AU17-PUBHHMP 4650-Midterm Dr. Tasleem Padamsee

National Health Insurance Model Systems

Contains elements of both Beveridge & Bismarck models Financing -- Government-run insurance program Providers -- Private sector Cost Containment -- Single payer Example Countries Canada, Taiwan, South Korea

Out-of-Pocket Model Systems

Financing --Patient payments Providers --Private sector for the wealthy Community healers for the poor Cost Containment -- Ability to pay Example Countries Many (~140)

What are some examples of proportional financing scheme?

Flat tax Health care expenditures funded. through government revenues. co-insurance payers of the same health plan?

HMO

Health maintenance organization an organization whose patients are required to receive their care from physicians and hospitals within the HMO

What is the main factor that influences people's health

Lifestyle_

Health Financing

One building block of the health system: raising funds for health

OECD

Organisation for Economic Co-operation and Development; economic organization of 34 countries to stimulate economic progress and world trade.

What are some examples of progressive financing scheme?

Progressive income tax Medicare Part B premiums

Public/Private Mix

Refers to both health care is financed, and how it delivers care. Options include:-- Government run services -- government takes care of both financing & delivery-- Government financed and administered insurance -- govenrment is the insurer-- Government-mandated insurance financing -- government says you must have insurance, but isn't the insurer-- Private, voluntary health insurance

Illness

"-- Identified by a person's perception and evaluation of how s/he feels

QOL

"Acronym for //quality of life//-- it is the overall satisfaction with life; -- H-QOL: overall self-perception of health; -- perceived quality of care: comfort, respect, privacy, security, autonomy"

Market-Maximized

"Ex. the US -- market dependence, demand side approach -- few or no governmental regulation -- Health Care system is basically run by the market -- elements included: individual medical accounts, high copayments, selective contracting, etc"

Individual Mandate

"Starting since 2014, all individuals are required to have at least minimal Health Insurance; will be fined if not enrolled in a health insurance plan. There are exemptions."

Market-based approach

"markets operate on the principle of the balance between supply and demand. * health care = economic good * free market * production based on market-based demand * access = ability to pay * healthcare is a privilege"

Payment by episode of illness

The physician or hospital is paid one sum for all services delivered during one illness, as is the case with global surgical fees for physicians and DRGs for hospitals.

Payment for all services delivered to all patients within a certain time period

This include global budget payment of hospitals and salaried payment of physicians.

Urbanization

Urbanization is the process where an increasing percentage of a population lives in cities and suburbs. This process is often linked to industrialization and modernization, as large numbers of people leave farms to work and live in cities

Access to health care

availability, accessibility, affordability, acommodation, acceptibility

In the US competition among provider results in what conclusion?

cost containment

Equity

necessary support to guarantee less or no disparities and everybody gets the same thing

community health center

one of the alternatives to fee-for-service medical practice. it emphasizes primary care and preventative care and also striving to take responsibilities for the health status of community served by the health center.

Medicare

provides health insurance to people age 65 and older, regardless of income or medical history; disabled entitled to social security benefits; people with end-stage renal disease. Risk is shared or pooled across society. Composed of 4 parts, Medicare Part A, B, C, D

Retrospective Payment System

"Fee for Service" method of reimbursing health care providers in which professional services are rendered ad charges are billed based on each individual service provided.

Social Justice Approach

"Judging the appropriateness of a particular action based on equity, fairness and impartiality in the distribution of rewards and cots among individuals and groups.* Health care = social resources * active goverment involvement * centralized planning/allocation of resources * ability to pay doesn't matter * healthcare is a right"

Health System

"The combination of resources, organization, financing, and management that culminate in the delivery of health services to the population ----Roemer 1991"

utilization review

Audit of the services and costs billed by health-care providers

Four basic healthcare system models

Beveridge Model Bismarck Model National Health Insurance Model Out-of-pocket Model

Equality

Everybody is given the opportunity to get the same thing.

Market-Minimized

Ex. the UK-- regulation, suuply-side approach-- HCS is basically run by the government-- government regulation-- elements include: uniform fee schedules, global budgets

Veteran's Health Administration

Government financed health care plan for retired military members (veterans retired for plausible reasons why they can't serve the military anymore, such as injury) If a veteran can get another job, they'll be covered by other health plans. Eligibility for this plan doesn't guarantee absolute enrollment in this plan.

Predisposing Characteristics

Individual characteristics that put a person at higher risk of poor health

primary care

Involves common health problems (eg. sore throats, diabetes, arthritis, depression or hypertension); and preventative measures (vaccinations or mammograms)

Medicaid

Medicaid

Bismarck Model

Named for Prussian Chancellor Otto von Bismarck, who invented the welfare state in the 19th century 1. Financing Insurance system - " sickness funds" Jointly financed by employers and employees Universalistic and non-profit2. Providers -- Hospitals tend to be privately owned Doctors are usually private employees 3. Cost Containment -- Tight government regulation Example Countries Germany, France, Belgium, Netherlands, Japan, Switzerland, Latin America

PCP (Primary Care Provider)

Physician, who provides supervises and coordinates the healthcare of a member. The PCP makes referrals to specialists and for advanced diagnostic obstetricians/gynecologists, nurse practitioners and physician assistance are primary care. provide (1) first contact care; (2) longitudinal; (3) comprehensive and (4) coordinated health care

Medicare Part D

Prescription Drug Benefit Eligibility: all enrollees under Part A/B/C; the disabled Regressive financing scheme: subsidize the low-income group; the low-income group pay less Have to pay a premium Medigap covers part D services so it's not necessary to buy into this plan.

Continuum of care

Programs that provide comprehensive, coordinated, and multidisciplinary services (EG. Primary and preventative care, acute care, transitional care, rehabilitation services, extended care, respite care, social services, home health care, adult day centers, and care management services)

Fragmented system

Promoted by the traditional fee-for-service payment model Care is fragmented and uncoordinated

Voluntary/Non Profit Agencies

Supported by donations, membership fees, fundraisers, and grants. Examples include OhioHealth, The Ohio State University Hospital, the American Cancer Society, American Heart Association, Alzheimer's Association, etc.

what is a health system

The sum of all the organizations, institutes, and resources whose primary purpose is to improve health

global budget/ payment per institution

a fixed payment is made for all hospital services for 1 year

Specialty Hospital

a hospital that treats only certain specified illnesses or serves only certain types of patients

Health

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity._

Dispersed model

an alternative model that allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. places higher value on services at the tertiary care than primary care.

What are triple aims

better patient experiences better patient outcomes lower costs

coordination

builds on longitudinality. through referral and follow-up, providing integrated services delivered by other care givers.

general practitioner

physicians practice in small- to medium-sized groups and whose main responsibility is ambulatory care.

longitudinality/continuity

sustaining a patient-caregiver relationship over time

comprehensiveness

the ability to manage a wide range of health care needs, in contrast with specialty care

federal poverty level (FPL)_

the income level for a certain family size that the federal government uses to define poverty.

regionalized model

the organization and coordination of all health resources and services within a defined area emphasizes primary care and a population-oriented framework for health planning Ex. NHS- national health system

Beveridge Model

Named for William Beveridge, Britain's social reformer who designed the British National Health Service (NHS) Financing -- Health is provided and financed by the government through taxpayers providers -- Most hospitals and clinics are owned by the government; most doctors are government employees cost containment -- Government as a sole payer Examples -- UK, Spain, most of Scandinavia, New Zealand, Hong Kong, Cuba

pay for performance

One of the most basic reforms is paying not just for units of services -- whether they be visits, hospital episodes, or hours of work -- but for how well physicians and other providers perform in delivering those services.

