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Unformatted text preview: Costs in Health Care Cost, Quality, Access, and Utilization of Health Care Services Services Access Chap. 2 (pp. 26 – 43), 3, and 20, PLB October 19, 2010 Cost AHS 330 - Fall 2010 - Unit 7 1 October 19, 2010 Cost Concerns AHS 330 - Fall 2010 - Unit 7 3 National Health Expenditures, United States 1940 projected through 2008 $2,500.0 16.2 Expenditure: what we and the government spend on health care Costs: price, sum of national expenditures, Costs: cost of producing health care Expenditures = Price * Quantity Quantity = Population * Utilization per capita As quantities increase, costs increase October 19, 2010 AHS 330 - Fall 2010 - Unit 7 4 Reasons for Concern Over Increasing Costs and Expenditures 18 16 14.3 14 12 $1,500.0 9.1 $1,316.20 % of GDP 7.4 8 5.2 4 10 $1,149.1 $699.4 4.4 6 Percentage of GDP $2,176.60 12.2 Billions of Dollars 2 13.5 $2,000.0 $1,000.0 AHS 330 - Fall 2010 - Unit 7 Cost vs. Expenditures We spent $2.2 trillion dollars in 2007, 16.2% of the GDP, and $ 7,421 per capita – only 12% was out-of-pocket out-ofGovernment policy of cost containment since Government policy of cost containment since 1983 1983 Public concern since 1990 We (typically and historically) don’t care about health care costs as individuals Care about cost of premiums and taxes October 19, 2010 Quality 4 $500.0 Health Expenditures $75.0 $4.0 $12.7 $26.9 $248.1 $0.0 Run out of money/life is at stake Increased taxes Increased cost of production cost of production Too much money being spent on the dying Malpractice/Defensive medicine 2 0 More tests, more referrals, refuse patients Unnecessary care 1940 1950 1960 1970 1980 1990 1998 2000 2008 Source: HCFA October 19, 2010 AHS 330 - Fall 2010 - Unit 7 5 October October 19, 2010 AHS 330 - Fall 2010 - Unit 7 6 1 http://www.kff.org/insurance/upload/7692_02.pdf October 19, 2010 AHS 330 - Fall 2010 - Unit 7 7 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 8 Planning for Future As the U.S. population ages, the number of people Age 65 and older who need long-term care will increase: Reasons for Increased Demand Despite Sharply Rising Prices Rising Prices Needing long-term care 1997 2005 2018 2030 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 9 October 19, 2010 Elderly 7.0 34.1 9.0 36.2 9.9 49.4 10.8 69.4 AHS 330 - Fall 2010 - Unit 7 10 Percentage of Adults Ages 25 and over by Level of Educational Attainment: 1960-2006 1960- http://aspe.hhs.gov/hsp/indicators08/ch3.shtml October 19, 2010 AHS 330 - Fall 2010 - Unit 7 11 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 12 2 Other Reasons for Inc. Demand Increase in the provider to population ratio Increase in the perceived effectiveness of Increase in the perceived effectiveness of medical medical care Improved technology Increased competition among providers Increase in insurance and prepayment October 19, 2010 AHS 330 - Fall 2010 - Unit 7 13 October 19, 2010 Defined by BLS as “the overall general upward price movement of goods and services in an economy.” http://www.bls.gov/bls/inflation.htm Health care inflation rose in double digits each Health care inflation rose in double digits each year year during the 1970’s, 1980’s and part of the 90’s. Health care inflation and general inflation slowed in the late 1990s (average 5.8%) Stabilized since 2002 (9.1%), averaging 6.7% over past 3 years October 19, 2010 AHS 330 - Fall 2010 - Unit 7 14 General Inflation vs. Health Care Inflation Inflation AHS 330 - Fall 2010 - Unit 7 If other prices increased at the same rate as health care, the following items would cost: Mayonnaise – $14.68 quart Sliced bacon - $14.62 per pound CocaCoca-Cola - $8.59 for six 12oz bottles Top of the line Ford: $70,014 Average house price: $534,593 15 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 16 17 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 18 Hospital Bill – 1948 Style Equates to $1,236.79 in 2008 dollars (non-medical adjustment) or $3,534 (medical adjustment). That would equal $393/day. 2005 mean charge: $19,280 for 3.1 days (mean) or $6,219/day! October 19, 2010 AHS 330 - Fall 2010 - Unit 7 3 Consumer Price Index Monthly measure of the average change in the prices paid by urban consumers for a fixed market basket of goods and services Weighted by the percent of income spent on the item Expressed in terms of a base period Medical care is 1 of 8 major groups of consumer items within the CPI The medical