Nursing-chpt 12-14

Will the expansion of health insurance adequately address the issue of access?

A mere expansion of health insurance will not adequately address the issue of access without a significant reform of the delivery infrastructure

Regulatory tools

Call on the government to prescribe and control the behavior of a particular target group by monitoring the group and imposing sanctions if it fails to comply

Who regularly collects data on topics of interest to them?

Federal government, state government, associations, and research institutions

How does waste and abuse play a role in high cost?

General waste as w ell as fraud and abuse of various programs increase costs of health care

How do practice variations play a role in high cost?

Geographic variations in treatment patterns across the country indicate cost-inefficient overtreatment

Micro perspective of costs

Health care costs refer to costs incurred by individuals when they receive health care services

_____ will remain one of the fastest growing components of the US economy.

Health care sector

Allocative tools

Involve the direct provision of income, services, or goods to certain groups of individuals or institutions

acceptability

It represents the individual perceptions and relationship between the client's attitudes about providers and providers' attitudes about acceptable client characteristics (e.g., perceptions of competence of care, previous family experiences, language, and cultural sensitivity of health care providers).

What re the three different meanings to cost?

Price of health care services, national health care expenditures, provider perspective

Risk management

Proactive efforts to prevent adverse events related to clinical care and facilities operations, and is especially focused on avoiding medical malpractice

Is cost expected to grow? by how much? why?

Projected increase in 2014: 8.3% (up from 5.5% in 2013) - mainly attributable to the ACA. Both private health insurance and Medicaid expenditures are projected to grow sharply.

Health planning

Refers to an undertaking by the government to align and distribute health care resources that, in the eyes of the government, would achieve desired health outcomes for all people

Peer Review

Refers to the general process of medical review of utilization and quality carried out directly by, or under the supervision of, physicians

Competitive Approaches

Refers to the rivalry among sellers for customers—e.g., various HMOs competing

What three things are intertwined with each other in the US health care delivery system?

The cost of health care, people's ability to obtain health care when needed, and the quality of services

How does an imperfect market play a role in high cost?

Utilization of health is driven by need rather than economic demand, the quantity of health care services produced and delivered is likely to be much higher than in a competitive market, and the prices charged for health care services will be permanently higher than the true economic costs of production

The importance of the role of individual states can be seen in programs involving what? 5

a) financial support for the care and treatment of the poor and chronically disabled b) quality assurance and oversight of health care practitioners and facilities c) regulation of health care costs and insurance carriers d) health personnel training e) authorization of local government health services

What is the president's role in legislative process?

a)If the president signs the bill, it becomes law b)The bill is vetoed if the president does not sign it c)The veto may be overturned by a two-thirds majority of the Congress, otherwise the bill is dead

How does a policy get implemented after it gets signed?

a)The agency responsible publishes the proposed regulations in the Federal Register b)Hearings are held c)Final regulations are drafted

How does the growth of technology play a role in high cost?

aResearch and development are costly, and are included in health care expenditures. Once developed, new technology often creates its own demand

cost-shifting

ability of providers to make up for lost revenues in one area by increasing utilization or charging higher prices in other areas that are free of controls

How does the multi-payer system and administrative costs play a role in high cost?

administrative costs in a multi-payer system are nearly double of what they would be in a single payer system

Health policies pertain to which level of health care?

all levels, including policies affecting the production, provision, and financing of health care services

US Health Care system is ____ (bad/average/good) in quality.

average

How are the employed predominantly covered?

by voluntary insurance through contributions made by themselves and their employers

How are trends in national health expenditures evaluated?

commonly evaluated by comparing medical inflation to general inflation in the economy (measured by changes in the consumer price index or CPI) and by comparing changes in national health spending to changes in the gross domestic product (GDP)

In terms of cost, what does the price of health care services mean?

consumers and financiers speak of the price of health care services as the cost of health care

What are the three major cornerstones of health care delivery?

cost, access, quality

When Medicare converted to a prospective system, where did the costs mainly shift to?

costs mainly shifted from the inpatient to outpatient center

____ can profoundly influence the acceptability of services.

culture

With the growth of managed care, what happened to encounter databases?

encounter databases have become increasingly critical in recording and evaluating access

Government responds to which most-cited problems?

escalating costs, bureaucratic inflexibility and red tape, excessive regulation, irrational paperwork, arbitrary and sometimes conflicting public directives, and etc

Government spending for health care has been largely confined to what?

filling the gaps in the private sector, such as environmental protection and preventive services

How does presidential leadership impact policy?

have the opportunity to influence congressional outcomes through their efforts to develop compromises that allow bills with at least some of their preferred agendas to be passed

_____ has been identified as a major problem in medicare and medicaid programs.

health care fraud

What was the cost of health care in the US like in the 1970s? Why?