PPO

Preferred provider organization. Is a loose-knit organization in which insurers contract with a limited number of physicians and hospitals who agree to care for patients, usually on a discounted fee-for-service basis with utilization review\ Insurers can reject payment for unreasonable services. managed care but little virtual integration

Accommodation

"-- fit between how resources are organized and person's ability to use the arrangement. -- people affected; hourly workers; chronic and/or acute patients; people with limited literacy"

Availability_

"-- fit between service capacity and individual's requirements -- people affected: people with limited English proficiency; low income; people with conditions that have acute flare-ups"

Medicaid

"-- launched since 1965; -- State programs of public assistance to persons, regardless of age, whose income are insufficient to pay for health care; alleviation; Great Society; means-tested -- some doctors refuse to take medicaid patients"

Accessibility

"-- locations of providers and patients -- people affected: low-income; disables; uninsured or underinsured."

Affordability

"-- patients' ability to pay; -- people affected: uninsured; underinsured; high copay/ deductible plan enrollees; people in need of uncovered services"

Summary of US health care system

"1. US spends more on health care than any other industrialized nation, yet is less healthy

The sum of all the organizations, institutes, and resources whose primary purpose is to improve health

A field of study concerned with -- Understanding how national health systems can be compared -- Comparing health systems -- Considering what health systems can learn

Medicare A

Hospital Insurance: inpatient health care; skilled nursing falicities (subacute situation) When reaching 65 y/o, people who are eligible for social security are automatically enrolled; people who have paid into Social Security system for 10 years (work for ≥10yrs?); people not eligible for Social Security system can pay a premium for enrollment. People under 65yrs but are permanently disabled, with amyotrophic sclerosis or end-stage renal diseases or transplant needing patients are eligible. (2 yrs waiting time)

What are the central differences between a Beveridge Model health care system and the U.S. health care system? Compare the two on each of the following points: (a) who the system covers, (b) how health care is financed, (c) how health care is organized or delivered, (d) the role of primary care, and (e) the political values the system expresses.

In Beveridge Model, healthcare is provided and financed by the government through tax payments, and providers of health care (hospitals and clinics, doctors) are owned or employed by the government, the government is the sole payer in the system. US health care system contains all for models within itself. The system is a market-maximized, even though there are public health programs, it is usually that only patients who can afford the payment are covered by an insurance plan. Health care is both publicly and privately financed. Medicare and Medicaid are examples of government financing, while out-of-pocket payment and individual/employer-sponsored insurance are examples of privately financed. Health care is organized in a dispersed model, where there is less coordination among all health care sectors. Primary care is desperately needed in this system, where tertiary care is more in practice. In this system, Health care is more of a privilege than a basic human right.

integration of services

draw together all sectors of healthcare service providers and coordinate with each other

gatekeeping

took on pejorative connotations in the heyday of managed care, when some types of financial arrangements with PCPs provided incentives for them to "shut the gate" in order to limit specialist referrals, diagnostic tests, and other services.

Medicaid Expansion

"* Pre-ACA: states determined coverage levels * AACA expansion: * Medicaid covers all those under 138% of FDL * States can decide whther or not to accept the expansion * Federal Governmern covers most of the costs in states that expand States don't accept the Expansion because they can't afford the cost of expansion or they don't think this is a good plan"

characteristics of the US health care system and why it is a market based one

"* no central governing agency * strong private sector * limited government role * little integration and coordination market-based system * imperfect market conditions * value market justice * multiple players and balance of power technology driven /focus on acute care high on cost, unequal in access, average in outcome"

Health Insurance Exchange/ Marketplace

"-- State-based regulated markets (to shop around for insurance plans); -- individuals and small businesses can negotiate for better_ prices ; -- Tax subsidies for people earning up to 400% FDL ; -- open to employees of small firms (staff Exch"

Determinants of Health

"-- a range of personal, social, economic, and environmental factors that influence health status; -- Includes: * policymaking * social factors * health services * individual behavior * biology and genetics"

Acceptability

"-- compatibility between patients' and providers' values and characteristics; -- racial and ethnic minorities and marginalized groups are affected."

Cost Containment

"A challenge to a good health care system: it is the methods used to control the cost of healthcare. -- providing modern healthcare is costly; -- some systems have more capacity to control costs than others; -- priority on containing costs in ways that least impact health outcomes"

Chronic

"A disease classification featured with: -- Less severe symptoms but long and continuous; -- Can be controlled but can lead to serious complications; Ex. mental disease; asthma; Hypertention"

Subacute

"A disease classification featured with: -- some acute features; -- Postacute treatment after discharge; Ex. Heart attack"

Acute

"A disease classification that is featured with -- relative severity; -- episodic of short duration; -- Often treatable; Ex. acute pancreatitis; acute appendixitis"

Patient protection and affordable Care Act_

"Health care reform law passed in 2010 that includes incentives and penalties for employers providing health insurance as a benefit. tries to reduce the uninsured number. key elements include: * Individual mandate : penalty for not having insurance; * Health insurance subsidies:_ through Medicaid or Federal subsidy; _ 400% FPL can get some help* Expansion of Medicaid:_ states determined coverage levels; income"

Political Values

"Health care system is a reflection of a nation's political value. They serve as an influence on how the health care system is organized, how effective the health care system is, as well as equality and equity. They are associated with health outcomes -- individual responsibility -- social solidarity -- free choice -- compulsion -- universality -- equality&equity -- health care as commodity vs. right"

The Patient-Centered Medical Home

(PCMH) is a model of care by which a personal primary care physician, who has an ongoing trusted relationship with a patient, provides comprehensive and continuous care with care coordination to meet the patient's multiple care needs including: wellness, risk reduction, preventive services, as well as acute, chronic, and end-of-life care four basic cornerstones: primary care, patient-centered care, newmodel practice, payment reform.

Managed Care

-- Any system of cost containment that closely monitors and controls health care providers' decisions about medical procedures, diagnostic tests, and other services that should be provided to patients.

Disease

-- Based on a professional evaluation-- Requires the therapeutic intervention

A field of study concerned with -- Understanding how national health systems can be compared -- Comparing health systems -- Considering what health systems can learn

-- Beveridge Model: Veterans Affairs -- Bismarck Model: Employer-Sponsored Insurance for Working Americans -- National Health Insurance Model: Medicare & Medicaid -- Out-of-Pocket Model: Uninsured Americans

Social Determinants of Health

-- Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work and age. AKA social and physical determinants of health. They impact a wide range of health, function, and QOL outcomes. -- These circumstances are shaped by the distribution of money. power and resources at global, national, and local levels. -- Responsible for health inequities.

Health disparity

-- represents an unequal distribution of illness, injury, disability, or mortality experienced by one population group relative to another group, resulting from differences in environment, access to care, utilization of care, and/or quality of care received. -- created by vulnerability (intersection of risks, such as, predisposing characteristics, enabling characteristics, need characteristics)

Health Outcomes

-- the overall point of health care system-- requires shifting focus to improve social environment to improve health, changing individual behavior, etc.

Summary of US health care system

1. US spends more on health care than any other industrialized nation, yet is less healthy2. despite dramatic improvements in life expectancy, the US faces significant challenges relative to health status ()increase in chronic diseases, risk factors for major diseases, disparities in health status)3. currently, our health care resources are invested to create a "sick care" rather than a health care system. (focus on acute diseases, limited focus on health promotion)

4 basic goal of Healthy People 2020

4 basic goal of Healthy People 2020

Discuss three distinct sets of factors that determine health. Name each type of factor, describe how each influences health, and give at least one example of each type of factor. Of the three types of factors you have discussed, which do you feel exerts the most important influence on population health, and why?