care component of the CPI shows trends in medical care prices based on specific indicators of hospital, medical, dental and drug prices October 19, 2010 AHS 330 - Fall 2010 - Unit 7 19 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 20 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 21 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 22 Final Report of the Committee on the Costs of Medical Care Costs are astronomical and routinely outstrip the general inflation rate Nowhere near what could be done in health promotion-disease promotionprevention is done. Medical labor is poorly distributed by specialty and geography; there is an inefficient, ineffective distribution of labor between the several health professionsprofessionsoccupations. Institutional care is neither organized nor used in an effective manner October 19, 2010 Quality in Health Care The High-Tech tail is wagging Highthe healthcare-dog healthcareThe deficiencies in primary care, already identified in the CCMC era when 90 percent of physicians were general physicians were general practitioners practitioners have worsened significantly. Deficiencies in doctor-patient doctorcommunication are significant and a major concern of patients Access Chap. 20, PLB PUBLICATION DATE OF THE FINAL REPORT: 1932 AHS 330 - Fall 2010 - Unit 7 23 Quality Cost October 19, 2010 AHS 330 - Fall 2010 - Unit 7 24 4 What is high quality health care? History Donabedian (1984): “that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken into account the balance of expected gains and losses that attend the process of care in all its parts.” AMA: “consistently contributes to the improvement or maintenance of quality and/or duration of life.” IOM: “consists of the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current knowledge.” October 19, 2010 AHS 330 - Fall 2010 - Unit 7 1863: Florence Nightingale; Crimean war 1869: Codan (MD) – end results Early 1900s: Flexner Report and CME 1960s: increasing access to care (Medicare and Medicaid) 1970s: reduce expenditures/utilization (PROs) 1980s: Donabedian – defining quality; expanded data management 1990s: public report cards 25 Quality Traditional Focus (Mostly Indirect Measures): Quality Provider Performance: Degree of excellence or conformity to established standards and criteria Quality in Medical Schools Quality of Residency Programs Licensure Specialty Certification Certification Facility Inspection/Accreditation Patient Redress Continuing Medical Education More Recently: Quality Assessment – measures the essential elements of the quality of care and the outcomes of care Quality Assurance – embraces the full cycle of activities and systems for maintaining the quality of patient care AHS 330 - Fall 2010 - Unit 7 27 October 19, 2010 Assessing Quality in Health Care Medicine is empirical and judgmental – it is difficult to assess the artsy parts No two patients are alike Reflects current knowledge & location Changes as knowledge advances and provider responsibilities are redefined Medicine has high standards & morals – it is selfselfpolicing Why are you bothering me? Few people like to be evaluated It is clear that bad medicine is practiced 1-5% 1where do you draw the line? October 19, 2010 AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 28 US News & World Report: Criterion for ranking hospitals 29 measurement of quality provided, and when necessary the attempt to improve it: conducting on-going quality measurement onactivities and combining these with feedback mechanisms aimed acti th at at continual quality improvement Most quality programs fall into this category (unfortunately, in some ways) Quality Improvement – the set of techniques for continually studying and improving the delivery of health services and products to meet the needs and expectations of the customers Access Patient Compliance Patient Satisfaction October 19, 2010 measurement of quality of care at some point in time 1/3 Reputational Score Mortality Rate Interns and Residents to beds R.N.s to Beds October October 19, 2010 Procedures to Beds Technology score Discharge planning Dischar Service mix Geriatric services AHS 330 - Fall 2010 - Unit 7 30 5 U.S. News and World Report 2009/10 Honor Roll 1. Johns Hopkins Hospital 2. Mayo Clinic 3. UCLA Medical Center 4. Cleveland Clinic 5. Massachusetts General Massach Gene Hospital Hospital 6. New York Presbyterian University (Columbia and Cornell 7. UCSF 8. Univ. of Pennsylvania 9. Barnes-Jewish