605 Health Mngt/Policy (Week 1)

  1. Core Public Health Functions (3)
    • 1. Assessment
    • 2. Policy Development
    • 3. Assurance

    • Assessment: assess health of population
    • -collect, analyze, and disseminate information about community’s health

    • Policy development:
    • -use scientific knowledge to develop strategies to improve population’s health

    • Assurance:
    • -make services available and accessible to everyone
  2. 10 Essential Public Health Services
    1. Research

    • Assessment: 
    • 2. Monitor health
    • 3. Diagnose & Investigate

    • Policy Development:
    • 4. Inform, Educate & Empower
    • 5. Mobilize Community Partnerships
    • 6. Develop Policies

    • Assurance:
    • 7. Enforce Laws
    • 8. Link to/Provide Care
    • 9. Assure Competent Workforce
    • 10. Evaluate
  3. Descriptions of 10 Essential Public Health Services (and examples)
    • Assessment:
    • 1. Monitor Health - monitor health status to identify community health problems
    • -Examples: assess community’s health (surveillance), determine needed services, collect data (vital statistics; disease & injury registries), analyze & disseminate results
    • 2. Diagnose & Investigate - health problems and health hazards in the community
    • -Examples: infectious and chronic disease programs, STD & TB services

    • Policy Development:
    • 3. Inform, Educate, & Empower - people about health issues
    • Examples: Social marketing & media/risk communication; provide health information
    • 4. Mobilize Community Partnerships - to identify and solve health problems
    • -Examples: partnerships & coalitions with community organizations (that are already trusted and can be more effective in the community than the Health Dept); defined plans/projects to improve health
    • 5. Develop Policies - and plans that support individual and community health efforts
    • Examples: develop policy & legislation (e.g. smoking, pollution, nutrition, etc.); track measurable health objectives in community

    • Assurance:
    • 6. Enforce Laws - and regulations that protect health and ensure safety
    • -Examples: Enforce housing, food quality, sanitation, & clean air laws; protect water supply
    • 7. Link to/Provide Care - link people to needed personal health service and assure the provision of health care when otherwise unavailable
    • -Examples: Provide culturally & linguistically appropriate materials and staff; transportation services; PH clinics (provider of last resort)
    • 8. Assure Competent Workforce - competent public and personal healthcare workforce
    • -Examples: training & continuing education programs; licensure of health professionals
    • 9. Evaluate - effectiveness, accessibility, and quality of personal and population-based services
    • Examples: evaluation of health programs to assess effectiveness

    • 10. Research - for new insights and innovative solutions to health problems
    • -Examples: new research to identify evidence-based best practices (e.g. Task Force on Community Preventive Services); partnerships with universities to conduct health services research
  4. Health care spending accounts for what percent of GDP?
    Over 17%
  5. Percent of population with employer-based health insurance (private)
    -a benefit and a downside of this type of insurance
    >60% of people have employer-based health insurance (private)

    • Pro: not taxable
    • Con: not transportable (can't take it with you if you change jobs)
  6. Patient Protection and Affordable Care Act (full name)
    -when was the legislation passed?
  7. Broad Goals of Affordable Care Act (ACA)
    1. Expand health insurance coverage - reduce number of uninsured

    2. Improve coverage for those with health insurance - insurance reforms (e.g. can't deny coverage for pre-existing conditions, can't rescind policy when ill, etc.)

    3. Improve quality of health care

    4. Control rising health care costs
  8. ACA provisions to insure more people:
    • -Expand Medicaid eligibility 
    • -New state insurance exchanges
    • -Insurance mandates (or pay penalty) - for individuals and employers
    • -Children <26 y.o. remain on parent's policy
  9. Managed Care
    -3 points
    -description of contractual arrangement
    • Managed care is the dominant health care delivery system in the U.S. today. It is a system that:
    • 1. seeks to achieve efficiency by integrating the basic functions of health care delivery
    • 2. employs mechanisms to control (manage) utilization of medical services
    • 3. determines the price at which the services are purchased, and consequently, how much providers get paid

