605 Health Mngt/Policy (Week 2&3)

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  1. Medical model
    • Presupposes the existence of illness or disease, thereby emphasizing clinical dx and medical intervention in the tx of dz of sx
    • -Under the medical model, health is defined as the absence of illness or disease
  2. WHO definition of health
    "a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity"

    -definition includes the physical, mental, and social dimensions (biopsychosocial model of health)
  3. Holistic model
    Seeks to treat the individual as a whole person

    -Incorporates the spiritual dimension in addition to the physical, mental, and social (hence, provides the most complete understanding of what health is)
  4. Indicators of health
    • -Self-reported health status
    • -Life expectancy
    • -Morbidity (disease)
    • -Mental well-being
    • -Social functioning
    • -Functional limitations
    • -Disability
    • -Spiritual well-being
  5. Illness vs. Disease
    Illness: recognized by means of a person's own perceptions and evaluation of how he or she feels (may feel pain, weakness, etc. but a disease may not be present)

    Disease: presence of dz determined by a medical professional's evaluation rather than the patient's assessment (it is possible to have a disease without feeling ill - HTN, DM)
  6. The 4 leading determinants of health:
    • -Environment
    • -Behavior and lifestyle
    • -Heredity
    • -Medical care
  7. Healthy People 2020's objectives (and how progress will be assessed)
    • 1. Identifying nationwide health improvement priorities
    • 2. Increasing public awareness and understanding of the determinants of health, disability, and disease 
    • 3. Providing measurable objectives and goals that are applicable at all levels
    • 4. Engaging multiple sectors to take action to strengthen policies and improve practices that are driven by the best scientific evidence and knowledge 
    • 5. Identifying critical research, evaluation, and data collection methods

    *Progress assessed through measures of general health status, health-related quality of life and well-being, determinants of health, and disparities
  8. Healthy People 2020: Overarching goals (4)
    • 1. Attaining high-quality, longer lives free of preventable disease, injury, and premature death
    • 2. Achieving health equity, eliminating disparities, and improving the health of all groups
    • 3. Creating social and physical environments that promote good health for all
    • 4. Promoting quality of life, healthy development, and health behaviors across all life stages
  9. Principle of Market Justice is based on these key assumptions (5):
    • 1. Health care is like any other economic good or service and, therefore, can be governed by the free market forces of supply and demand
    • 2. Individuals are responsible for their own achievements. When individuals pursue their own best interests, the interests of a society as a whole are best served.
    • 3. People make rational choices in their decisions to purchase health care products and services to rectify their health problems and restore their health
    • 4. People, in consultation with their physicians, know what is best for themselves. This assumption implies that people place a certain degree of trust in their physicians and that an ongoing physician-patient relationship exits.
    • 5. The marketplace works best with minimum interference from the government. In other words, the market, rather than the government, can allocate health care resources in the most efficient and equitable manner.
  10. Principle of Social Justice is based on these assumptions (4):
    • 1. Health care is different from most other goods and services. Health-seeking behavior is governed primarily by need rather than cost
    • 2. Responsibility for health is shared. Individuals are not held totally responsible for their condition because factors outside their control may have brought on the condition. Society feels responsible for a lack of control over certain environmental factors such as economic inequalities, unemployment, unsanitary conditions, and air pollution.
    • 3. Society has an obligation to the collective good. The well-being of the community is held to be superior to that of the individual. An unhealthy individual is a burden on society (a person carrying a deadly infection, for example, poses a threat to society). Society is obligated to eliminate (cure) the problem by providing health care to the individual because doing so benefits society as a whole. 
    • 4. The government, rather than the market, can better decide through rational planning how much health care to produce and how to distribute it among all citizens.
  11. 4 main strategies to reduce health disparities
    *Requires interventions in both the social and medical domains

    • 1. Social or medical care policy interventions
    • -e.g.; product safety regulations, screening food and water, enforcing safe work environments (OSHA)

    • 2. Community-based interventions
    • -e.g.; addressing neighborhood poverty; presence of local health and social welfare resources; societal cohesion and support
    • (community partnerships can be effective - reflect priorities of local population, often managed by members of the community, minimize cultural barriers and improve community buy-in to programs)

    • 3. Health care interventions
    • e.g.; EMRs  (incr. efficiency, better coordination and integration among providers)

    • 4. Individual interventions
    • e.g. altering behaviors such as smoking and exercise
  12. What was the first broad-coverage health insurance in the U.S.?
    Workers' compensation 