BarnesHospital/Washington Univ October 19, 2010 Medical Medical Errors UAB Specialties Ranked #39 in Cancer #42 in Ear, Nose & Throat #42 in Gastroenterology #24 in Geriatrics #24 in Geriatrics #17 in Gynecology #31 in Heart & Heart Surgery #13 in Kidney Disorders #31 in Neurology & Neurosurgery #24 in Pulmonology #11 in Rheumatology #24 in Urology AHS 330 - Fall 2010 - Unit 7 “Failure of a planned action to be completed as intended” “Use of a wrong plan to achieve an aim” Examples Adverse Drug Events and Improper Transfusions Surgical injuries and wrong-site surgery wrongSuicides Restraint related injuries Death, Falls, Burns, Pressure Ulcers, mistaken identities 31 October 19, 2010 IOM: To Err is Human AHS 330 - Fall 2010 - Unit 7 33 Negligence, ignorance, intentional wrongdoing Negligence: Provider has a duty to the patient Standard of care (professional standard in malpractice, reasonable prudent person in general ) Physician violates standard of care Patient injury direct result of violation of standard of care October October 19, 2010 98,609 adverse events for hospitalizations (3.7%) Of these, 27.6% resulted from negligence. October 19, 2010 AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 34 Comparison 34,000 hospital records from 1984 1,133 adverse events 280 from negligent care from negligent care Generalized to population 32 Malpractice: Act that does not meet professional standards and results in provable damages. Harvard Medical Malpractice Study AHS 330 - Fall 2010 - Unit 7 Malpractice 44,00044,000-98,000 hospital deaths attributable to PREVENTABLE medical errors each year. Total cost of medical errors (cost of care, lost productivity and income and disability): $17 productivity and income, and disability): $17 billion billion to $29 billion per year Physical and psychological discomfort Loss of trust in health care system Loss of morale by providers Societal Costs October 19, 2010 Institute of Medicine, To Err is Human, 1999 35 In the state of New York in 1984, was a person more likely to die from: A: Homicide Homicide B. Car Accident C. Medical Negligence October 19, 2010 AHS 330 - Fall 2010 - Unit 7 36 6 Quality Problems Generally Fall Into Three Categories Malpractice Concerns Increase costs of malpractice insurance cause: Doctors to leave practice to leave practice Doctors practice defensive medicine Increased cost to consumers (premiums and costcost-sharing) Increased cost to government October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Underuse Overuse appropriateness skill Interpersonal Aspects of Care humanhuman-level interactions Amenities of Care relates to the properties of the place of care October 19, 2010 AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 38 Characterization of Quality Assessment Studies Technical Care Example: 500 preventable injuries due to the medication errors occur each year at every large hospital in the US; Each preventable complication adds nearly $5,000 to the cost of each stay where the injury occurred October 19, 2010 Aspects of care that may be evaluated Example: 16% of women who had hysterectomies didn’t need the operation; 24 million children & adults received antibiotics in 1992 Misuse 37 Example: 18,000 people who have heart attacks each year die because they do not receive beta blockers after the attack 39 Retrospective - making a decision about the quality/appropriateness of care that has already been delivered Concurrent - assessing quality as it is being provided Prospective – assessing quality and appropriateness prior to receipt of care October 19, 2010 AHS 330 - Fall 2010 - Unit 7 40 Total Quality Management and Continuous Quality Improvement Major Quality of Care Initiatives TQM/CQI principles October 19, 2010 AHS 330 - Fall 2010 - Unit 7 41 Focus on underlying processes and systems as causes of failure (rather than individuals) Use of structured problem-solving approaches problemUse of cross-functional employee teams crossEmployee empowerment Focus on both internal and external customers October 19, 2010 AHS 330 - Fall 2010 - Unit 7 42 7 Approaches to Quality Assessment STRUCTURE • Involves evaluation of the settings & instrumentalities available & used for the provision of care Avedis Donabedian “Father of quality in health care” 1. Structure 2. Process • Measures the qualification of providers and the appropriateness of facilities and organizations to provide th the services Three Components of Medical Care: 3. Outcome Two