Chapter 1

Singapore's healthcare system

-Based on market competition in Self reliance. -Singapore has achieved universal coverage through a policy that requires mandatory private contributions but little government financing -each month you have to deposit a portion of earnings into a medicine in which employers then match the employee contributions. These savings are used to pay for hospital services or to purchase government sponsored insurance for catastrophic illness -for basic and routine services people are expected to pay out of pocket but those who cannot afford receive government assistance -Fee for service system of payment is used throughout

Developing countries healthcare systems

-Moving toward adopting universal health coverage to decrease financial impoverishment. -Some common trends are increasing enrollment in government sponsored health insurance, expanded benefits packages, expenditures, and increasing the governments share of health spending.

Canada's healthcare system

-National health insurance (NHI) -Bulk of financing comes from tax revenues. -physicians are paid fee for service which are negotiated between the government in the medical Association -Use of control costs with global budgets.

China healthcare system

-The system is tiered depending on location. -if they go to a small hospital or clinic usually 70 to 80% of the bill is covered, if they go to a county hospital usually about 60% is covered, if they use a specialist at a large modern hospital only about 30% is covered. -China a newly reestablished community health centers to improve access to primary care

Japan's healthcare system

-Universal coverage through either employer based system (SHI) or and NHI program -Day laborers, Seaman, agricultural workers, self employed, retirees, are all covered under the NHI. -Individual employees roughly pay 8% of their salaries as premiums and receive coverage for approximately 90% of medical services

Why is it important for healthcare managers and policymakers to understand the intricacies of the healthcare delivery system?

-an understanding of the system can help with relationships amongst healthcare professionals -it can help them understand changes in the impact those changes have in each others practices -it will help with an adaptation and help cope with ongoing changes in the future.

Germany healthcare system

-based on the SHI model -Government mandated contributions by employers and employees to finance healthcare -private providers deliver the healthcare services -working to improve hospitals.

Great Britain healthcare system

-it's in NHS system founded on the principles of primary care and strong community health services -The system owns hospitals and employees hospital specialist and other staff on salary basis while general practitioners are mostly private -emphasizes free points of access in equal access to all. -primary care occurs through primary care trusts in which everyone is assigned a PCT based on geographic location -10.9% of the British population still maintains private health insurance

Israel's healthcare system

-publicly funded in which general tax revenues supplement the health tax revenues which the government distributes -each year the government determines how much from the general tax revenue should be contributed toward the NHI -Health plans or sickness funds offer a predefined a basic package of healthcare services and are prohibited from discriminating against those with pre-existing conditions -there has been a development of multiple health plans to foster competition among the funds.

What additional factors limit the ability of patients to make decisions in a healthcare system?

1. Decisions about the utilization of healthcare are often determined by need rather than by price based demand. 2. The delivery of healthcare can result in demand creation. This leads to greater utilization which creates artificial demand because the prices are not taking into consideration.

What are the objectives of an acceptable healthcare system

1. Enable all citizens to obtain needed healthcare services 2. Ensure that services are cost-effective and meet certain establish standards of quality

How can managed-care organizations implement effective cost saving measures without compromising access and quality?

1. Ensuring access to needed health services 2. Emphasizing preventative care 3. Maintaining abroad provider network

What was the USAIDs Plan for healthcare progression?

1. Human resources for health 2. Health finance 3. Health governance 4. Health information 5.Medical products, vaccines and technologies 6.Service delivery. *** The ultimate goal is to strengthen the system so they will contribute to positive health outcomes and create an environment for universal health coverage.

Describe some trends in directions in healthcare delivery in the US.

1. Illness to wellness 2. Acute care to primary care 3. Inpatient to outpatient. 4. Individual health to community well-being 5, fragmented care to managed care 6.Independent institutions to integrated systems 7. Service duplication to continuum of services *** Health is now increasingly seen as the presence of wellness rather than Soli the absence of illness.

How does a multiple hair system become more cumbersome?