    • Contractual arrangement: between the MCO and the enrollee (member) is referred to as the "health plan" (covers the services to which the enrollee is entitled) 
    • -Employer finances the care by purchasing a plan from an MCO > the MCO is responsible for negotiating with providers
    • -Providers typically paid through a capitation (per head) arrangement or via a discounted fee arrangement
  10. 4 key functions necessary for the delivery of health services within a managed care environment:
    • 1. Financing (employers, Medicare, Medicaid, individuals)
    • 2. Insurance (insurance companies)
    • 3. Delivery (providers - physicians, hospitals, nursing homes, medical equipment vendors, community health centers)
    • 4. Payment (capitation or discounts - paid by insurance companies or third-party claims processors)
  11. 3 Focuses of Veterans Administration (VA)
    • 1. Hospital care
    • 2. Mental health services
    • 3. Long-term care

    (available to retired veterans with priority given to those who are disabled)
  12. Medicare
    -who is eligible 
    -coverage offered
    Eligible: elderly, disabled, end-stage renal disease

    Coverage: hospital care, post-discharge nursing care, hospice care, outpatient services, prescription drugs
  13. Medicaid
    Eligibility: low income adults, children, the elderly, and individuals with disability

    • *3rd largest source of health insurance in the country
    • *largest provider of long-term care to older Americans and individuals with disabilities
  14. Children's Health Insurance Program (CHIP)
    -When was it created and why
    -What does it cover
    • Created in 1997 to provide insurance to children in uninsured families. The program expanded coverage to children in families who have modest incomes but do not qualify for Medicaid. 
    • -Pays for children's physician visits, immunizations, hospitalizations, ER visits
  15. Integrated Delivery Systems (IDSs)
    -What is it?
    -Major participants?
    • An IDS represents various forms of ownership and other strategic linkages among hospitals, physicians, and insurers.
    • -Can be defined as a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of that population

    Objective: to have one health care organization deliver a range of services

    Major participants: physicians, hospitals, insurers

    *Cost-effectiveness is negligible, but clinical quality performance is significantly improved with IDSs (possibly due to better communication between providers)
  16. Long-term care (LTC)
    -What government program covers LTC?
    • LTC consists of medical and non-medical care that is provided to individuals who are chronically ill or who have a disability. 
    • -health care + support services for daily living
    • -delivered across a wide variety of venues (pt homes, assisted living facilities, nursing homes)
    • -family members and friends provide the majority of LTC services

    • *Medicare does NOT cover LTC
    • *Medicaid covers several different levels of LTC services but a person must be an indigent to qualify
  17. Main characteristics of U.S. health care system
    • -No central governing agency and little integration and coordination
    • -Technology-driven delivery system focusing on acute care
    • -High in cost, unequal in access, and average in outcome
    • -Delivery of health care under imperfect market conditions
    • -Government as subsidiary to the private sector
    • -Fusion of market justice and social justice
    • -Multiple players and balance of power
    • -Quest for integration and accountability
    • -Access to health care services selectively based on insurance coverage
    • -Legal risks influence practice behaviors
  18. Financing in U.S. healthcare system
    -% private vs. % government pays towards total health care expenditures
    Private financing (predominately through employers): 54% of total health care expenditures 

    Public financing (government): 46% of total health care expenditures
  19. -Item-based pricing
    -Package Pricing
    Item-based pricing: Refers to the costs of ancillary services that often accompany major procedures such as surgery (hard to anticipate how much these costs will come to - cost of anesthesiologists, pathologists, hospital supplies, etc.)

    Package pricing: covers services that are bundled together for one episode of care

    Capitation: covers all services an enrollee may need during an entire year
  20. Market justice vs. Social Justice
    • Market justice: places the responsibility for fair distribution of health care on market forces in a free economy
    • -medical care and its benefits are distributed on the basis of people's willingness and ability to pay

    • Social justice: emphasizes the well-being of the community over that of the individual
    • -the inability to obtain medical services because of the lack of financial resources is considered unjust

    *In a system that blends public and private resources, the two theories often work together, but the contrasts between the theories can create conflicts (people that can't afford insurance but don't qualify for government programs)
  21. The Emergency Medical Treatment and Labor Act of 1986
    Requires screening and evaluation of every patient, provision of necessary stabilizing treatment, and hospital admission when necessary, regardless of ability to pay.

    (Unfortunately, the inappropriate use of EDs results in cost-shifting, making it more expensive for those who can pay.)
  22. The main outcome criteria for evaluating the success of a health care delivery system (3)
    • -Access
    • -Cost
    • -Quality
Card Set
605 Health Mngt/Policy (Week 1)
605 key points from lecture 1