According to Dahlgren and Whitehead, health determinants could fall into the following categories: Personal Characteristics: age, sex, ethnicity, constitutional factors. Genes decide whether you are more susceptible to certain diseases, and naturally, when people reach a certain age, people the possibility of getting one specific disease increases. individual life style: aka life choices, refers to behaviors such as smoking, alcohol and other drug misuse, poor diet and lack of activity. So people with healthier life style, such as avoiding alcohol or smoking, exercising regularly tend to have better health outcome. Social and community networks: Ex. family, friends and the wider social circles around people. The quality of relationship matters. it acts as a protective factor. Living and working conditions: Ex. access to or opportunities in relation to education, training, and employment, health, welfare services, housing, public transport and amenities.Also includes facilities like running water and sanitation, and having access to essential goods like food and fuel. General socio-economic, cultural and environmental conditions: Ex. wages, disposable income(税后所得), availability of work, taxation, and prices; fuel, transport, food, clothing. I think socio-economic factors exerts the most important factors.

health information

Gathering data about how the system is working , and using that data to improve performance.

Tricare

Government financed health care plan for active military members. Doesn't cover military members involved in a war Honorably retired members will be covered. Officers like secretaries are not covered.

Indian Health Service

Government financed health care service for Native Americans. No specific health care plan is offered. Native Americans have access to facilities that accept IHS Native Americans have options to be in other health care plans.

IMG

Integrated medical groups a second generation of HMOs which have a tighter organizational structure consisting of groups in which physicians no longer own their practices and office assets, but become employees of an organization that owns and manages their practice Mayo Clinic; Palo Alto Medical Foundation

Critiques on Medicare Part D

Major gaps in coverage coverage has been farmed out to private insurance companies rather than administered by the federal government Medicare program the government is not allowed to negotiate with pharmaceutical companies for lower drug prices.

Medicare Part B

Medical Insurance. Pay for physician services, outpatient services, certain home health services, durable medical equipment, and other items. Premium is required and goes to commercial insurance companies. Payment adjustment is made concerning risk pooling. Progressive scheme -- Higher income, pay a higher premium. if people choose not to enroll into part B, when they later want to get into it they need to pay a higher premium. Financed by monthly premium, in part by general federal revenues.

Medicare Part C

Medicare Advantage Plans: covers what A&B cover, but need enrollees buy into both of the plans; Paycheck goes into private health insurance providers, while they provide care Helps cover vision, dental, etc., services usually not included in traditional health insurance Private sectors are reimbursed. Patients can choose to go into Part C or Medigap based on their needs.

Donut hole

Medicare Part D -- The standard benefit has a $320 deductible and a 25% coinsurance up to $2960, after that is the coverage gap (donut hole) where enrollees pay a larger share of the total drug cost until the total out-of-pocket spending reaches $4700.It is a major problem for chronic patients.

What are the two most widely used programs of government-financed health care in the United States? For each program, describe the populations it serves, how one becomes eligible for the program, one way in which the program contributes effectively to population health, and one problem with the program.

Medicare：serves people age 65 and older or people with disability or chronic renal diseases. one qualifies for it as long as he/ she is 65 years old regardless of income or medical history, disabled who have been receiving Social Security disability benefits for 24 months, renal disease patients requiring dialysis or transplant. After ACA, the income criterion for qualification is 138% FPL, before it was 133% FPL. Good thing is: the elderly once were badly influenced by experience rating are able to get healthcare. Bad thing comes from Part D, it only provides partial coverage of prescription drugs, major gaps (donut hole) in coverage, especially for chronic illness patients. also cause confusion for patients, pharmacists, physicians and a high cost. Medicaid：serves low income people, besides being poor one should meet "categorical" eligibility criteria (being a young child, pregnant, elderly, or disabled) to be qualified for the program. After accountable act, the income criteria is set to below 133% federal poverty level. Good thing is the poor who were unemployed or employed in a job without fringe benefits couldn't afford premiums now can be covered by Medicaid and have medical care. Bad thing is Medicaid program doesn't pay as much to the physicians so that Medicaid patients might be declined or the number of Medicaid patients that a doctor sees will be limited.

Service delivery/Provision

One of the building blocks of the health system: delivering medical and preventative health services to people who need them

What are some examples regressive financing scheme?

Out-of-pocket payment Medicare Part D Experience-rated private health insurance Community-rated private health insurance (regressive, but less so) Sales tax Property tax

Care coordination payments

Paying care practice through a blended model that adds a small capitation payment to the main fee-for-service payment to provide resources and incentives for better management of patients with chronic conditions.

Prospective payment

Payment system in which an organization accepts a fixed, predetermined amount to treat a patient, regardless of the true ultimate cost of that treatmentEx: DRGs (Medicare pays hospitals fixed amount for an episode of treatment based on that treatment based on that treatment's DRG

What is primary care? Why is it described as the "core" of health care services? Name and describe two of the key tasks of primary care, and two of the proven benefits of providing primary care to populations.

Primary care involves common health problems (eg, sore throat, diabetes, arthritis, depression, or hypertension) and preventative measures (eg, vaccination, or mammograms) that counts for 80% to 90% of visits to a physician or other caregiver. It is the core of health care because primary care focus on continuing and comprehensive health care and it connects different parts of health care (diagnostic service, impatient care, surgery and specialists). Key tasks of primary health care include: (CHOOSE TWO) point of entry essential care comprehensive care continuity / longitudinality Coordination Integrated/ team-based accountability According to Barbara Starfield: first contact care: performing the initial evaluation longitudinality: sustaining a patient-caregiver relationship over time comprehensiveness: consists of the ability to manage a wide range of health care needs coordination: through referral and follow-up, the primary care provider integrates services delivered by other caregivers. proven benefits: (CHOOSE TWO) greater satisfaction more prevention better control of chronic health problems more likely to adhere to treatment fewer hospitalizations lower costs lower infant mortality better life expectancy lower total health expenditures fewer disparities in care

Coverage gap

The "donut hole". Patients have to pay a larger share for prescription drugs from $2960-$4700.

Health Literacy

The degree to which, individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Federal subsidy /tax credit

The federal governments help people pay for insurance if they're too poor to afford in on their own but not poor enough for Medicaid.

Universality

The idea that a major of a Health Care System is to cover everyone._

Fee for service

The unit of payment it the visit or procedure. The physician or hospital is paid a fee for each office visit, ECG, intravenous fluid, or other service or supply provided The only form of payment that is based on individual components of health care.

Catastrophic coverage

Total drug cost spending reaches $8071, plan pays 15% and Medicare pays 80% of prescription drugs.

bundled payments

Under this model, Medicare bundles payments into more aggregated units using an episode-based rather than fee-for-service method; the physician and hospital payments are also bundled together into a single payment.

Describe the vertically integrated and virtually integrated models of health care organization, and the main differences between them. Describe two of the advantages integrated models have been demonstrated to have over the dispersed model, and provide one piece of evidence for each advantage.

