Key Concepts, Chapter 11, The Health Care Delivery System
· Health care planners have always worried about access, quality, and cost of care. Who should get what quality of care at what cost? In 2001, describing a “new health system for the 21st century,” the Institute of Medicine (IOM) called for six outcomes, envisioning a system that is safe, effective, efficient, patient-centered, timely, and equitable.
· Nearly 48 million nonelderly Americans were uninsured in 2011. Decreasing the number of uninsured is a key goal of the 2010 Patient Protection and Affordable Care Act (PPACA), which provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty, beginning in 2014. As of the end of 2015, the number of uninsured nonelderly Americans stood at 28.5 million, a significant reduction. Even under the ACA, many uninsured people site the high cost of insurance as the main reason they lack coverage.
· In 2001, the IOM defined
quality as the degree to which health services for people and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge.
· In 2011, Medicare finalized a plan to alter reimbursements based on the quality of care hospitals provided and patients’ satisfaction during their stays.
· Health care financing involves two streams of money: the collection of money for health care (money going in), and reimbursement of health care providers for health care (money going out). The United States is a multipayer system: its “payers” are both private insurance companies and the government. Distinctive to the United States is the dominance of the private element over the public.
· An IOM Report,
Best Care at Lower Cost, concluded that a substantial proportion of US health care expenditures is wasted, leading to little improvement in health or in the quality of care. The IOM workshop summary,
The Health Care Imperative: Lowering Costs and Improving Outcomes,
estimates excess costs in six domains: unnecessary services, services inefficiently delivered, prices that are too high, excess administrative costs, missed prevention opportunities, and medical fraud.
Compared with the health care systems of six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—the US health care system ranks last or next to last in five dimensions of a high-performance health system: quality, access, efficiency, equity, and healthy lives.
· On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (PPACA), into law. The intent of the law was to expand coverage, control health care costs, and improve the health care delivery system.
· For a long time, health care delivery in the United States has been characterized by fragmentation at the national, state, community, and practice levels. Patients and families navigate unassisted across different providers and care settings, fostering frustrating and dangerous patient experiences.
· Health care delivery systems include health care providers and hospitals, multispecialty practice groups, community health centers, prepaid group practice, accountable care organizations, medical homes, and medical neighborhoods.
· One of the more innovative models of care delivery emerging from the PPACA is the accountable care organization (ACO). This new organizational structure is a departure from the traditional fee-for-service model of reimbursement. In the fee-for-service model, providers are incentivized to do more and more, but not necessarily in a coordinated manner. ACOs turn this model around by offering incentives to provide integrated, well-coordinated care to patients.
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