to determine the disease they want to combat and how they're going to do that Step 2: Preclinical Research = lab and animal testing for safety questions Step 3: Clinical Research = tested on people; done for efficacy; specific population by age and sex; specific protocol Step 4: FDA review = FDA data related to the drug or device. approve or not Step 5: FDA Post-Market = FDA monitors drug and device safety once products are available for use by the public

Quality of Care between Physicians, NPs, and PAs

Studies Suggest That For Many Primary Care Services Quality of Care Is Similar Between Physicians and NPs and PAs States With Serious PC Shortages Allow NPs and PAs More Independence

Why can't US play NICE?

Systems are different ( no single payer in US); Myth of death panels: Negative term used as a political weapon against health reform Refers to rationing care Patients demand more choice in US ;ACA allows for comparative effectiveness research: But only in a limited way A supposed government committee responsible for choosing which patients receive healthcare, ostensibly witholding life-saving treatment from the some, in order to reduce costs.

Why do we spend so much money on health care in america?

The health system is decentralized - no one is in charge of controlling the flow of money into the system Salaries in the health system are high We have a relatively low proportion of primary care doctors (who can provide care more cheaply than specialists) We can't control drug prices Third-party payment system - when someone else (insurance companies or government payers) is paying the bill, patients aren't careful about how much care they use, and doctors aren't careful about how much care they deliver We're spending more over time - aging population, people living longer Prices for healthcare and prescription drugs are rising over time

Why do we spend so much money?

The health system is decentralized - no one is in charge of controlling the flow of money into the system Salaries in the health system are high We have a relatively low proportion of primary care doctors (who can provide care more cheaply than specialists) • We can't control drug prices

How would public reporting work?

Three sets of actors: patients and families, professionals delivering care, and managerial and supervisory bodies (ex: payers, government) Causal Pathways Selection: clients (patients, referring physicians, insurers, public agencies) modify their choices based on available performance measures Change - providers use performance measure to improve their performance

Why are there high costs for healthcare in the United States?

Total Costs = Price x Quantity Quantity/utilization: Overuse, misuse, underuse Technology Tax treatment of insurance Low direct cost to individual (moral hazard) Payment incentives Prices

Education for Registered Nurses

Types of Training for RNs Hospital-Bases 3yr Diploma Community College 2-3Yrs Associate Degree University 4yr Baccalaureate Degree MA Nurse Practitioner/Advanced Nurse Practitioner Ph.D.--- Dr. of Nursing Most RNs today Associate Degree Trained But Largest Growth in BA and Above Pressure to Make BA Degree or Higher Required In Future Many New Programs to Provide Advance Education for RNs with Less Than a BA

Importance of Primary Care

U.S. has a smaller percentage of primary care physicians Than Other Countries Less Than 20% (Many Other Countries at 50%) And falling--% of medical school graduates choosing family medicine fell from 14% (2000) to 8% (2005) and still falling And 75% of internal medicine residents become subspecialists or hospitalists More specialists seem to result in greater use of hospital care for Ambulatory Sensitive Admissions And International Comparisons suggest less coordination of care in U.S.

What does the term "upstream" mean in terms of social determinants of health?

Upstream: eduction, income, neighborhood environment

Is the US physician workforce relatively small compared to other countries?

A Commonwealth Fund Analysis indicates that the U.S. is below the OECD (Organization for Economic Cooperation and Development) median for physicians per 1,000 population.

What is the difference between horizontal integration and vertical integration?

A horizontal integration consists of companies that acquire a similar company in the same industry, while a vertical integration consists of companies that acquire a company that operates either before or after the acquiring company in the production process. Horizontal integration occurs when individual physicians join grouppractices or existing groups merge with each other. There are numerous theoretical reasons to expect that this type of integration might lead to improved quality and cost savings, including enhanced operating efficiency and economies of scale. Another form of vertical integration is between providers and health insurance plans. There are several well-known examples of these systems, including Kaiser Health Plan and other major integrated systems (e.g., Mayo Clinic, Cleveland Clinic).