1. It becomes challenging for providers to keep up with which services are covered under which plan and how much the services cost 2. Providers must hire claims processors to bill services and monitor receipt of payments. No standard billing practices. 3. Payments can be denied for not precisely following requirements set up by each payer 4. When only partial payment is received sometimes a balance bill is sent to the patient this summarizes the difference between provider charges and insurance payment 5. Sometimes it takes a long time for provider to get their money 6. Complex government regulations for determining whether payment is made for services actually delivered

Describe the 10 basic characteristics that differentiate the US healthcare system from most other countries.

1. No central agency governs the system 2. Access to healthcare services is selectively based on insurance coverage 3. Healthcare is delivered under imperfect market conditions 4. Insurers from a third-party act as intermediaries between the financing and delivery functions 5. The existence of multiple payers makes the system cumbersome 6. The balance of power among various players prevent any single entity from dominating the system 7. Legal risks influence the practice behavior of physicians 8. Development of new technology creates an automatic demand for it to use 9. New service settings have evolved along a continuum 10. Quality is no longer accepted as an on achievable goal

What came out of the ACA?

1. Required that all US citizens and legal residence because of her by either public or private insurance. 2.16.5 million uninsured Americans gain health insurance coverage by march 2015 3. States that expanded Medicaid side large decline in the uninsured rate wow states that did not expand Medicaid experienced a comparably smaller decline in uninsured 4. The uninsured rate declined among all race categories with the greatest being among blacks and Hispanics 5. Females experienced a great decline in their uninsured rate

Why can't some individuals get insuranceThrough their employer?

1. Some small businesses cannot get group insurance at affordable rates. 2. In some work settings, participation and health insurance programs is voluntary so employees are not required to join

Best describe the major component of the US healthcare system

1. There is no central agency 2. Partial access: not everyone has access to health insurance. 3. It's an imperfect market 4. Third-party insurers and payers: Insurance companies have no incentive to be a patient advocate on price or quality. 5. Multiple payers: many prayers often represent a billing and collection nightmare. 6. There's a power balance between positions administrators insurance companies and the government. 7. Litigation risks: High risk and being a doctor so they're forced to practice defensive medicine 8. High technology: at the forefront of medical innovation and new technology 9. Continuum of services: it is lopsided with a heavier emphasis on specialized services

Describe the health care fundamental changes during the 1990s?

1. There was a tighter integration of the basic function through managed care 2. Previously the determination of the utilization of health services in price charged had been left up to the insured individuals in the providers of healthcare, this changed along with the current delivery mechanisms which now institute some controls over both utilization and price

What are some common global health challenges?

1. There's a huge gap in healthcare and health status between developing and developed countries 2. There are a wide variations in healthcare for pregnant women, availability of specialties, skilled personnel for childbirth, and access to medicine. 3. Poor quality and low efficiency of healthcare services in many countries 4. Rising out-of-pocket costs in a high numbers of uninsured

What external factors shape the delivery of healthcare services?

1.Social values and culture: such as ethnic diversity, cultural diversity, social cohesion 2.Global influences: immigration, trade, Terrorism, epidemics 3.Population characteristics: demographic trends, health needs, social morbidity. 4. Physical environment: toxic waste, sanitation, global warming 5. Technology development: bio technology, information systems 6.Economic conditions: general economy, competition 7. Political claimant: president and Congress, interest groups, laws

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them.

National health system

A tax supported national health care program in which the government finances and also controls the service infrastructure for delivery of care. Example, the United Kingdom.

What are the three Main outcome criteria used to evaluate the success of a healthcare delivery system?

Access, cost, quality

provider-induced demand

Artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes. Call starfollow up appointment, excessive medical tests, unnecessary surgeries.

Why am I someone say that our healthcare delivery system is not a system at all? Give an example

Because the system fall short of the two basic ideals of an acceptable healthcare delivery system. Enable all citizens to obtain needed healthcare services and ensure that services are cost-effective and meet certain established standards of quality. Example: employees at small businesses may not be able to afford insurance because their company can't pay for it and they can't pay for it.

CHIP

Children's Health Insurance Program: The program for children from low income families, which is funded by the federal and state government

System

Consist of a set of interrelated and inter-dependent, logically coordinated components designed to achieve common goals.

