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week_1-_lecturepp.pptxMCHM 6301: Health Care Policy Analysis
WEEK 1: Introduction to health care policy, and the key players involved.
WELCOME AND INTRODUCTION
Click the sound icon to hear the introduction and lecture overview.
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Overview
A Look at Health Care Policy by Definition
Determinants of health
Policy analysis
Key issues at the state, local, institutional, provider levels.
Current state of U.S. health care system; how do we evaluate it? (Donabedian’s Model)
The status of Healthcare professions and professionals (Starr’s account)
Definitions of Health
Absence of illness
WHO
“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
The best outcome that medicine can buy
The best outcome that we can afford
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Determinants of Health
Illness care
Preventive care
Mental health care
Oral health care
Social determinants, such as:
Housing
Education
Income
Built environment
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What is health policy?
Health policy addresses the following questions:
Where are we with health care and where do we want to be?
What other alternatives are available here and elsewhere?
How can we get there effectively and efficiently?
What is likely to work given our political process? Given our resources?
Policy Analysis Process
Problem definition
Process definition
Process analysis
Delivery modes and expected impacts
Evaluation
Technological feasibility
Political feasibility
Economic and financial viability
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Some Key Issues to Watch
Relationship between insurance and employment
Status, compensation and autonomy of health professionals
Equity in dealing with underserved populations
Adequate supplies of trained personnel
Responsibility for intellectual property
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Issues to Watch - 2
Democratic processes for reaching difficult health policy decisions
Technology development and dissemination
Impacts of social meta-issues, such as:
Aging
Terrorism
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State and Local Policy Issues
What services to provide under Medicaid?
Use the licensure and insurance regulatory processes to promote adequate supply, increase quality, control costs
Determine role of the public health system
Assure access, especially for uninsured
Emergency response planning & delivery
Deliver mental health services
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Policy Issues for Institutions
How much uncompensated care?
Stance on National Health Information Net
Participation level in emergency services
Role of volunteerism
Whether or not to rationalize local services
Dealing with antitrust issues locally
Building and maintaining quality services and reputation
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Policy Issues for Provider Professionals
Breadth of services to provide
Participation in efforts of professional organizations on reimbursement, licensure, regulation, supply of providers
Should I be in an independent practice or join a large group or institution?
Amount of effort to devote to professional leadership and leadership skills.
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WHERE ARE WE?
When compared to other countries, we find a vast difference in the cost of care in the U.S. making costs of care in the U.S. extremely high. However, the life expectancy in the U.S. is well below that of other countries.
WHERE ARE WE?
US medical error rates –improving
Preventive care getting more attention, but impact of high deductibles unclear
Withdrawal of employer support
Long waits for some for primary care visits
Rapid access to specialists and elective surgery
Lots of repeated tests and unnecessary visits
Considerable inequity in access largely due to inability to pay
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Contrarian Views
Case-specific results are good for a number of cancers and AIDS
Multi-country statistics are not comparable for a number of reasons
U.S. is paying for much of R&D for rest of world
Cost due to lack of patient financial responsibility
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Employment-Based Insurance Seen By Some as the Culprit
Costs went up sharply after Medicare and Medicaid started
Most Americans do not bear the cost consequences of health care decisions
Because someone else is paying, consumers:
Do not demand efficiency
Have not demanded price transparency
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Donabedian Model
Structure Process Outcome
Access
Technical Management
Management of Interpersonal Relationships
Continuity of Care
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Access & Availability
Primary concern in most states – working poor and underinsured
Poor distribution of resources, many pockets of underserved
Racial disparities still abound
Specialists increasing, primary care not
Heavy reliance on immigration of nurses and physicians
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Access
Structure
Pretty good facilities, spotty provider cover
Long waits for primary care in some areas
Process
Dependent on income and/or insurance
Outcome
Very dependent on location and income
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Technical Management
Structure
Good education, but high regional variability
Fairly tight credentialing processes
Process
High level of waste
Limited attempts to optimize approaches
Outcomes
Quality action, but much room to improve
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Interpersonal Relationships
Structure
Reimbursement systems shorten contact time
Process
Patients feel rushed, prevention weakened
Doorknob moments lost
Outcome
Emphasis on patient satisfaction
Not clear whether the providers get feedback
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Continuity of Care
The real casualty in many cases as:
Patients self-refer to triage or for lower costs
People and providers change plans
Was not a concern of Medicaid, changing
Some programs seeing need for case management work on “medical home” concept, but care tends to be diagnosis-related, not oriented to total care
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Complexity
Programs to help needy are incredibly complex and mutually inconsistent
Each program has own eligibility criteria and payment policies
Each state gets different Medicaid reimbursement via complex formula, mostly based on state income.
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State Governments Are Where Action Is
Many states have refused Medicaid expansion and some cut back on alternatives; yet most seem to acknowledge some responsibility for care
ERISA is a barrier to effective state plans because it exempts many major employers from state regulation
Many experiments going on – stay tuned.
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Starr’s Forecast - 1982
Change in ownership and control
Integration into multi-site organizations
Use of holding companies
Vertical integration of stages
Concentration of ownership and control
To what extent have these been happening?
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Professional Issues of Interest
Labor substitution
Outsourcing
Rising educational barriers
Disintermediation
Consumer-centered (also called consumer-driven) care
Incentive systems based on quality, cost, or access.
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Factors Supporting Industrialization
Science replacing art
Concerns about cost and efficiency
Heightened belief in markets
Introduction of information technology
Perceived loss of disinterestedness
Higher education levels of general public
Greater access to information sources
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Medicalization of Society
High proportion of GDP and employment
Continual reminders about health issues
Direct-to-consumer advertising growth
Health-related programs in diverse institutions – workplaces, churches, schools
Reliance on sector for employment growth
Disease mongering
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