What is a health disparity?

A particular type of health difference that is closely linked with social, economic and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender;age;mental health' cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion

Further describe bundled payments

A single payment for a bundle of services implicit in an episode of care, itself contingent upon an inpatient admission The episode based on some period of time after (and before) the admission The payment is all-inclusive for the episode: Physician services, supplies, facilities, etc. Physician services, specialty care, inpatient, post-acute, etc. Based on clinical guidelines

What is health?

A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity

Delivery System Demonstrations included in affordable care Act

ACA Establishes Medicare "Innovation Center" Funded With $1 Billion per Year for 10 Years Innovation Center Supports Organizations That Agree to Set Up "Accountable Care Organizations" and/or "Bundled Payment Demonstration" ACO or Bundled Payment Group Can Share Savings With Government

Briefly describe the features of ACO versus Bundled Payments

ACO: Organization and Structure Payment and financial risk Other features --> Quality measurement and Emphasis on primary care Bundled Payments: Features of a "bundle" What's in, what's out? Describe the financial risk

How the UK does it (NICE)

Uses 'quality adjusted life years' (QALYs) to compare different drugs/technologies Only recommends drugs that represent value typically between £20,000 and £30,000 per QALY National Health Service (NHS) only pays for drugs approved by NICE Since UK has a single payer health system, led by NHS, NICE is the gatekeeper of drug/technology access

Features of ACOs

Voluntarily formed by providers, hospitals, or combinations of both along all phases of care continuum ---> Primary care, inpatient, post-acute, etc. Global budget with shared savings/risk: Based on historical average Partially tied to quality Emphasis on primary care Manage patients appropriately, coordinate care Discourage unnecessary hospitalizations, use of specialists Flexibility: Providers decide how to reduce costs, improve quality Encourage innovation (e.g., provide "non-medical" services) Voluntary patient participation

What is adverse selection

can be defined as strategic behavior by the more informed partner in a contract against the interest of the less informed partner(s). In the health insurance field, this manifests itself through healthy people choosing managed care and less healthy people choosing more generous plans.

What various factors are health care due to?

African-Americans and Latinos have lower rates of education and income. more likely to be uninsured. Asians have lower rates of illicit drug and alcohol use than whites Latinos are on average younger than whites and more likely to be in age groups that have higher prevalence of mental illness Providers have biases that may lead to discrimination. Hospitals and community health centers have had a legacy of racist policies Simkins v Moses H. Cone Memorial Hospital (1963), challenged the federal government's use of public funds to expand and maintain segregated hospital care differential harm from research, detention, involuntary commitment

FDA role and Review Processes

After early stage development Ensure safety and effectiveness for approval Oversee drug development process Randomized controlled trials as gold standard Monitors safety and effectiveness post marketing Reviews labeling and promotion Balancing regulatory power: Safety vs rapid innovation

What is health equity?

All have an opportunity to survive, develop, and reach their full potential without discrimination or bias Absence of systematic unfair disparities between population groups in their opportunities to obtain healthy development

How do disparities arise?

differences in the quality of care received within the health care system differences in access to health care, including preventive and curative services differences in life opportunities, exposures, and stresses that result in differences in underlying health status

Define adverse outcome

e.g., an injury due to a medical treatment such as perforation during surgery.

Define clinical outcome

e.g., level of hemoglobin A1c, a measure of control of glucose metabolism in individuals with diabetes; change in symptoms; mortality as an outcome of a clinical condition.

Define Health risk state or behavior

e.g., not being a smoker as an outcome measure for smoking cessation counseling.

Solutions for lack of primary care physicians

expand the capacity of medical schools, lift/raise caps on residency programs, recruit internationally

Solutions for "we rely too heavily on physicians to provide primary care"

increase scope of practice in all states for non-physicals who can provide primary care: nurse practitioners and physician assistants

Define functional status

measure of an individual's ability to perform normal activities of life.