major assumptions: October 19, 2010 1. Better care is provided when better qualified staff and improved physical facilities are employed 2. We know what is “good” in terms of structure AHS 330 - Fall 2010 - Unit 7 43 Examples of Structural Measures of Quality October 19, 2010 AHS 330 - Fall 2010 - Unit 7 44 PROCESS • Specific way in which care is provided Licensure Certification Accreditation • Evaluation of the activities of physicians and other health professionals in the management of patients ti •Criterion: the degree to which providers conform with standards and expectations October 19, 2010 AHS 330 - Fall 2010 - Unit 7 45 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Percentage of General Practioners Who Failed to Perform Specified Procedures or Who Performed then Inadequately (1953-1954) How do we measure process? Percent of Physicians Procedure A. Physical Examination Disrobing Patient for Examination Percussion of Lungs Ausculation of Lungs Physical Examination of Heart Examination of Abdomen Rectal Examination Ophthalmoscopy Implicit - subjective; person bases their judgment on his/her own training/background AHS 330 - Fall 2010 - Unit 7 45 60 23 65 16 83 66 B. Diagnostic Tests Urine Hemoglobin White Blood Cell Count X-Rays Electrocardiograms Explicit - objective; there is a “check list”; standards are pre-determined (often prenational criteria) October 19, 2010 46 11 26 45 18 45 C. Treatment Use of Antibiotics Treatment of Anemia Treatment of Hypertension Treatment of Congestive Heart Failure 47 October 19, 2010 67 85 57 39 AHS 330 - Fall 2010 - Unit 7 Explicit Process Measure Source: Peterson, LP et al (1956) Journal of Medical Education 48 8 Examples of Outcome Measures of Quality Outcomes Evaluation of the end results in terms of health and satisfaction Provides the final evidence of whether Provides the final evidence of whether care care has been good or bad Mortality/Survival Rates Residual Disability Sick Days Days Birth Weight Assumption: A good outcome is the result of a good process October 19, 2010 AHS 330 - Fall 2010 - Unit 7 49 October 19, 2010 Donabedian’s Model for the Measurement of Quality in Medical Care Genetics Access Environment Structure Process Outcome Patient Behavior Public Health October 19, 2010 AHS 330 - Fall 2010 - Unit 7 51 Education and Training Certification Clinical Experience Experience Previous Actions Regarding Licensure and Privileges Experience with Professional Liability October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Types of Review: PrePre-admission Concurrent Retrospective AHS 330 - Fall 2010 - Unit 7 52 National Practitioner’s Data Bank 53 Medicare required Utilization Review by Hospitals Quality of Care Medical Necessity Cost Containment Internal process—Usually carried out by Doctors October 19, 2010 Information Necessary to Judge Clinical Competencies 50 Peer Review Organizations (PRO’s) Patient Satisfaction & Compliance AHS 330 - Fall 2010 - Unit 7 Health Care Quality Improvement Act of 1986 By FEDERAL Law all medical malpractice payments and certain adverse actions must be reported Also contains, licensing, credentialing and Also contains, licensing, credentialing and professional professional society actions Hospitals must check the data bank before granting physicians privileges Access is granted to: hospitals, state licensure boards, some professional societies, and other health care entities under certain circumstances. October October 19, 2010 AHS 330 - Fall 2010 - Unit 7 54 9 Joint Commission The Joint Commission accredits hospitals Scope expanded by 1987 to include: HMO’s Nursing Homes Ambulatory Care New Emphasis: PrePre-admission and concurrent review Focus on variations: October 19, 2010 AHS 330 - Fall 2010 - Unit 7 55 National Committee on Quality Assurance (NCQA) 57 AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 58 CAHPS – Consumer Assessment of Healthcare Providers and Systems Consumer Assessment of Healthcare Providers and Systems (CAHPS) program (CAHPS) is a public-private initiative to develop publicstandardized surveys of patients experiences standardized surveys of patients' experiences with with ambulatory and facility-level care facilityConsumers and patients are the best and/or only source of information. Consumers and patients have identified them as being important. October October 19, 2010 Effectiveness of Care Access/Availability of Care Satisfaction With the Experience of Care (uses CAHPS) Health Plan