Vertical integration: refers to consolidating under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the staff and the facilities necessary to provide this full spectrum of care. Virtually integration: an integration of services based on contractual relationship rather than unitary ownership under one roof. Managed care relationship involving IPAs and medical groups consists of contractual links between HMOs and autonomous physician groups, hospitals, and other health provider units, rather than under one roof model of vertical integration. advantages integrated models have over dispersed model lies in : integrated, provides coherent plan (the permanente medical groups half primary half specialists, easy referral, all service under one roof, easy access to different services ) and regionalize services (serve the population of plan enrollees, though not responsible for the whole population). So that quality of care, quality improvement tools, prevention, satisfaction, fit with PCMH model, Evidence

accountable care organization (ACO)

a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for defined population. spectrum of organizational structures, from vertically integrated to dispersed structures ACA authorized Medicare to initate a ACO program beginning in 2012, the Medical Shared Savings Program

Describing how the United States compares to other OECD countries in terms of (a) proportion of the population covered by health insurance of some kind; (b) key health outcome indicators; (c) the price of common medical procedures; and (d) how many medical procedures are performed each year. For two of these items, give a specific example comparing the US to another OECD country. Finally describe why we compare the US to other OECD countries.

a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Health System The combination of resources, organization, financing, and management that culminate in the delivery of health services to the population ----Roemer 1991 Market-based approach markets operate on the principle of the balance between supply and demand. health care = economic good free market production based on market-based demand access = ability to pay healthcare is a privilege Social Justice Approach Judging the appropriateness of a particular action based on equity, fairness and impartiality in the distribution of rewards and cots among individuals and groups. Health care = social resources active goverment involvement centralized planning/allocation of resources ability to pay doesn't matter healthcare is a right characteristics of the US health care system and why it is a market based one no central governing agency strong private sector limited government role little integration and coordination market-based system imperfect market conditions value market justice multiple players and balance of power technology driven /focus on acute care high on cost, unequal in access, average oin outcome Urbanization Urbanization is the process where an increasing percentage of a population lives in cities and suburbs. This process is often linked to industrialization and modernization, as large numbers of people leave farms to work and live in cities Summary of US health care system 1. US spends more on health care than any other industrialized nation, yet is less healthy2. despite dramatic improvements in life expectancy, the US faces significant challenges relative to health status ()increase in chronic diseases, risk factors for major diseases, disparities in health status)3. currently, our health care resources are invested to create a "sick care" rather than a health care system. (focus on acute diseases, limited focus on health promotion) Flexner report survey by Alexander Flexner. He went around to every medical school and then made recommendations at the end. Because there was a feeling that it was disorganized. Recommendations: Admission should require a min of a high school diploma and at least 2yrs of college study, The length of medical school should be 4 yrs and follow the Council of Medical Education's suggestions. Proprietary medical schools (for profit) should either close or be incorporated into existing universities. Result/impact: number of medical schools decreased from 163 to 66, and so number of physicians each year decreased. Flexner said that pharmacy was not a professional profession. This banded the pharmacists together and they tried to make it a school program and so the the profession became much better. Patient protection and affordable Care Act Health care reform law passed in 2010 that includes incentives and penalties for employers providing health insurance as a benefit. tries to reduce the uninsured number key elements include: Individual mandate : penalty for not having insurance; Health insurance subsidies: through Medicaid or Federal subsidy; ≤ 400% FPL can get some help Expansion of Medicaid: states determined coverage levels; income < 133%FPL are covered Insurance regulations: Insurees may not revoke coverage or institute annual/lifetime limits; preventative services must be covered; limited out-of-pocket spending; children stay under parents' insurance until 26 y/o; only age and smoking are considered when deciding premium cost Employer requirements: employers <25 are exempted from offering health services Health insurance exchanges: state based regulated market; negotiaton available; tax subsidies; open to small firms; exchange inspect plans; Medicare changes: closes gaps in preventative care and drug benefits; limited payment rate to private plan; experimental new model Medicaid -- launched since 1965-- State programs of public assistance to persons, regardless of age, whose income are insufficient to pay for health care; alleviation; Great Society; means-tested -- some doctors refuse to take medicaid patients Medicaid Expansion Pre-ACA: states determined coverage levels AACA expansion: Medicaid covers all those under 138% of FDL States can decide whther or not to accept the expansion Federal Governmern covers most of the costs in states that expand States don't accept the Expansion because they can't afford the cost of expansion or they don't think this is a good plan Individual Mandate Starting since 2014, all individuals are required to have at least minimal Health Insurance; will be fined if not enrolled in a health insurance plan. There are exemptions. Health Insurance Exchange/ Marketplace -- State based regulated markets (to shop around for insurance plans);-- individuals and small businesses can negotiate for better prices ;-- Tax subsidies for people earning up to 400% FDL; -- open to employees of small firms (staff <100)-- Exchange inspect plans for adequate coverage and require insurers to justify rate increases Summary of stakeholders of the US Health care system -- multiple stakeholders-- influenced by historical factors -- Preindustrial Era: Medical care was rudimentary and the field was in its early stages-- Postindustrial Era: Medicine (care and profession) advanced in complexity, technology and quality Illness -- Identified by a person's perception and evaluation of how s/he feels-- People are ill when they have a diminished capacity to perform tasks and roles expected by society Disease -- Based on a professional evaluation-- Requires the therapeutic intervention Acute A disease classification that is featured with-- relative severity-- episodic of short duration-- Often treatable Ex. acute pancreatitis; acute appendixitis Subacute A disease classification featured with: -- some acute features -- Postacute treatment after discharge Ex. Heart attack Chronic A disease classification featured with: -- Less severe symptoms but long and continuous -- Can be controlled but can lead to serious complications Ex. mental disease; asthma; Hypertention QOL Acronym for //quality of life//-- it is the overall satisfaction with life-- H-QOL: overall self-perception of health -- perceived quality of care: comfort, respect, privacy, security, autonomy Determinants of Health -- a range of personal, social, economic, and environmental factors that influence health status -- Includes: policymaking social factors health services individual behavior biology and genetics Social Determinants of Health -- Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work and age. AKA social and physical determinants of health. They impact a wide range of health, function, and QOL outcomes. -- These circumstances are shaped by the distribution of money. power and resources at global, national, and local levels. -- Responsible for health inequities. Health Literacy The degree to which, individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Access to health care Availability -- fit between service capacity and individual's requirements -- people affected: people with limited English proficiency; low income; people with conditions that have acute flare-ups Accessibility -- locations of providers and patients-- people affected: low-income; disables; uninsured or underinsured. Affordability -- patients' ability to pay-- people affected: uninsured; underinsured; high copay/ deductible plan enrollees; people in need of uncovered services Accommodation -- fit between how resources are organized and person's ability to use the arrangement.-- people affected; hourly workers; chronic and/or acute patients; people with limited literacy Acceptability -- compatibility between patients' and providers' values and characteristics-- racial and ethnic minorities and marginalized groups are affected. Health disparity -- represents an unequal distribution of illness, injury, disability, or mortality experienced by one population group relative to another group, resulting from differences in environment, access to care, utilization of care, and/or quality of care received. -- created by vulnerability (intersection of risks, such as, predisposing characteristics, enabling characteristics, need characteristics) Predisposing Characteristics Individual characteristics that put a person at higher risk of poor health health information Gathering data about how the system is working , and using that data to improve performance. Service delivery/Provision One of the building blocks of the health system: delivering medical and preventative health services to people who need them Health Financing One building block of the health system: raising funds for health Cost Containment A challenge to a good health care system: it is the methods used to control the cost of healthcare. -- providing modern healthcare is costly; -- some systems have more capacity to control costs than others-- priority on containing costs in ways that least impact health outcomes In the US competition among provider results in what conclusion? cost containment Health Outcomes -- the overall point of health care system-- requires shifting focus to improve social environment to improve health, changing individual behavior, etc. What is the main factor that influences people's health Lifestyle OECD Organisation for Economic Co-operation and Development; economic organization of 34 countries to stimulate economic progress and world trade. Political Values Health care system is a reflection of a nation's political value. They serve as an influence on how the health care system is organised, how effective the health care system is, as well as equality and equity. They are associated with health outcomes. -- individual