Who contributes to research and development?

Both public and private sources Basic research, translational research, clinical research

Why are US prescription drug prices so high?

new drug development/profitability, advertising costs + increases demand, US Healthcare is big business (industry and market structure), Insurance: discounts, rebates keep published prices high, patient protection, and federal pricing rules (US only country to not have government

Comparative Effectiveness Research

Cannot use CER to make coverage or reimbursement decisions that treat value the lives of young, nondisabled, or not terminally ill persons above those who are elderly, disabled, terminally ill Cannot use CER to make coverage/reimbursement decisions that precludes or discourages an individual from choosing a health care treatment based on how the person values the tradeoff between extending the length of life and the risk of disability. Cannot use quality-adjusted life-year (or similar measures) as a threshold to determine coverage, reimbursement, or incentive programs under Medicare. PCORI cannot develop or employ dollars-per-quality-adjusted life-year (or similar measures) as a threshold to establish what type of health care is cost-effective or recommended.

Concerns about current system

Care uncoordinated, fragmented, and inefficient: Little information sharing Duplication of services Little or no coordination or care transitions Poor quality (high rates of avoidable care defects Fee-for-Service (FFS) payments reward "volume" over "value" No constraints on prices Want to: Increase coordination Reduce excess use of services Reward higher quality (not just cost)

In contract to the US technology policy, Market approach other develop countries more regulatory

Centralized Top down allocations Government more directive (Australia, Canada, GB) Evaluation approaches differ: economic, social, etc. Other countries are also struggling with questions of affordability, sustainability, and efficiency

What are drugs?

Chemical: produced by chemical synthesis, low molecular weight, well-defined structure, mostly process-independent, completely characterized, stable, mostly non-immunogenic Trade name; Generic Biologic: produced by living cell cultures, high molecular weight, complex heterogenous structure, strongly process-dependent, impossible to fully characterize the molecular composition and heterogeneity, unstable sensitive to eternal conditions, and immunogenetic Trade name Biosimilar

What is comparative effectiveness and give an example

Comparative Effectiveness (according to Institute of Medicine) is: Generation and synthesis of evidence that compares the cost and harms of alternative methods to prevent, diagnose, treat and monitor a clinical conditioner to improve the delivery of careThe direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. Very important applied way on how to improve health and healthcare in the US by comparing alternatives For example: Will the information be timely and effective, given that knowledge (i.e. technology) is constantly changing?

What drives disparities?

Complex, integrated, and overlapping social structures and economic systems that are partially responsible for health inequities Social determinants of health (neighborhood and built environment, health and health care, social and community context, education, and economic stability Discrimination (ex: racism, sexism, homophobia) Chronic stress

What are the potential issues/challenges with Bundled payments

Complexity What's an "episode"? What's in an episode? Prospective or retrospective payment? Are we ready? Potential for undesirable behavior Only limited success thus far

Solutions for the distribution of physicians

Do it by specialty: Increase/equalize payments for primary care physicians, public funding for primary care residencies, loan repayment Do it by geography: restrict growth of practices in particular areas (certificate of need), expand financial incentives for practicing in underserved areas (student loan repayment, grants), increase provider diversity

List all of the social determinants of health and what falls under each category

Economic stability: employment, income, expenses, debt, medical bills, support Neighborhood and Physical environment: housing, transportation, safety, parks, playgrounds, walkability, zip code/geography Education: literacy, language, early childhood education, vocational training, higher education Food: hunger, access to healthy options Community and Social context: social integration, support systems, community engagement, discrimination, stress Health Care System: health coverage, provider availability, provider and linguistic and cultural competency, quality of care

The ACA's Role in Addressing Health / Health Care Disparities

Emphasis on quality measurement Address differential access to health insurance Medical Homes and Accountable Care Organizations (ACO's) Emphasis on preventive health services Emphasis on cultural competency

Britain's National Institute for Health and Care Excellence (NICE)

Evaluates a wide range of technologies: Pharmaceuticals Devices Procedures Diagnostic methods Health Promotion techniques ;Quasi-Independent entity ;Reports to Secretary Health Minister ;U.K. NHS must incorporate (i.e. pay) when NICE decides positively

What are the potential issues/ challenges with ACOS?