Stability Use of Service Cost of Care Health Plan Descriptive Information October 19, 2010 CAHPS 56 HEDIS: Health Plan Employer Data and Information Set Measures (Largely Process Measures): Ratings: Excellent, Commendable, Accredited, Provisional, Denied AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 HEDIS Access and Service and Service Qualified Providers Staying Healthy Getting better Living with illness October 19, 2010 Education to communicate desirable processes and outcomes STRUCTURE, PROCESS and OUTCOMES October 19, 2010 Accreditation Body for Managed Care Organizations Accreditation (HMO and PPPO) based on: a) Care delivery b) Outcomes 59 Core Survey Enrollment/Coverage Access Global Rating Utilization How well Doctors Communicate Health Status Screeners for Chronic Conditions Demographics October October 19, 2010 Supplements Chronic Conditions Cost Sharing Personal Doctor Prescription Drugs Quality of Care Access to Routine Care Access to Specialist Care After Hours Care Calls to Personal Doctor’s Office Coordination of Care from Other Health Providers AHS 330 - Fall 2010 - Unit 7 60 10 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Provider October 19, 2010 •HEDIS •Medicare Health Outcomes Survey •CAHPS •Subset of HEDIS (in testing phase) •National Data Bank of Practitioners •CAHPS •Peer Review Organizations (PRO) •US News and World Report •Hospital Core Performance Measure Physicians Hospitals Most agree that quality is important However, how do you measure it? Cost vs. Quality 63 Penalize for poor quality or incentivize for high quality Provider Attitudes Towards Quality Provider Attitudes Towards Quality Assessment Assessment •CAHPS AHS 330 - Fall 2010 - Unit 7 62 Carrot or the Stick Set: (Being tested for Medicare) •CAHPS General Beneficiary Based October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Quality of Care Policy Issues Initiative MCO 61 Efforts to reduce costs may adversely impact quality October 19, 2010 AHS 330 - Fall 2010 - Unit 7 64 Pay for Performance (P4P) The carrot method for hospitals and providers Incentive payment based on quality measures Goal is to improve quality and avoid unnecessary costs Medicare 2% bonus for hospitals in top 10%, 1% bonus for hospitals in next highest 10%, based on 34 measures Source: CMS, 2008; http://www.hospitalcompare.hhs.gov/Hospital/Search/compareHospitals.asp October 19, 2010 AHS 330 - Fall 2010 - Unit 7 65 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 66 11 Cost vs. Quality Criteria for Never Events “Unambiguous— “Unambiguous—clearly identifiable and measurable, and thus feasible to include in a reporting system; Usually preventable—recognizing that some events are preventable— not always avoidable, given the complexity of health care; Serious—resulting in death or loss of a body part, disability, or more than transient loss of a body function; and Any of the following: Adverse and/or, Indicative of a problem in a health care facility’s safety systems and/or, Important for public credibility or public accountability.” Directly quoted from CMS at http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 67 October 19, 2010 Access Quality AHS 330 - Fall 2010 - Unit 7 Can You Predict Utilization? Forecasting Models Andersen Rosenstock Determine whether demand equals need Assists in the planning and marketing of services services Includes not only access, but also Chap. 2 (pp. 26 – 43, PLB) October 19, 2010 68 Utilization of Medical Services – Why Are We Interested ? Utilization in Health Care Cost AHS 330 - Fall 2010 - Unit 7 69 What types of care are accessed? With what frequency? Under what circumstances? October 19, 2010 AHS 330 - Fall 2010 - Unit 7 70 Rosenstock’s Model Four factors that predict use: 1. Perceived susceptibility to disease 2. Perceived threat of the disease Perceived threat of the disease 3. Belief in the benefit of action 4. Cues to action: * Environmental * Social Trends * Reminders 12 Rosenstock’s Health Belief Model October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Andersen’s Expanded Health Behavior Model 73 October 19, 2010 Andersen’s Expanded Health Behavior Model Technology Norms Resources Organization Individual Determinants Predisposing, Enabling, Illness Level AHS 330 - Fall 2010 - Unit 7 75 Societal Determinant: Technology More births and deaths occur in hospitals as compared with 100 years ago Technology Type, Site, Purpose, Time Interval October 19, 2010 Norms: Formal legislation