responsibility-- social solidarity-- free choice-- compulsion-- universality-- equality&equity-- health care as commodity vs. right Equality Everybody is given the opportunity to get the same thing. Equity necessary support to guarantee less or no disparities and everybody gets the same thing federal poverty level (FPL) the income level for a certain family size that the federal government uses to define poverty. Universality The idea that a major of a Health Care System is to cover everyone. Market-Maximized Ex. the US-- market dependence, demand side approach-- few or no governmental regulaton-- Health Care system is basically run by the market-- elements included: individual medical accounts, high copayments, selective contracting, etc Market-Minimized Ex. the UK-- regulation, suuply-side approach-- HCS is basically run by the government-- government regulation-- elements include: uniform fee schedules, global budgets Role of Government and HC continuum Public/Private Mix Refers to both health care is financed, and how it delivers care. Options include:-- Government run services -- government takes care of both financing & delivery-- Government financed and administered insurance -- govenrment is the insurer-- Government-mandated insurance financing -- government says you must have insurance, but isn't the insurer-- Private, voluntary health insurance Four basic healthcare system models Beveridge Model Bismarck Model National Health Insurance Model Out-of-pocket Model Beveridge Model Named for William Beveridge, Britain's social reformer who designed the British National Health Service (NHS) Financing -- Health is provided and financed by the government through taxpayers providers -- Most hospitals and clinics are owned by the government; most doctors are government employees cost containment -- Government as a sole payer Examples -- UK, Spain, most of Scandinavia, New Zealand, Hong Kong, Cuba Bismarck Model Named for Prussian Chancellor Otto von Bismarck, who invented the welfare state in the 19th century 1. Financing Insurance system - " sickness funds" Jointly financed by employers and employees Universalistic and non-profit2. Providers -- Hospitals tend to be privately owned Doctors are usually private employees 3. Cost Containment -- Tight government regulation Example Countries Germany, France, Belgium, Netherlands, Japan, Switzerland, Latin America National Health Insurance Model Systems Contains elements of both Beveridge & Bismarck models Financing -- Government-run insurance program Providers -- Private sector Cost Containment -- Single payer Example Countries Canada, Taiwan, South Korea Out-of-Pocket Model Systems Financing --Patient payments Providers --Private sector for the wealthy Community healers for the poor Cost Containment -- Ability to pay Example Countries Many (~140) Which model does the U.S. have All of the four what is a health system The sum of all the organizations, institutes, and resources whose primary purpose is to improve health What is comparative health system? A field of study concerned with -- Understanding how national health systems can be compared -- Comparing health systems -- Considering what health systems can learn from each other. How do we compare health systems? Their form organization funding methods values they express issues best dealt with issue worst dealt with health outcomes assesing health care systems Triangle cost, quality, access assessing health care systems Diamond cost, quality, access, innovation How are the four health care models manifested in the US? -- Beveridge Model: Veterans Affairs -- Bismarck Model: Employer-Sponsored Insurance for Working Americans -- National Health Insurance Model: Medicare & Medicaid -- Out-of-Pocket Model: Uninsured Americans providers health care facilities of health professionals that provide health care services payers people or organizations paying for healthcare services patients persons who are cared for in a hospital Fragmented system Promoted by the traditional fee-for-service payment model Care is unfragmented and uncoordinated 4 basic goal of Healthy People 2020 High quality long life health equity (elimination of inequity) create social & physical environments promoting health promote health through all stages of life Uninsured People without insurance Underinsured People have limited benefits of health insurance. They are covered in a health care insurance plan but services provided cannot meet all of their needs. Deductible the amount of money insurees have to pay before health insurance starts to pay for their care Co-pay A fixed amount of money that patients have to pay for each medical visit Co-insurance A fixed percentage of money patients have to pay for service while insurance companies pay as well after deductible met. Employer-sponsored insurance Health insurance coverage provided to employees through workplace, and, in some cases, their spouses and children, as benefits as part of their jobs Government Financing -- Funding for health care is provided by federal, state, municipal sources.-- Government stepped in long before 1960s -- Includes 5 different programs：1. Tricare2. Veterans health service3. Indian Health Service4. Medicaid5. Medicare Individual Private Insurance A third party, the insurer is added to the two basic parties of the health care transaction. out-of-pocket payment The simplest mode of financing, which is direct purchase by the consumer of goods from the provider Employed-Based Private Insurance Due to a limited ability of companies to increase wages since WWII. Health insurance is offered as a fringe benefit. In addition to the direct employer subsidy, indirect government subsidy through tax-free status of employer contributions for health insurance plans. Federal government sees the employer premium as a tax deductible business expense. Employed-based private insurance results in a reduction of tax collected. Government is in essence of subsidizing the insurance. What are the four modes of paying for health care? Out-of-pocket payment Individual private insurance Employer-sponsored private insurance government financing Progressive financing People pay a rising proportion of their income for a certain purpose as their income increases Regressive Financing People pay a falling percentage of their income for certain purpose as their income increases Proportional financing The ration of the payment to income is the same for all income classes. What are some examples of progressive financing scheme? Progressive income tax Medicare Part B premiums What are some examples regressive financing scheme? Out-of-pocket payment Medicare Part D Experience-rated private health insurance Community-rated private health insurance (regressive, but less so) Sales tax Property tax What are some examples of proportional financing scheme? Flat tax Health care expenditures funded. through government revenues. co-insurance payers of the same health plan? Asymmetry of information A person in need of health care may have little knowledge of what s/he is buying at the time when care is needed so that s/he has to rely on physician recommendations. Unpredictability of needs Most people do not know if or when they may become severely ill or injured or what the cost of care will be, so the cost and needs of health care services are unpredictable. Experience rating Based on experience of each group using health services risk pooling used to estimate how much a specific group will cost the payer/insurer in terms of medical care all riskless patients go to a cheaper plan risk of unhealthiness increases, premium goes up Community Rating The insurance provider considers the risk factor of the community as a whole and offers the same premium to the whole community. premium based on the average medical spending of a community those who are healthy are going to spend more with this rating than with the experienced one Government often disallows the experience rating People with more health problems are less likely to afford the high premium programs. They are more likely to go into the community rated programs but this can cause a lot of trouble. Fee for service The unit of payment it the visit or procedure. The physician or hospital is paid a fee for each office visit, ECG, intravenous fluid, or other service or supply provided The only form of payment that is based on individual components of health care. Payment by episode of illness The physician or hospital is paid one sum for all services delivered during one illness, as is the case with global surgical fees for physicians and DRGs for hospitals. Per diem payment Hospital or the physician is paid for all services delivered to a patient during one day. Capitation payment One payment is made for each patient's care during a month or a year. Pay in advance in a fixed amount no matter how much care is used. Payment for all services delivered to all patients within a certain time period This include global budget payment of hospitals and salaried payment of physicians. Tricare Government financed health care plan for active military members. Doesn't cover military members involved in a war Honorably retired members will be covered. Officers like secretaries are not covered. Veteran's Health Administration Government financed health care plan for retired military members (veterans retired for plausible reasons why they can't serve the military anymore, such as injury) If a veteran can get another job, they'll be covered by other health plans. Eligibility for this plan doesn't guarantee absolute enrollment in this plan. Indian Health Service Government financed health care service for Native Americans. No specific health care plan is offered. Native Americans have access to facilities that accept IHS Native Americans have options to be in other health care plans. Medicaid, Medicare Established through social security amendments of 1965 Adds taxpayers to health care financing equation Medicare provides health insurance to people age 65 and older, regardless of income or medical history; disabled entitled to social security benefits; people with end-stage renal disease. Risk is shared or pooled across society. Composed of 4 parts, Medicare Part A, B, C, D Medicaid State programs of public assistance to persons, regardless of age, whose income are insufficient to pay for health care; alleviation; Great Society; means-tested Medicare A Hospital Insurance: inpatient health care; skilled nursing falicities (subacute situation) When reaching 65 y/o, people who are eligible for social security are automatically enrolled; people who have paid into Social Security system for 10 years (work for ≥10yrs?); people not eligible for Social Security system can pay a premium for enrollment. People under 65yrs but are permanently disabled, with amyotrophic sclerosis or end-stage renal diseases or transplant needing patients are eligible. (2 yrs waiting time) Medicare Part B Medical Insurance. Pay for physician services, outpatient services, certain home health services, durable medical equipment, and other items. Premium is required and goes to commercial insurance companies. Payment adjustment is made concerning risk pooling. Progressive scheme -- Higher income, pay a higher premium. if people choose not to enroll into part B, when they later want to get into it they need to pay a higher premium. Financed by monthly premium, in part by general federal revenues. Medicare Part