    -between 1910 and 1915, workers' compensation laws made rapid progress
  13. In what form did private health insurance first begin?
    Disability insurance (early 1900s)- coverage that provided income during temporary disability due to bodily injury or sickness
  14. Blueprint for modern health insurance:
    • Conceived in 1929 when Justin F. Kimball began a hospital insurance plan for teachers at the Baylor University Hospital in Dallas, TX. 
    • -Within a few years, it became the model for Blue Cross plans around the country (nonprofit - no shareholders)
    • -Plans sponsored by groups of hospitals became more popular because they offered consumers a choice of hospitals
  15. First physician health insurance plan
    In 1939, the California Medical Association started the first Blue Shield plan, which was designed to pay physician fees
  16. Three main factors that explain how health insurance in the U.S. became employer based:
    • 1. During the WWII period, Congress imposed wage freezes to control wartime inflation - employees accepted employer-paid health insurance to compensate for loss of raises
    • 2. In 1948, the Supreme Court ruled that employee benefits were a legitimate part of union-management negotiations. Health insurance became an important component of collective bargaining between unions and employees.
    • 3. In 1954, Congress amended the Internal Revenue Code to make employer-paid health coverage nontaxable
  17. Reasons why national health care has historically failed in the U.S.:
    • 1. Unlike in Europe where labor unrest threatened political stability and universal health care was seen as a means to obtain workers' loyalty and thwart uprisings, U.S. national health care failed to get an early footing because of labor and political stability in the U.S.
    • 2. A decentralized American system gave the U.S. federal government little direct control over social policy
    • 3. The German social insurance system was denounced during WWI. Since then, the term "socialized medicine" has been used as a synonym for national health insurance.
    • 4. The AMA opposed national health care initiatives (as did the AHA and other health organizations/special interest groups who viewed it as a potential threat to independence and livelihood)
    • 5. Middle-class Americans have traditionally had beliefs and values consistent with capitalism, self-determination, and distrust of big government (viewed national health insurance as government takeover of medical care)
    • 6. Middle-class Americans have been averse to higher taxes to pay for the increased cost of a national health care program
  18. Compare/contrast Medicare and Medicaid
    • Medicare
    • -Covers all elderly persons (65+), non-elderly disabled persons on Social Security, and non-elderly persons with end-stage renal disease
    • -No income/means test
    • -No class distinction
    • -Part A for hospitalization and short-term nursing home stay 
    • -Part B for physician and other outpatient services
    • -Nationally uniform program
    • -Title 18 of the Social Security Act
    • -Part A financed through Social Security taxes
    • -Part B subsidized through general taxes, but the participants pay part of the premium cost
    • -Seen as an entitlement that people pay into (not technically correct b/c we don't pay enough to offset all costs)

    • Medicaid
    • -Covers only the very poor
    • -Income criteria established by the states (means test)
    • -All services are covered under one program
    • -Program varies from state to state
    • -Title 19 of Social Security Act
    • -Financed by the states, with matching funds from the federal government according to each state's per capita income
    • -Seen more as social welfare (stigma)
  19. Creation of Medicaid and Medicare
    • -Before 1965, private health insurance was the only widely available source of payment for health care and it was available primarily to middle-class working people 
    • -The exception to Americans not wanting government intervention in health care was for reform initiatives for the underprivileged classes
    • -In 1964, health insurance for the aged and poor became a top priority of President Lyndon Johnson's "Great Society" programs
    • -In 1965, a three part program was adopted > Medicare Part A and Part B (initially just covered the elderly) and Medicaid (for the eligible poor)
  20. Healthcare Expenditures - How the nation's health dollar was spent in 2013
    • 2013 Top areas of spending
    • -Hospital care (32%)
    • -Physicians and clinics (20%)
    • -Other (14%) - Health/Residental/Personal (5%), Gov't PH (3%), other med products (3%), home health care (3%)
    • -Prescription drugs (9%)
  21. Healthcare funding - Where the nation's health dollar came from in 2013
    • Health insurance (72%)
    • - Private (33%) - particularly large jump from 1970-1980
    • -Medicare (20%)
    • -Medicaid (16%)
    • (note Medicare + Medicaid = 36% - there have been increases in these two areas since they bagan, large increases especially at start-up)
    • -VA/DOD/CHIP (4%)

    Out-of-pocket (12%) - has decreased dramatically since 1960 (56% in 1960 to 14% in 2013)
  22. Trends in national health expenditures: 1960-2013
    -% increase (due to what?)
    -comparison to rest of economy
    -% of GDP in 1960 compared to 2013
    -% of GDP in 2000 compared to 2010
    • There has been roughly a 10,550% increase in healthcare expenditures during the past 43 years. 
    • -Some of this increase is expected due to inflation and population growth, but much of it goes beyond that (health expenditures increased at a greater rate than the overall economy)
    • -5% of GDP in 1960; 17.4% of GDP in 2013 (kind of level from 2010 to 2013) - so healthcare is taking resources from other parts of economy
    • -Just from 2000 to 2010 %GDP went from 13.5 to 17.4 (almost 30% increase over one decade)
  23. Possible reasons for faster increase in health expenditures
    -Inflation (how is this defined)
    -Greater population (describe factors)
    Total expenditure = price (per unit) x quantity