Exploiting incentives - Remember adverse selection? Are savings incentives/disincentives strong enough? Are we ready? Only limited success thus far

Moving forward with the health care workforce points

Further expansion of the active physician workforce should be carefully considered The perception of scarcity does not necessarily imply shortages, but rather a mismatch between demand and "availability". There are risks to expansion: actual costs; potential harms; opportunity costs; greater inequality in distribution Different regions -- and organizations -- appear to produce equal or better health outcomes with fewer physician labor inputs -- and a different mix. A key question: how can we foster the development of high performing organizations -- those capable of providing high quality care with fewer resources.

What are the three sides of the physician supply debate

the composition's all wrong there's a shortage geographic distribution is problematic

List the problems of HMOs and what ACOs do differently

HMO problem:Provide networks created by insurers (Medical insurance organization) What ACO did differently: Initiated and formed by providers and hospitals (Group of networked health care prof.) HMO problem:Primary care physician acts as gatekeeper to other pre-selected health care providers What ACO did differently:PCP in charge of a member's care team HMO problem:Members cannot choose health care provider or additional medical treatment What ACO did differently: Members can choose any health care providers or additional medical services HMO problem:Capitation placed all financial risk on providers while benefits went to payers What ACO did differently:Savings (and losses, if applicable) are shared; savings (and losses) are on a sliding scale HMO problem: Focus was only on reducing costs (availability of quality measures was limited) What ACO did differently:Financial rewards partially tied to increased quality as well as costs HMO problem:Insurers imposed tight restrictions and rules (e.g., gatekeeping, prior authorization) on providers What ACO did differently: Providers and hospitals granted complete flexibility to decide how to best provide care and experiment with new ideas

What is Performance measurement

Health care performance measurement is the process of using a tool based on research (performance measure) to evaluate a managed care plan, health plan or program, hospital, or health care practitioner Performance implies that the responsible health care providing entity can be identified, held accountable, has control over the aspect of care being evaluated

Summarized definition of what health equity is

Health equity is the principle underlying a commitment to reduce - and, ultimately, eliminate - disparities in health and in its determinants, including social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention the needs of those at greatest risk of poor health, based unsocial conditions.

Difference between a health inequality and a health inequity

Health inequalities: differences in health status between population groups Health inequities: differences in health status between population groups that are: socially produced, systematic in their unequal distribution across the population, avoidable and unfair Oftentimes people use the words equity and equality interchangeably. To easily remember the difference, imagine that you're standing amongst a group of 30 people. Everyone in the group is given a size 9 pair of sneakers. While it's exciting to have been given free sneakers, there are only four people in group who are a size 9, therefore the majority of people won't be able to wear the sneakers. While the size 9 sneakers were equally distributed to everyone in the group, it wasn't equitable because not everyone wears that size.

Define proxy for outcome

Healthcare utilization used as an indicator of health status, e.g., an admission to hospital used as an indication of increased severity of illness.

Challenges to public reporting

How much information to present: depends on type of decision,cognitive psychology suggests 5-7 items of data, information must be interpretable by target audience, depends on the use of the information, ex: "selection or change" Complexity of information: difficulty of processing the amount of information, lack of relevance to level of specific decision making Challenges to assumption of higher quality information influencing consumers' behavior: information not reaching population at risk, conflicting information from more trusted sources such as physicians friends and family, consumers may have misinterpreted the data or been assured that quality problems had been fixed, consumers may have been limited in their choice of hospitals, and the ceiling effect-consumers issue that the U.S. health care system operates at a generally high quality

What are the drawbacks of controlling health spending?

If we try to control health spending, we would need to sacrifice healthcare jobs Potential reductions in access and quality