C Medicare Advantage Plans: covers what A&B cover, but need enrollees buy into both of the plans; Paycheck goes into private health insurance providers, while they provide care Helps cover vision, dental, etc., services usually not included in traditional health insurance Private sectors are reimbursed. Patients can choose to go into Part C or Medigap based on their needs. Medicare Part D Prescription Drug Benefit Eligibility: all enrollees under Part A/B/C; the disabled Regressive financing scheme: subsidize the low-income group; the low-income group pay less Have to pay a premium Medigap covers part D services so it's not necessary to buy into this plan. Donut hole Medicare Part D -- The standard benefit has a $320 deductible and a 25% coinsurance up to $2960, after that is the coverage gap (donut hole) where enrollees pay a larger share of the total drug cost until the total out-of-pocket spending reaches $4700.It is a major problem for chronic patients. Coverage gap The "donut hole". Patients have to pay a larger share for prescription drugs from $2960-$4700. Catastrophic coverage Total drug cost spending reaches $8071, plan pays 15% and Medicare pays 80% of prescription drugs. Critiques on Medicare Part D Major gaps in coverage coverage has been farmed out to private insurance companies rather than administered by the federal government Medicare program the government is not allowed to negotiate with pharmaceutical companies for lower drug prices. State Children's health insurance program (SCHIP) this program was enacted in 1997, it offers families who are 200% under the poverty line to buy low cost insurance for children and some states cover the parents by a federal waiver. Federal subsidy /tax credit The federal governments help people pay for insurance if they're too poor to afford in on their own but not poor enough for Medicaid. Premium the amount that a policyholder must pay for insurance coverage Health reimbursement plan A Healthcare Reimbursement Plan (HRP) is an employer-funded, tax advantaged employer health benefit plan that can reimburse employees for individual health insurance premiums. An HRP is not considered health insurance. Rather, it is a way to provide allowances for individual health insurance. pay for performance One of the most basic reforms is paying not just for units of services -- whether they be visits, hospital episodes, or hours of work -- but for how well physicians and other providers perform in delivering those services. bundled payments Under this model, Medicare bundles payments into more aggregated units using an episode-based rather than fee-for-service method; the physician and hospital payments are also bundled together into a single payment. Care coordination payments Paying care practice through a blended model that adds a small capitation payment to the main fee-for-service payment to provide resources and incentives for better management of patients with chronic conditions. health plan a plan, program, or organization that provides health benefits enrollment people sign up for receiving the benefits of a specific plan public plan a health care plan provided by the government for those who could not afford private health insurance premiums. infant mortality infants' death during the first year of life. MORBIDITY Refers to ill health in an individual and the levels of ill health in a population or group. global budget/ payment per institution a fixed payment is made for all hospital services for 1 year Salary form of periodic payment from an employer to an employee, which may be specified in an employment contract Salaried practice aggregates payment for all services delivered during a month or year into one lump sum Managed Care -- Any system of cost containment that closely monitors and controls health care providers' decisions about medical procedures, diagnostic tests, and other services that should be provided to patients. what are the forms of managed care? fee-for-service practice with utilization review preferred provider of organizations (PPOs) health maintenance organizations (HMOs) PPO Preferred provider organization. Is a loose-knit organization in which insurers contract with a limited number of physicians and hospitals who agree to care for patients, usually on a discounted fee-for-service basis with utilization review\ Insurers can reject payment for unreasonable services. managed care but little virtual integration HMO Health maintenance organization an organization whose patients are required to receive their care from physicians and hospitals within the HMO Utilization review Audit of the services and costs billed by health-care providers referral a recommendation to a doctor from another doctor IPA Independent Practice Association PHO Physician Hospital Organization, Legal entity for contracting with MCOs Incentive the more the hospital provides, the more they get paid. may result in overutilizing and waste of medical services PGP prepaid group practice DRG Diagnostically Related Groups primary care Involves common health problems (eg. sore throats, diabetes, arthritis, depression or hypertension); and preventative measures (vaccinations or mammograms) secondary care involves problems that require specialized clinical expertise such as hospital care for a patient with acute renal failure tertiary care involves the management of rare disorders such as pituitary tumors and congenital malformations. highly specialized, multi-specialty, high tech, services like transplant, specialty ICU regionalized model the organization and coordination of all health resources and services within a defined area emphasizes primary care and a population-oriented framework for health planning Ex. NHS- national health system Dispersed model an alternative model that allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. places higher value on services at the tertiary care than primary care. general practitioner physicians practice in small- to medium-sized groups and whose main responsibility is ambulatory care. PCP (Primary Care Provider) Physician, who provides supervises and coordinates the healthcare of a member. The PCP makes referrals to specialists and for advanced diagnostic obstetricians/gynecologists, nurse practitioners and physician assistance are primary care. provide (1) first contact care; (2) longitudinal; (3) comprehensive and (4) coordinated health care coordination builds on longitudinality. through referral and follow-up, providing integrated services delivered by other care givers. longitudinality/continuity sustaining a patient-caregiver relationship over time comprehensiveness the ability to manage a wide range of health care needs, in contrast with specialty care integration of services draw together all sectors of healthcare service providers and coordinate with each other What are triple aims better patient experiences better patient outcomes lower costs gatekeeping took on pejorative connotations in the heyday of managed care, when some types of financial arrangements with PCPs provided incentives for them to "shut the gate" in order to limit specialist referrals, diagnostic tests, and other services. The Patient-Centered Medical Home (PCMH) is a model of care by which a personal primary care physician, who has an ongoing trusted relationship with a patient, provides comprehensive and continuous care with care coordination to meet the patient's multiple care needs including: wellness, risk reduction, preventive services, as well as acute, chronic, and end-of-life care four basic cornerstones: primary care, patient-centered care, newmodel practice, payment reform. Medical neighborhood the constellation of of services, providers, and organizations in a health system that contributes to the care of a population patients. biomedical model the viewpoint that illness can be explained on the basis of aberrant somatic processes and that psychological and social processes are largely independent of the disease process; the dominant model in medical practice until recently professionalism involves a social contract, i return for the privilege of autonomy, physicians bear the responsibility for acting as the patient's agent, and the profession must regulate itself to preserve the public trust. hospital facility for care of sick and injured general hospital private non-profit (privately owned) traditional hospital provide many services to meet needs of general population Specialty Hospital a hospital that treats only certain specified illnesses or serves only certain types of patients Public Hospital a hospital owned by the federal, state, or local government. US Department of Veterans Affairs; MetroHealth Voluntary/Non Profit Agencies Supported by donations, membership fees, fundraisers, and grants. Examples include OhioHealth, The Ohio State University Hospital, the American Cancer Society, American Heart Association, Alzheimer's Association, etc. private for-profit hospital owned by individuals, partnerships, or corporations. Financially benefits stockholders. Tenet health, HCA (Hospital corporation of America) Vertical integration consolidation under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the facilities and staff necessary to provide this full spectrum of care. Kaiser Permanente HMO regionalized, population health focus. virtual integration network model HMOs directly or indirectly contract with providers and with all facilities and staff necessary for health care but not under the same organization roof. 2-tiered model；HMO directly contract with physicians: 3-tiered model: HMOs contract with physicians through IPAs, IMGs, PHOs. San Joaquin foundation for medical care. network model HMO model in which HMO contracts with multiple physician groups to deliver health care to health plan members. Physician network can be large multi-specialty group or composed of many small groups of primary care physicians, or a combo. of both. IMG Integrated medical groups a second generation of HMOs which have a tighter organizational structure consisting of groups in which physicians no longer own their practices and office assets, but become employees of an organization that owns and manages their practice Mayo Clinic; Palo Alto Medical Foundation accountable care organization (ACO) a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for defined population. spectrum of organizational structures, from vertically integrated to dispersed structures ACA authorized Medicare to initate a ACO program beginning in 2012, the Medical Shared Savings Program inpatients patients who stay overnight at a health care facility outpatients patients who don't need to stay overnight at a health care facility Accountability Being answerable for one's own actions Continuum of care Programs that provide comprehensive, coordinated, and multidisciplinary services (EG. Primary and preventative care, acute care, transitional care, rehabilitation services, extended care, respite care, social services, home health care, adult day centers, and care management services) Retrospective Payment System "Fee for Service" method of reimbursing health care providers in which professional services are rendered ad charges are billed based on each individual service provided. Prospective payment Payment system in which an organization accepts a fixed, predetermined amount to treat a patient, regardless of the true ultimate cost of that treatmentEx: DRGs (Medicare