health care spending spiraled upward at double-digit rates during the 1970s following a massive growth in access created by Medicare and Medicaid in 1965 government expenditures for health care services and supplies had grown by 140%, from $7.9 to $18.9 billion dollars

What are the two dominant concerns over the debate about Medicare policy

i)spending must be restrained to keep the program viable ii)program must be made truly comprehensive by adding services not currently covered or covered inadequately

positive outcomes suggest an overall ______ (improvement/decline) in health status.

improvement

What are some examples of distributive tools?

include funding of medical research through the NIH, the construction of facilities (e.g., hospital construction under the Hill-Burton program during the 1950s

How are the aged predominantly covered?

insured through a combination of coverage financed out of Social Security tax revenues, voluntary insurance for physician and supplementary coverage, and voluntary purchase of Medigap plans

What are some other nations that are facing severe cost challenges?

japan, germany, britain, taiwan

Who's duty is it to ensure equitable access to an adequate level of health care for all?

society's

Distributive type of allocative tool

spread benefits throughout society

What are three things that are closely linked when looking at quality?

structure, process, outcomes

redistributive type of allocative tool

take money or power from one group and give it to another

Health Policy

the aggregate of principles, stated or unstated, that...characterize the distribution of resources, services, and political influences that impact on the health of the population

Which sector plays a dominant role in policy?

--the private sector

What are two things that helped with price control? and when did they occur?

-1971: Nixon imposed the Economic Stabilization Program (ESP), which placed limits on the amount hospitals could raise their prices from year to year -1983: conversion of hospital Medicare reimbursements from a retrospective to a prospective system based on diagnosis-related groups (DRGs) as authorized under the Social Security Amendments

What are some different forms of health policies?

-By product of public social policies enacted by the government -Health policies affecting specific categories of individuals, such as physicians, the elderly, or children. -Health policies affecting certain types of organizations, such as hospitals, nursing homes, or employers.

What are some traditional American beliefs and values?

-Capitalism -Individual achievement -Disenchantment with national programs such as the public education system

Administrative costs & what it includes

-Costs associated with the management of the financing, insurance, delivery, and payment functions. -include expenditures for management of the enrollment process, setting up contracts with providers, claims processing, utilization monitoring, denials and appeals, and marketing and promotional expenses.

micro quality indicators and examples

-Focuses on delivery of health care at the point of delivery or within organizations -Example: medical errors, patient satisfaction, quality of life, and health outcomes

Fraud

-Involves a knowing disregard of the truth and typically occurs when billing claims or cost reports are intentionally falsified -may also occur when more services are provided than are medically necessary or when services not provided are billed to third-party payers

Macro quality indicators and examples

-Looks at quality at the population level/standpoint; reflects the performance of the entire healthcare systems -cost, access, etc.

What are some examples of policies that were impacted by presidential leadership?

-President Lyndon B. Johnson's role in the passage of Medicare and Medicaid -Patient Protection and Affordable Care Act (ACA), signed into law by President Barack Obama on March 23,2011

What is the Donabedian Model/Framework?

-assesses quality in a system by looking at structure, process, outcomes

CPI & what it can be used for

-consumer price index -defined by the Bureau of Labor Statistics as "a measure of the average change over time in the prices paid by urban consumers for consumer goods and services." -It can be used to adjust for inflation, salaries and wages.

outcomes

-effects or final results obtained from utilizing the structure and processes of health care delivery -examples: patient satisfaction; health status; recovery; improvement; nosocomial infections; injuries; re-hospitalization; mortality; incidence and prevalence

GDP & what can it be an indicator of

-gross domestic product -the market value of all officially recognized final goods and services produced within a country in a given period of time. -GDP per capita is often considered an indicator of a country's standard of living.

process

-specific way in which care is provided -the actual delivery of care -also includes the interpersonal aspects of health care -examples: correct diagnostic tests, correct prescriptions, accurate drug administration, pharmaceutical care, waiting time to see a physician, communication, dignity and respect, compassion and convern

structure

-the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work -resource inputs -examples: facilities, equipment, staffing levels, staff qualifications, programs, and the administrative organizations

What are the two major reasons why attemps to control health care expenditures have failed?

1) Implementing a system wide cost-control initiative has not been feasible in such a fragmented health care system 2) Cost-shifting

What are the two main reasons why rising health care expenditures need to be controlled?

1) Rising health care costs mean that Americans have to forgo other goods and services when more is spent on health care 2) Economic resources should be directed to their highest-valued uses, even though consumers decide how much should be spent on purchasing a product or service based on their perception of the value they expect to receive

The formation and implementation of health policy occurs in a policy cycle comprising of 5 components. what are they?

1) issue raising 2)policy design 3) building of public support, 4) legislative decision making and building of a policy support 5) legislative decision making and policy implementation

What are 9 reasons for high cost?