Continuum of health care services

Curative: drugs, treatments, surgeries Restorative: physical, occupational, speech therapies. Preventative: prenatal care, mammograms, immunizations. *** in the US there's a heavier emphasis on specialized services compared to preventative services and primary care

premium cost sharing

Employers rarely pay 100% of the insurance premium so this is the amount required for employers to pay

Define access and explain what determines if an American is granted access to healthcare services?

Excess is the ability of an individual to Obtain healthcare services when needed this is different from having health insurance. 1. Have health insurance through their employer's 2. Or be covered under government healthcare programs 3. Can afford to buy insurance with their own private funds 4.Are able to pay for services privately 5.Or can obtain charity or subsidized care.

What are global budgets and what are their consequences?

Global budgets determine the total healthcare expenditures on a national scale and allocate resources within budgetary limits. 1. Both availability of services and payments to providers are subject to budgetary constraints. 2. The governments of these nations also control the proliferation of healthcare services such as costly medical technology 3. Systemwide controls over the allocation of resources determine the extent to which government sponsored health care services are available

Socialized Health Insurance (SHI)

Government mandated contributions by employers and employees finance health care. Private providers deliver health care. -Private not for profit insurance companies are responsible for collecting the contributions ad paying physicians and hospitals. -insurance and payment functions are closely integrated - Delivery is characterized by independent private arrangements, but the government exercises overall control.

Electronica health records

Have helped provide clinical measures and decision support tools, enabled provider to automate processes to reduce redundancy, and captured more clinical data.

universal coverage

Health insurance coverage for all citizens.

What has health information technology improved?

Helps improve access to information, and consequently health.

Describe what a free market is and what this looks like if it were true in the United States

In a free market the patients or the buyers and providers or the sellers act independently, with patient able to choose the services from any provider there is no collusion to fix prices rather prices are determined by supply and demand

Describe how and why the US healthcare delivery system is unlike any other healthcare system in the world.

It is extremely complex with little standardization and is functionally fragmented. It also runs on free market ideals instead of a central agency. 1. A multiplicity of financial arrangements for healthcare services 2. Numerous insurance agencies or MC owes that employee various mechanisms for ensuring against risk 3.Multiple players that make their own determinations regarding how much to pay for each type of service 4. A diverse array of settings were medical services are delivered 5. Numerous consulting firms offering expertise in planning, cost containment, electronica systems, quality, and restructuring of resources

What is the greatest challenge to the US healthcare system?

It is the quest to control costs while still meaning the increasing healthcare demands of an aging population and a population with chronic diseases.

With the US healthcare system being predominantly run by private entrepreneurial systems, what does this mean as a large scope of things?

It means that these entrepreneurial systems seek to manipulate financial incentives for their own advantage hence cost containment is not one of the main goals

What is the quad function model of health care?

It's a delivery system that is made up by four components. These components are financing, insurance, delivery, and payment

What is managed care and what is it about?

It's a system of healthcare delivery that seeks 1. To achieve efficiency by integrating the four functions of healthcare 2. Employees mechanisms to control the utilization of medical services. 3. Determines the price of services and how much providers are paid.

What is the biggest difference between fee for service plans and managed care

Managed care was successful in accomplishing cost control and greater integration of healthcare delivery.

Australia's healthcare system

Medicare - financed by income taxes and income-based. -built on the philosophy that everyone should contribute to the cost of healthcare according to his or her capacity to pay. -many still carry private coverage for things like dental -Hybrid model

Who are the main players in the US healthcare system?

Physicians, administrators, insurance executives, large employers in the government.

Talk about each players economic interests In the US healthcare system.

Physicians: want to maintain their income and have minimal interactions with the way they practice medicine. Institutional administrators: want to maximize reimbursement from private and public insurers Insurance companies: are interested in maintaining their share of the health insurance market Large employers: want to contain the costs they incur providing health insurance to their employees. The government: tries to maintain or enhance existing benefits for those covered under public insurance programs along with containing the cost of providing these benefits

What are the positive and negative affects of the often conflicting self interests of these players?