pays hospitals fixed amount for an episode of treatment based on that treatment based on that treatment's DRG Multispecialty group practice clinics are owned and ministered by physicians in various specialties where physician practice. Mayo, Menninger Clinic, Palo Alto Medical Foundation community health center one of the alternatives to fee-for-service medical practice. it emphasizes primary care and preventative care and also striving to take responsibilities for the health status of community served by the health center. group practice a medical management system in which three or more licensed physicians share the collective income, expenses, facilities, equipment, records and personnel for the business Describe three differences between market-based and justice-based approaches to the provision of health services. For each of your three points, discuss whether the U.S. health care system is more consistent with the market-based or the justice-based approach. Which approach do you think is a better set of principles for a society's health care system, and why? markets operate on the principle of the balance between supply and demand. health care = economic good free market production based on market-based demand access = ability to pay healthcare is a privilege Judging the appropriateness of a particular action based on equity, fairness and impartiality in the distribution of rewards and cots among individuals and groups. Health care = social resources active goverment involvement centralized planning/allocation of resources ability to pay doesn't matter healthcare is a right US health care system is more consistent with the market-based model. Since 1. it has no central governing agency, the role of the government is limited, US health system has strong private sectors; 2. the cost is high, which means people can have access to it only if they have money, those who cannot pay fall into the category of uninsured or underinsured, without being covered by health plans. 3. Disparities of health accessibility and outcomes caused by different incomes in turn can prove that health care is a privilege, which is not a human right that everybody enjoys. 4. Different health providers compete with each other. Social Justice based is better for a society. Disparities, aim is to improve health status on a macroscopic and population level. Discuss three distinct sets of factors that determine health. Name each type of factor, describe how each influences health, and give at least one example of each type of factor. Of the three types of factors you have discussed, which do you feel exerts the most important influence on population health, and why? According to Dahlgren and Whitehead, health determinants could fall into the following categories: Personal Characteristics: age, sex, ethnicity, constitutional factors. Genes decide whether you are more susceptible to certain diseases, and naturally, when people reach a certain age, people the possibility of getting one specific disease increases. individual life style: aka life choices, refers to behaviors such as smoking, alcohol and other drug misuse, poor diet and lack of activity. So people with healthier life style, such as avoiding alcohol or smoking, exercising regularly tend to have better health outcome. Social and community networks: Ex. family, friends and the wider social circles around people. The quality of relationship matters. it acts as a protective factor. Living and working conditions: Ex. access to or opportunities in relation to education, training, and employment, health, welfare services, housing, public transport and amenities.Also includes facilities like running water and sanitation, and having access to essential goods like food and fuel. General socio-economic, cultural and environmental conditions: Ex. wages, disposable income(税后所得), availability of work, taxation, and prices; fuel, transport, food, clothing. I think socio-economic factors exerts the most important factors. What is primary care? Why is it described as the "core" of health care services? Name and describe two of the key tasks of primary care, and two of the proven benefits of providing primary care to populations. Primary care involves common health problems (eg, sore throat, diabetes, arthritis, depression, or hypertension) and preventative measures (eg, vaccination, or mammograms) that counts for 80% to 90% of visits to a physician or other caregiver. It is the core of health care because primary care focus on continuing and comprehensive health care and it connects different parts of health care (diagnostic service, impatient care, surgery and specialists). Key tasks of primary health care include: (CHOOSE TWO) point of entry essential care comprehensive care continuity / longitudinality Coordination Integrated/ team-based accountability According to Barbara Starfield: first contact care: performing the initial evaluation longitudinality: sustaining a patient-caregiver relationship over time comprehensiveness: consists of the ability to manage a wide range of health care needs coordination: through referral and follow-up, the primary care provider integrates services delivered by other caregivers. proven benefits: (CHOOSE TWO) greater satisfaction more prevention better control of chronic health problems more likely to adhere to treatment fewer hospitalizations lower costs lower infant mortality better life expectancy lower total health expenditures fewer disparities in care What are the five dimensions of access to health care? Name all five, then for two of them: a) describe the dimension in more detail b) discuss one way health care access can be problematic on this dimension c) give at least one piece of evidence we have studied about this potential access problem. availability: the fit between the service capacity and individuals requirement; Problem: language proficiency, acute flare-ups accessibility: location of patients and providers; Problem: low income people, disabled, people with no or less desirable insurance. Solution: organization of hospitals (rural areas, secondary, tertiary hospitals) affordability: patients' ability to pay; Problem: uninsured, underinsured, high copays or deductibles, needing un-covered services. Expansion of medicaid. government subsidies. accommodation: fit between how resources are organized and person's ability to use the arrangement. Problem: hourly workers, people with chronic/ acute conditions, people with limited literacy or language skills. acceptability: compatibility between patients' attitudes and providers' persona/ practice characteristics, providers' attitudes toward patients' personal characteristics and values. What are the two most widely used programs of government-financed health care in the United States? For each program, describe the populations it serves, how one becomes eligible for the program, one way in which the program contributes effectively to population health, and one problem with the program. Medicare：serves people age 65 and older or people with disability or chronic renal diseases. one qualifies for it as long as he/ she is 65 years old regardless of income or medical history, disabled who have been receiving Social Security disability benefits for 24 months, renal disease patients requiring dialysis or transplant. After ACA, the income criterion for qualification is 138% FPL, before it was 133% FPL. Good thing is: the elderly once were badly influenced by experience rating are able to get healthcare. Bad thing comes from Part D, it only provides partial coverage of prescription drugs, major gaps (donut hole) in coverage, especially for chronic illness patients. also cause confusion for patients, pharmacists, physicians and a high cost. Medicaid：serves low income people, besides being poor one should meet "categorical" eligibility criteria (being a young child, pregnant, elderly, or disabled) to be qualified for the program. After accountable act, the income criteria is set to below 133% federal poverty level. Good thing is the poor who were unemployed or employed in a job without fringe benefits couldn't afford premiums now can be covered by Medicaid and have medical care. Bad thing is Medicaid program doesn't pay as much to the physicians so that Medicaid patients might be declined or the number of Medicaid patients that a doctor sees will be limited. Describe the vertically integrated and virtually integrated models of health care organization, and the main differences between them. Describe two of the advantages integrated models have been demonstrated to have over the dispersed model, and provide one piece of evidence for each advantage. Vertical integration: refers to consolidating under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the staff and the facilities necessary to provide this full spectrum of care. Virtually integration: an integration of services based on contractual relationship rather than unitary ownership under one roof. Managed care relationship involving IPAs and medical groups consists of contractual links between HMOs and autonomous physician groups, hospitals, and other health provider units, rather than under one roof model of vertical integration. advantages integrated models have over dispersed model lies in : integrated, provides coherent plan (the permanente medical groups half primary half specialists, easy referral, all service under one roof, easy access to different services ) and regionalize services (serve the population of plan enrollees, though not responsible for the whole population). So that quality of care, quality improvement tools, prevention, satisfaction, fit with PCMH model, Evidence: 括号 What are the central differences between a Beveridge Model health care system and the U.S. health care system? Compare the two on each of the following points: (a) who the system covers, (b) how health care is financed, (c) how health care is organized or delivered, (d) the role of primary care, and (e) the political values the system expresses. In Beveridge Model, healthcare is provided and financed by the government through tax payments, and providers of health care (hospitals and clinics, doctors) are owned or employed by the government, the government is the sole payer in the system. US health care system contains all for models within itself. The system is a market-maximized, even though there are public health programs, it is usually that only patients who can afford the payment are covered by an insurance plan. Health care is both publicly and privately financed. Medicare and Medicaid are examples of government financing, while out-of-pocket payment and individual/employer-sponsored insurance are examples of privately financed. Health care is organized in a dispersed model, where there is less coordination among all health care sectors. Primary care is desperately needed in this system, where tertiary care is more in practice. In this system, Health care is more of a privilege than a basic human right. Describing how the United States compares to other OECD countries in terms of (a) proportion of the population covered by health insurance of some kind; (b) key health outcome indicators; (c) the price of common medical procedures; and (d) how many medical procedures are performed each year. For two of these items, give a specific example comparing the US to another OECD country. Finally describe why we compare the US to other OECD countries.