1) third-party payment 2) imperfect market 3) growth of technology 4) increase in elderly population 5) medical model of health care delivery 6) multi-payer system and administrative costs 7) defensive medicine 8) waste and abuse 9) practice variations

What is the senate's role in legislative process?

1)The bill goes through the appropriate committee and subcommittee, and goes through similar procedures as in the House 2)If recommended, the bill is presented to the full Senate where it may be amended 3)Changes require the bill to go back to the House for a vote 4)Controversial changes ma y trigger re view by a Conference Committee (includes committee members from the House and Senate) 5)After the bill has passed both the House and Senate in identical form, it is sent to the president for signature.

What is the House's role in the legislative process?

1.A bill is introduced in the House of Representatives 2.The bill is assigned to the appropriate committee 3.It is assigned to a subcommittee--forwarded to affected agency, hearings and testimonies, amended if needed, decision to recommend, not recommend, or table the bill 4.If recommended, the bill is presented to the full House where it may be amended 5.If approved, the bill is forwarded to the Senate

After the ACA, how many will still remain uninsured?

21 million

How many people relied on the nation's welfare program to buy food?

46 million

Macro perspective of costs

A widely used measure for national health expenditures is the proportion of the gross domestic product (GDP) a country spends on the delivery of health care services

Access to care

Access to care can be defined as the ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner

What are some access initiatives?

Access to care has been incrementally addressed by the US government through a variety of public programs including Children's Health Insurance Program (CHIP) and the 2010 Patient Protection and Affordable Care Act (ACA)

How does defensive medicine play a role in high cost?

Additional tests and medical services are used merely as a protection against lawsuits

public policies

Authoritative decisions made in the legislative (congressional), executive (presidential), or judicial (courts, including the Supreme Court) branches of government that are intended to direct or influence the actions, behaviors, or decisions of others.

How does third-party payment play a role in high cost?

Contributes to moral hazard and provider-induced demand because it insulates the consumers against the cost of health care

What are some aspects of culture that impact health care? (13)

Language; Time orientation; Family practices; Childbirth practices; Child-rearing practices; Food habits; Sexuality and gender issues; Beliefs about health and illness; Beliefs about aging; Death practices; Pain response; Grief response; Touch and privacy

How does the medical model of health care delivery play a role in high cost?

Medical interventions are costlier than prevention and health promotion.

After the ACA, will universal access be realized? If not, what needs to happen in order for it to become realized?

No,will remain unrealized without supply-side rationing and an adequate health delivery infrastructure

In terms of cost, what does provider perspective mean?

Notion of cost refers to staff salaries, capital costs for building and equipment, rental of space, purchase of supplies, and other costs of production

How does the increase in an elderly population play a role in high cost?

They consume more health care than younger people.

In terms of cost, what does national health care expenditures mean?

refers to how much a nation spends on health care services-> reflects the consumption of economic resources in the delivery of health care

What two things are associated with lower overall health care usage and access?

low socioeconomic status and minority group membership

What do structural measures indicate?

measures indicate the extent to which health care organizations have the capability to provide adequate levels of care

What was the cost of health care like in the 1990s?

medical inflation was finally brought under control to a single-digit rate of growth, mostly because medical care costs and utilization were controlled through managed care

The government or system are ______(able/not able) to control the actual price for healthcare.

not able

____ is viewed as the bottom-line measure of the effectiveness of health care delivery system.

outcome

critical pathways

outcome-based and patient-centered case management tools that are interdisciplinary and that facilitate coordination of care among multiple clinical departments and caregivers

Dependency on the government has increased because of what?

persistently high unemployment

What are some examples of allocative tools?

policies include subsidies to providers to deliver care to specific groups (e.g., the elderly, the poor, and veterans), the development of personnel (e.g., medical education for those who participate in the National Health Service Corps)

________ surveys supported by _____ statistical agencies are the major data sources for conducting analyses on access to care.

population-based; federal

Affordability

the price of provider services or payment requirements and the client's ability to pay

What was the cost of health care like in the 1980s?

the rate of increase began slowing down

Accommodation

the relationship between how services are organized (e.g., hours of operation, appointment systems) and the client's ability to accommodate to these factors

availability

the relationship between the amount (number of providers and facilities) and type of client needs; the presence of health services

How are the poor predominantly covered?

through Medicaid via federal, state, and local revenues

Who do providers of health care services try to attract?

try to attract patients who have the ability to choose from several different providers

Affordability of health care services also affects health care _____.

utilization

In response to findings of small area variations, what happened?

various professional groups, MCOs, and the government have embarked on the development of standardized practice guidelines (or clinical practice guidelines)

How are special populations predominantly covered?

veterans, Native Americans, and members of the armed forces, have coverage provided directly by the federal government