    • Inflation:
    • -Inflation increases the "price" in the total expenditure equation

    • Greater population:
    • -Increases the "quantity" in the total expenditure equation
    • -More people receiving services; longer life expectancies (more people over 65 and over 80 - more expensive); more services per year (independent of population growth)
  24. Growth of healthcare expenditure depending on type of health care service:
    Expenditures on types of healthcare services did NOT all grow at same rate since 1960. 

    • Hospital expenditures:
    • -increased through 1960s and 1970s, peaked in 1980s, then decreased through 2000s (small increase since 2000)
    • -DRGs implemented in early 1980s, which is why hospital expenses decreased (before that hospitals were being paid what they said it took to care for a pt to make sure they would take Medicare/Medicaid pts)

    • Physician services:
    • -Increased from 1980 to 1990 and then decreased again

    • Prescription costs:
    • -Decreased from 10% in 1960 to below 5% by 1980 (generic drugs became more available because patents started expiring)
    • -Then increased back to almost 10% in 2010 (huge advances in pharmaceutical development; Medicare part D; TV ads, pricing of meds)
    • -Since 2010 has decreased to just over 9%

    • Admin costs:
    • -Increased since 1970 (HMOs, managed care in general increased through 1980s and 1990s)

    • Home health:
    • -Increased steadily since 1970 (partially linked to DRGs - hospitals discharged pts as soon as possible, Medicare increased coverage of home health care due to this)

    • Nursing homes:
    • -More stable (they have limited coverage by Medicare)
  25. Explanation of hospital changes in expenditures (increase and then decrease)
    • -Cost-based reimbursement: pay based on how much it cost to take care of patient (this is how Medicare and Medicaid paid hospitals for a while when it first started in 1960s in order to get hospitals to take patients with these types of insurance) - really increased expenditures on hospitals as a share of total expenditures
    • -DRG (diagnosis related groups): were implemented in 1980 - changed the rules under which hospitals operated (no longer got paid whatever they said it cost). Paid according to diagnosis (how much it cost on average for patients with a certain diagnosis).
  26. Health expenditures (2013): What % of total expenditures was spent on different types of health care in 2013? 
    -Hospital care
    -Physician services
    -Prescription drugs
    -Nursing home care
    -Home health care 
    -Net cost of private insurance
    -Government public health activities
    • -Hospital care 32.1%
    • -Physician services 20.1%
    • -Prescription drugs 9.3%
    • -Nursing home care 5.3%
    • -Home health care 2.7%
    • -Net cost of private insurance 5.9%
    • -Government public health activities 2.6%
  27. Main % sources of funds for: 
    -Prescription drugs
    -Nursing homes
    -Home health

    And highest and lowest type by source
    • Hospitals:
    • -Private insurance pays for 37.1%
    • -Medicare 25.9%
    • -Medicaid 17.5%
    • -Out-of-pocket 3.5%

    • Physicians:
    • -Private insurance 45.6%
    • -Medicare 22.2%
    • -Medicaid 8.5%
    • -Out-of-pocket 9.4%

    • Prescription drugs:
    • -Private insurance 43.5%
    • -Medicare 27.5%
    • -Medicaid 7.8%
    • -Out-of-pocket 16.9%

    • Nursing Homes:
    • -Private insurance 8.1% (very low!)
    • -Medicare 22.2%
    • -Medicaid 30.1%
    • -Out-of-pocket 29.4%

    • Home Health:
    • -Private insurance 7.9%
    • -Medicare 43.1%
    • -Medicaid 36.5%
    • -Out-of-pocket 8%

    • By Source 
    • Out-of-pocket
    • -Highest % - nursing homes 29%
    • -Lowest % - hospital 3.5%

    • Private Insurance:
    • -Highest % - physicians/Rxs 44-46%
    • -Lowest % - nursing homes/home health 8%

    • Medicare:
    • -Highest % - home health 43%
    • -Lowest % - nursing homes/physicians 22%

    • Medicaid:
    • -Highest % - home health 37%
    • -Lowest % - physicians 8.5%
  28. Health Care Delivery in Preindustrial America (Pre-1900s)
    Disorganized medical practice and consumer sovereignty