as well as growing consensus of beliefs and homogeneity of values which pervade the society Health Services Utilization 74 Andersen: Societal Determinants Health Services System Societal Determinants AHS 330 - Fall 2010 - Unit 7 Asepsis and anesthesia made surgery a much more viable option, thus increasing utilization October 19, 2010 AHS 330 - Fall 2010 - Unit 7 76 Societal Determinant: Technology In the last century, better public health (an example of technology) decreased the prevalence in infectious diseases. October 19, 2010 AHS 330 - Fall 2010 - Unit 7 77 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 78 13 Societal Determinants: Norms Societal Societal Determinants: Tech and Norms Number of Inpatient Days in Psychiatric Hospitals Fewer inpatients in mental hospitals over the past 40+ years www.hcup-us.ahrq.gov/.../facts_figures_2006.jsp October 19, 2010 AHS 330 - Fall 2010 - Unit 7 79 October 19, 2010 Andersen: Health Services System Health Services System Resources Resources – labor and capital Organization Distribution Access Structure AHS 330 - Fall 2010 - Unit 7 81 Volume - number Distribution geographic Distribution - geographic Organization – what the system does with its resources October 19, 2010 Access – how patients get into the system Structure – the characteristics of the system October 19, 2010 Small Area Variation (SAV) AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 82 Causes of SAV Attributed to John Wennberg Studied patterns of care among similar populations mostly in the northeast US populations, mostly in the northeast US. Rate of tonsillectomies in 2 NE Counties Inpatient use by older adults higher in New Haven (Yale) than in East Boston (Harvard) October 19, 2010 80 Andersen: Health Services System Volume AHS 330 - Fall 2010 - Unit 7 83 Scientific Uncertainty Practice Style Differences in Incidence and Prevalence of Differences in Incidence and Prevalence of Disease Disease Differences in SES/Ethnicity Supply of Health Care Resources Available October October 19, 2010 AHS 330 - Fall 2010 - Unit 7 84 14 Average Length of Stay by Region U.S. 1998 5.9 Andersen’s Behavioral Model of Health Services Utilization (1968) 5.8 5.7 days 5.5 5 .3 5 .1 5.1 4.9 4.7 4.7 4.6 4.5 northeast midwest south west region Predisposing Factors--variables that describe Factors--variables ones propensity to use health care services Enabling Factors--variables that describe the Factors--variables means available to an individual for use of health care services Need— Need—illness level - most important determinant of use Source: Statistical Abstract of the United States, table no. 1999 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 85 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 86 Individual Determinants of Health Service Utilization Predisposing Enabling Demographic Age, Sex Marital Status Past Illness Family Community Income, Health Insurance, Type of Regular Source, Access to Regular Source Illness Level: Need Predisposing Factors Perceived Disability, Symptoms Diagnosis General State Community Education, Race, Occupation, Family Size, Ethnicity, Religion, Residential Mobility Beliefs Values Concerning Health & illness, Attitudes Toward Health Services, Knowledge about Disease October 19, 2010 Ratios of Health Personnel and facilities to Population; Price of Health Services; Region of Country; Urban/Rural Evaluated Symptoms Diagnosis AHS 330 - Fall 2010 - Unit 7 87 AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 88 Predisposing Factors: Gender Predisposing Factors: Age October 19, 2010 October 19, 2010 89 http://www.cdc.gov/nchs/data/nhsr/nhsr005.pdf October 19, 2010 AHS 330 - Fall 2010 - Unit 7 90 15 Predisposing Factors: Race Predisposing Factors: Race Physician office visits per 100 persons by race 1998 indian/eskimo/Aleut race asian/pacific islander black white physician offices 0 100 200 300 400 visits per 100 Source: Statistical Abstract of the United States 2001, table no. 191 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 91 October 19, 2010 Enabling Factors: Children AHS 330 - Fall 2010 - Unit 7 92 1996 Enabling Factors: Race mchb.hrsa.gov/CHSCN/pages/needs.htm October 19, 2010 AHS 330 - Fall 2010 - Unit 7 93 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 94 Enabling Factors: Insurance Status Enabling Factors: Income October 19, 2010 AHS 330 - Fall 2010 - Unit 7 95 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 96 16 Enabling Factors: Insurance Status October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Need for Health Services: Health Status, Income, and Race 97 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 98 Need for Health Services: Health Status Andersen: Characteristics of Utilization Type, Site/Location Purpose – primary vs. secondary vs. tertiary care; tertiary care; Time Interval of Use October 19, 2010 AHS 330 - Fall 2010 - Unit 7 99 How do we measure utilization? Type or Site/Location Hospital Physician Drugs and Medications Dentist Nursing Home Other Purpose October 19, 2010 October 19, 2010 100 Access Cost Contact Volume Episodic Care AHS 330 - Fall 2010 - Unit 7 AHS 330 - Fall 2010 - Unit 7 Access to Health Care Services Primary Care Secondary Care Tertiary Care Custodial Care Ca Unit of Analysis Contact Volume Frequency Quality Chap. 3, PLB 101 October 19, 2010 AHS 330 - Fall 2010 - Unit 7 102 17 Defining Access Access to Health Care Few industrialized countries outside of the U.S. do not have universal access to health care services We have the “right” to emergency care Elderly have the “right” to Medicare services Penchansky and Thomas (1981): the measure of fit between characteristics of providers and health services, and characteristics and expectations of clients characteristics and expectations of clients, incorporating five reasonably distinct dimensions: October 19, 2010 AHS 330 - Fall 2010 - Unit 7 103 Iron Triangle & Dimensions to Access Availability, accessibility, accommodation, affordability, and acceptability October 19, 2010 AHS 330 - Fall 2010 - Unit 7 104 Factors Affecting Access to Health Services Increasing access will decrease costs (and possibly expenditures) Limited access may decrease quality October 19, 2010 AHS 330 - Fall 2010 - Unit 7 Financial Access to Health Care Services: Private Health Insurance Among Persons, AGE & GENDER 105 Financial Access to Health Care Services: Private Health Insurance Among Persons, RACE & ETHNICITY 18 Financial Access to Health Care Services: Private Health Insurance Among Persons, POVERTY STATUS Financial Access to Health Care Services Private Health Insurance Obtained Through the Workplace, AGE & GENDER Most people under < 65 get insurance through their employer HIPAA: Health Insurance and Portability and Accountability Act – helped people keep their insurance after they leave a job FINANCIAL ACCESS TO HEALTH CARE SERVICES: Private Health Insurance Obtained Through the Workplace, RACE RACE & ETHNICITY Health Insurance Coverage, All Ages FINANCIAL ACCESS TO HEALTH CARE SERVICES: Private Health Insurance Obtained Through the Workplace, Federal Poverty Level Comparison of Medicare and Medicaid Programs 19 Government Sponsored Programs: VA Expenditures for Health Care Government Sponsored Health Care Services Inmates in State or Federal Prisons and Local Jails by Gender, Race, and Ethnicity, 2006 Health care for veterans 153 hospitals and 895 outpatient clinics $33.8B/year in expenditures Other government care: DOD, Tricare POTENTIAL ISSUES WITH REDUCED ACCESS Reduced Access to Medical Care During the Previous 12 Months Because of Cost, by Selected Characteristics THE UNINSURED No Health Insurance Coverage Among Persons Age Age Group and Gender 96% of those > 65 have access through Medicare 84% of those < 65 have access through private insurance, government provider, or some other source THE UNINSURED No Health Insurance Coverage Among Persons Race/Ethnicity THE UNINSURED No Health Insurance Coverage Among Persons By Federal Poverty Level (FPL) (FPL) 20 Initiatives to Expand Coverage Reasons for Lack of Insurance Employment (or employer) Choice – healthy and/or young High costs High costs – both self-insured and through self insured and through employment employment Demographic and SES characteristics October 19, 2010 AHS 330 - Fall 2010 - Unit 7 121 Expand Medicare Expand Medicaid TennCare failure SCHIP’s successes SingleSingle-payer system Health reform! October 19, 2010 DISPARITIES IN ACCESS AHS 330 - Fall 2010 - Unit 7 122 NEXT NEXT WEEK 2006 National Healthcare Disparities Report Unit 8 & Review Unit 7 Unit 7 Quiz Multiple Choice and True/False Questions Covering Assigned Textbook Chapter, Unit 6 PowerPoint Slides, & Lecture Unit 7 Discussion Question Comment on a 200 word discussion question and post a 50 word response to another student’s blog October 12, 2010 AHS 330 - Unit 6 - Fall 2010 124 21 ...
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