What are the five dimensions of access to health care? Name all five, then for two of them: a) describe the dimension in more detail b) discuss one way health care access can be problematic on this dimension c) give at least one piece of evidence we have studied about this potential access problem.

availability: the fit between the service capacity and individuals requirement; Problem: language proficiency, acute flare-ups accessibility: location of patients and providers; Problem: low income people, disabled, people with no or less desirable insurance. Solution: organization of hospitals (rural areas, secondary, tertiary hospitals) affordability: patients' ability to pay; Problem: uninsured, underinsured, high copays or deductibles, needing un-covered services. Expansion of medicaid. government subsidies. accommodation: fit between how resources are organized and person's ability to use the arrangement. Problem: hourly workers, people with chronic/ acute conditions, people with limited literacy or language skills. acceptability: compatibility between patients' attitudes and providers' persona/ practice characteristics, providers' attitudes toward patients' personal characteristics and values

Multispecialty group practice

clinics are owned and ministered by physicians in various specialties where physician practice. Mayo, Menninger Clinic, Palo Alto Medical Foundation

Vertical integration

consolidation under one organizational roof and common ownership all levels of care, from primary to tertiary care, and the facilities and staff necessary to provide this full spectrum of care. Kaiser Permanente HMO regionalized, population health focus.

what are the forms of managed care?

fee-for-service practice with utilization review preferred provider of organizations (PPOs) health maintenance organizations (HMOs)

Salary

form of periodic payment from an employer to an employee, which may be specified in an employment contract Salaried practice aggregates payment for all services delivered during a month or year into one lump sum

Medical neighborhood

he constellation of of services, providers, and organizations in a health system that contributes to the care of a population patients.

professionalism

involves a social contract, i return for the privilege of autonomy, physicians bear the responsibility for acting as the patient's agent, and the profession must regulate itself to preserve the public trust.

secondary care

involves problems that require specialized clinical expertise such as hospital care for a patient with acute renal failure

tertiary care

involves the management of rare disorders such as pituitary tumors and congenital malformations. highly specialized, multi-specialty, high tech, services like transplant, specialty ICU

virtual integration

network model HMOs directly or indirectly contract with providers and with all facilities and staff necessary for health care but not under the same organization roof. 2-tiered model；HMO directly contract with physicians: 3-tiered model: HMOs contract with physicians through IPAs, IMGs, PHOs. San Joaquin foundation for medical care.

Describe three differences between market-based and justice-based approaches to the provision of health services. For each of your three points, discuss whether the U.S. health care system is more consistent with the market-based or the justice-based approach. Which approach do you think is a better set of principles for a society's health care system, and why?

markets operate on the principle of the balance between supply and demand. health care = economic good free market production based on market-based demand access = ability to pay healthcare is a privilege Judging the appropriateness of a particular action based on equity, fairness and impartiality in the distribution of rewards and cots among individuals and groups. Health care = social resources active goverment involvement centralized planning/allocation of resources ability to pay doesn't matter healthcare is a right US health care system is more consistent with the market-based model. Since 1. it has no central governing agency, the role of the government is limited, US health system has strong private sectors; 2. the cost is high, which means people can have access to it only if they have money, those who cannot pay fall into the category of uninsured or underinsured, without being covered by health plans. 3. Disparities of health accessibility and outcomes caused by different incomes in turn can prove that health care is a privilege, which is not a human right that everybody enjoys. 4. Different health providers compete with each other. Social Justice based is better for a society. Disparities, aim is to improve health status on a macroscopic and population level.

network model HMO

model in which HMO contracts with multiple physician groups to deliver health care to health plan members. Physician network can be large multi-specialty group or composed of many small groups of primary care physicians, or a combo. of both.

private for-profit hospital

owned by individuals, partnerships, or corporations. Financially benefits stockholders. Tenet health, HCA (Hospital corporation of America)

general hospital

private non-profit (privately owned) traditional hospital provide many services to meet needs of general population

Flexner report

survey by Alexander Flexner. He went around to every medical school and then made recommendations at the end. Because there was a feeling that it was disorganized. Recommendations: Admission should require a min of a high school diploma and at least 2yrs of college study, The length of medical school should be 4 yrs and follow the Council of Medical Education's suggestions. Proprietary medical schools (for profit) should either close or be incorporated into existing universities. Result/impact: number of medical schools decreased from 163 to 66, and so number of physicians each year decreased. Flexner said that pharmacy was not a professional profession. This banded the pharmacists together and they tried to make it a school program and so the the profession became much better.

State Children's health insurance program (SCHIP)

this program was enacted in 1997, it offers families who are 200% under the poverty line to buy low cost insurance for children and some states cover the parents by a federal waiver.