Primary, Secondary, Tertiary levels of care
Primary: general visits
- Ex: PCP
Secondary: more specialized treatment
- Ex: ob/gyn or surgery
Tertiary: rare and complex care
-Ex: organ transplants
Regionalized model of healthcare
Highly structured
Base is primary care, organization upward as needed
General physician practitioners (GPs) practice exclusively at the primary care level
Relies on resources coordinated in a geographic region
Dispersed model of healthcare
More fluid model – allows patients to go where they wish, tertiary expertise emphasized
Primary care is spread among specialists, total supply of generalists
Why the dispersed model has grown in the U.S.
- Biomedical Model
-Medical training was reformed with an emphasis on:
- Academically oriented training
- Technology and basic science
- Specialist training - Financial Incentives
- Medicare encourages specialization through extra payments to hospitals to cover costs associated with residency training
- Blue Shield - Reimbursement for specialized procedures - fees remained high despite the physician time needed for procedures declined
- Hill Burton Hospital Construction Act of 1946: billions toward expansion of hospital capacity instead of ambulatory services - Professionalism
- Physicians have been sovereign, American Medical Association (AMA) has supported physician independence
- System has been weighted toward hospital and specialty care
Arguments for and against a dispersed model
For:
- Pluralism enables providers and facilities to be more available
- Americans value choice of providers, access to specialists and technology
Against:
- It lacks coordination
- Quality of care can be maintained with use of fewer resources
- It is not consistent with the health needs of the majority of the population
- Costly
Vertical integration
Consolidates all levels of care, staff, and facilities under one organizational ownership
First generation HMOs - Kaiser Permanente Model
-Does not cover an entire population but responsible for delivering all services to a population of enrolled
-Physician group practice provides care to members under a capitated plan
-Enables a more population based model of health
-Vertical integration
Virtual integration
Hospitals and insurers recruit office based fee for service community physicians into an IPA creating a basis for an HMO and negotiate contracts with the physicians to provide care
Independent Practice Association Model (IPAs)
- IPAs consist of independent, community-based physicians who maintain their own practices and fee-for-service arrangements
- Allows insurers, etc. to respond to market changes by renegotiating contract bargains with providers
- Has the advantage of low capital costs because the HMO does not have to own buildings
- Virtual integration
Integrated Medical Group Model
- Physicians do not own their practices but the medical group organization employs them
- Virtual Integration
Health expenditures as a percent of GDP
-Total healthcare expenditure is the sum of public and private health expenditure. It covers the provision of health services (preventitive and curative), family planning activities, nutrition activites, and emergency aid designed for health
-In 2021 U.S. national health care expenditures were approximately 18% of the Gross Domestic Product (GDP)
Health costs and outcomes model
-Provides a framework for discussion, analysis and decision making
- Enables examination of the relationship between healthcare costs and benefits in terms of improved health outcomes
Assumptions of Health costs and outcomes model
- The relevent outcome of interest is the overall health of a population rather than one individual
- It is possible to quantitate health at a population level
-Y axis = health outcomes = aspects of health status directly under the influence of healthcare, not the broader economic and social factors
Examples of Painless Cost Control
- Controlling fees and provider incomes
- Cutting the price of pharmaceuticals and other supplies
- Reducing administrative waste
- Eliminating medical intervention of no benefit
- Substituting less costly technologies that are equally effective
- Increasing the provision of those preventive services that cost less than the illness they prevent
Types of Financing Controls
- Competitive strategies (primary U.S Model): Health insurance plans compete on basis of price and market forces pressure plans to restrain their premium prices and overall costs as employers, employees, and individuals are more cost conscious in choosing plans
- Regulatory strategies: Government regulation of taxes serves as a control over public expenditures for health care
Types of Reimbursement Controls
Changing the Unit of Payment
Patient Cost Sharing
Utilization Management
Supply Limits
Controlling the Type of Supply
What should cost containment policies focus on?
1- Macro-management issues of capacity and budgets (setting the supply thermostat)
2- Global cost containment tools
- Paying by capitation or aggregated method
- Limiting size and specialty mix of providers
- Concentrating high tech services regionally
Primary reasons why quality is lacking in the U.S.
Lack of access to care
Practice variations
Practice defects requiring change
Overuse
Underuse of effective care
Misuse and errors in medical waste
Inefficiency and waste
“Never Events”
Medicare/Aid have stopped reimbursing hospitals and physicians for:
- Surgery on the wrong body part or wrong patient
- Wrong surgery on a patient
- Foreign object left in patient after surgery
- Death/disability associated with intravascular air embolisms, incompatible blood, or hypoglycemia
- Stage 3 or 4 pressure ulcers after admission
Donabedian’s quality assessment model:
- Structure
- Facilities
- hospital/place itself
- Licensing and accreditation
- Equipment
- Staffing levels
- Staff qualifications
- Delivery system - Process
- Actual delivery of Services
- Interpersonal aspects of care
- Communication
- Respect and dignity
- Compassion and concern
- Technical aspects of care
- Diagnosis and treatment procedures
- Waiting time
- Cost of services - Outcomes
What is Healthcare Effectiveness Data and Information Set (HEDIS)?
Used increasingly to evaluate the quality of health plans operating in the US
Goal is to compare performance and publicize that information to help clinicians improve clinical care and to counter financial incentives to restrict appropriate care
Indicators of Healthcare Effectiveness Data and Information Set (HEDIS)
Children immunized
Mammograms
Pap smears
Prenatal exams
Eye exams for diabetic patients
Osteoporosis screnning
Flu shots
BMI Assessment
Proposals to improve quality of healthcare
Licensure, Accreditation, and Peer Review
Clinical practice guidelines
Measuring practice patterns
Continuous quality improvement
Electronic health records
AI
Interdisciplinary teams
Public reporting of quality
Pay for performance
Balancing payment incentives