    • -*Medical practice was not organized; not viewed as a learned profession
    • -Medical training and education were not grounded in science
    • -Primitive medical procedures were practiced
    • -Intense competition existed b/c any tradesman could practice medicine
    • -*Travel costs to physicians & hospitals high (especially in rural areas, had to travel to cities)
    • -People relied on family members, neighbors, and publications for domestic remedies
    • -*No health insurance; use of personal funds (limited demand; spawned fee-for-service programs)
    • -Healthcare was delivered in a free market
    • -*Only a few bona fide hospitals in U.S. - located only in big cities
    • -Most hospitals had poor sanitation and unskilled staff
    • -Almshouses - served the destitute and disruptive elements of society and provided some basic nursing care (forerunner of today's hospitals and nursing homes)
    • -Asylums - operated by state governments for pts with untreatable, chronic mental illnesses (forerunner of today's inpt psych)
    • -Pesthouses - quarantined people with contagious diseases
    • -Dispensaries - delivered outpt charity care in urban areas (forerunner of today's free clinics)
    • -*Eventual growth in # of med schools in early 1800s
  29. Healthcare delivery in postindustrial era (1900s)
    Growth of professional sovereignty (professionalism in medicine)

    • -Urbanization (easier and less costly to consult MDs; greater # of pts)
    • -Growing importance of public health (health problems related to urbanization and communicable dz; local health depts and safety net providers)
    • -Lifestyle changes: shift from infectious to chronic disease
    • -Hospitals became true medical care institutions - increased number of hospitals
    • -Growth of private health insurance

    • -Growth of medical profession
    • -organization of medical profession (AMA) - political influence over healthcare delivery, supported laws/regulations to restrict medical practice
    • -increase power, prestige, incomes
    • -licensing to restrict medical practice (legal monopoly on practice of medicine)
    • -increased medical education; more science and lab-based; longer duratoin, more rigorous admission standards (*Flexner report of 1910 - called for higher standards in med ed)
    • -organized medicine- powerful political interest group
    • -opposition to national health insurance proposals (support of private entrepreneurship)

    • -Scientific developments reduced epidemics of infectious disease
    • -advanced science based tx
    • -increase healthcare costs
    • -growing imbalance between specialists and generalists

    • -Expanding role of government:
    • -Social Security Act (1935): legislative basis for most health & welfare programs; focus on planning & legislation (Hill-Burton Act - federal subsidies to stimulate hospital construction; local health planning authorities to monitor growth and resources)
    • -Medicare and Medicaid (1965)
  30. Growth in private insurance in 1900s
    • -Medical care more valued due to greater prestige, more effective care, increased technology used (more science based)
    • -Need for medical care was not predictable and insurance pools risk
    • -Growth in employment-based private insurances (b/c of wage freezes during WWII and beginning in 1954 the tax system subsidized insurance by making it tax exempt to employees)
  31. Political influences on health care
    • 1. Kennedy-Johnson administrations
    • -1963: Health Professions Educational Assistance Act
    • -1965: Medicare and Medicaid

    • 2. Nixon-Ford administrations
    • -Shifted many categorical programs to state block grants
    • -HMO Act of 1973: to stimulate growth of HMOs, policy said that employers who provide insurance coverage to their employees must offer at least one HMO option (payment incentives are different - employer would provide a certain amount a month to HMO, then HMO had to cover costs with that set amount of money, so provided encouragement to control expenditures)
  32. Before managed care, there was . . .
    • Planning and control efforts
    • -1966: Comprehensive Health Planning Act
    • -1974: National Health Planning & Resources Development Act
  33. Health policy often results in unintended consequences:
    -Examples from Medicare & Medicaid and Hill-Burton Act of 1946
    • Medicare and Medicaid:
    • -improved access for millions, but costs skyrocketed
    • -when started, favorable reimbursements for MDs/hospitals to ensure they would participate

    • Hill-Burton Act of 1946:
    • -increased hospital capacity; soon "over-capacity" > cost-implications
  34. Major Influences in Health Care
    • New drugs; technology
    • -profit driven
    • -new tx/dx potential, but higher costs

    • Increased costs (especially for businesses)
    • -prompted growth in managed care

    • Aging population
    • -increased demand, cost escalation, pressure on categorical programs (Medicare)

    • Interest groups
    • -Have a huge influence
    • -Health insurance lobbies (HIAA), Hospital lobbies, Professional lobbies (AMA), Business lobbies, Labor lobbies (AFL-CIO, etc. - support employer-provided insurance); Consumer lobbies (AARP, etc.)
Card Set:
605 Health Mngt/Policy (Week 2&3)
2015-09-09 18:49:08
605 Policy Management
Week 2 review
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