Positive: not one single entity dominates the whole system Negative: Difficult to achieve systemwide reform

phantom providers

Practitioners who generally function in an adjunct capacity. The patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologists, radiologists, and pathologists.

What are some of the problems with the United States healthcare system?

Problems of duplication, overlap, inadequacy, inconsistency and waste. Also there is lack of systemwide planning, direction, and coordination

Healthcare Reform

Refers to the expansion of health insurance to cover the uninsured

Enrollee

Refers to the individual covered under the specific plan

standards of participation

Standards established though health policy and regulation that state that providers must comply with standards established by the government to be certified to provide services to Medicaid, CHIP, and Medicare beneficiaries.

US healthcare system fall short in both primary objectives but what do they do well?

The US healthcare system offers the most sophisticated institutions, products, and processes of healthcare delivery.

universal access

The ability for all citizens to obtain healthcare when needed but this remains mostly a theoretical concept

Need

The amount of medical care that medical experts believe a person should have to remain or become healthy.

health plan

The contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to.

National Health Insurance

The government finances healthcare through general taxes, but the Actual care is delivered by private providers. Example, Canada.

Medicare

The program for the elderly and certain disabled individuals, which is administered by the federal government

Utilization

The quantity of health care consumed

Define demand and explain its curve

The quantity of healthcare purchased. Under the free market conditions, the quantity demanded will increase as the price is lowered. There is an inverse relationship between the quantity of medical services demanded in the price of medical services. As the quantity demand goes up the prices go down.

Why is there a power balancing problem in the US healthcare system?

There are many key players in a system such as physicians, administrators, insurance companies, large employers, the government, high-priced lobbyists, lawmakers. Each set of players has its own economic interests to protect for example, Physicians want to maintain their income and have minimal interference with the way they practice medicine.

What must be done in a free market healthcare system? How is this failing today?

There must be an unrestrained competition between providers based on price and quality. However today there is a consolidation of buying power which forces providers to form alliances in integrated delivery systems on the supply side. For example in rule areas A single giant medical system has taken over the many sole providers.

What is the primary goal of medical insurance?

To protect against the rest of unforeseen catastrophic medical events. However insurance today Generally covers basic and routine services that are meant to be paid out of pocket. Medical insurance is different from homeowners insurance because homeowners insurance is not used for basic things such as a leaky faucet.

single-payer system

a national health care program in which the financing and insurance functions are taken over by the federal government. Providers are paid by the government.

Reimbursement

amount paid to patient toward the cost of healthcare services

Provider

any entity that delivers health care services and can either independently bill for those services or is tax supported

Describe Package Pricing And give an example.

bundling of fees for an entire package of related services. For example in surgery this would mean one all inclusive price that includes the surgeons fees, hospital facilities, supplies, diagnostics, anesthesia, post surgical follow up

Administrative costs

costs associated with billing, collections, bad debts, and maintaining medical records

Describe the four components of the quad function model and the "players" in each.

financing: is the way people obtain healthcare for example employers Medicare Medicaid or self funding. Insurance: The insurance function determines the package of health services that the insured individual is entitled to receive. This makes up insurance companies such as Blue Cross Blue Shield or self insurance. Delivery: refers to the provision of healthcare services by various providers. This includes physicians, hospitals, nursing homes, diagnostic centers, medical equipment vendors, community health centers. Payment: this deals with the reimbursement to providers for the services that they delivered the insurer or determines how much is paid for a specific service. This includes insurance companies like Blue Cross Blue Shield and third-party claim processors.

Primary Care

health care at a basic rather than specialized level for people making an initial approach to a doctor or nurse for treatment.

Affordable Care Act

law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient's Bill of Rights

What is defensive medicine? Why did it come about?

prescribing additional diagnostic tests, scheduling checkup appointments, and maintaining abundant documentation on cases. Because providers are increasingly susceptible to litigation and the risk of malpractice so they do this to protect themselves.

Uninsured

those without private or public health insurance coverage