pristineliving
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4 years ago Reflection by Tianran
It was surprising for me to realize that the assessment of some measures on hospital performance could actually discourage clinicians and lead to more conservative decisions. For instance, a hospital may have worse rank if its clinicians accept patients with more severe and complicated symptoms. If the patients have medical complications and fragile health status, the insurance company may not fund the hospital well enough for bad health outcomes (e.g., too fast re-admission or death). In this case, the brutal rank may not benefit the improvement of the overall/national health outcome. We might run out of sufficient clinical data if pioneering treatments and surgeries have insufficient funding from the hospitals or the insurance companies. The clinicians might also encounter disagreement with risky yet potentially life-saving decisions from colleagues or supervisors if their success or failure in surgeries or treatment could cause a worse rank in the market. As a potential patient, I think improper ranking is worse than no ranking at all. Regarding issue of funding, one possible way out (from my limited perspective) is to analyze chronic diseases and acute/emergent cases differently. Meanwhile, we could have strategies on saving costs for chronic disease management so that ER and cancer departments have more freedom to deal with costly interventions. Improving healthcare quality not only needs efficient collaboration within the hospital from all departments but also calls for support and understanding from the entire society.
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1. Healthcare Cost and Financing
For the healthcare cost and financing part, different modes of paying for healthcare are mentioned, methods of payment for health care providers and payment reform is discussed, the relationship between health care costs and outcomes is presented, and ways to control health care costs are introduced.
1.1 Paying for healthcare
Paying for healthcare can be managed in one of the four following modes: out-of-pocket payment, individual private insurance, employment-based group private insurance, and government financing. Where out-of-pocket payment is a payment paid directly from patient to healthcare provider, the flow of payment for individual private insurance, employment-based group private insurance, and government financing all involve a third party. The payment would first flow from individual/group to health care insurance, and later from health care insurance to healthcare provider. Employment-based health insurance is paid by employers but also subsidized by the government through tax reduction. Government financing includes Medicare and Medicaid, enacted in 1965, for two populations often not covered by employment-based health insurance: the elderly and the poor. The Patient Protection and Affordable Care Act, also known as the Affordable Care Act, PPACA, ACA, Obamacare, enacted in 2010, resulted in a major transform of healthcare after Medicare and Medicaid.
1.2 Payment to health care providers
Methods of payment include fee-for-service payment, payment by an episode of illness, per diem payments to hospitals, capitation payment, and payment for all services delivered to all patients within a certain time period. These payments differ by units, that is, they are payments to physicians or hospitals for a patient's care per visit or procedure, per illness, per day, per month or year, per time period for patients collectively. Managed care plans are used to control costs, including fee-for-service practice with utilization review, preferred provider organizations (PPOs), and health maintenance organizations (HMOs). Payment reform in recent years aims to transform a traditionally fee-for-service payment to a value-based payment, which includes pay-for-performance, bundled payments, care coordination payments, Accountable Care Organization (ACO) payments.
1.3 Relationship between health care costs and outcomes
The relationship between health care costs and health outcomes is not a linear one. Initially, higher health care costs result in better health outcomes. However, after passing a certain point, increasing health care costs no longer have a large effect on better health outcomes. The curve for these two relationships is steeper in the beginning but begins to become flatter over a certain point. To shift the curve to achieve a better outcome with equal health care costs would require healthcare with higher efficiency. There are many ways to control for costs, some are painless, others are painful and include tradeoffs. Cost controlling strategies include controlling price inflation, eliminating ineffective and inappropriate care, reducing administrative waste, innovation and cost savings, prevention, and prioritization and analysis of cost-effectiveness.
1.4 Cost-control strategies
The flow of money is divided into two parts, financing and payment, and both of them can be targeted for cost-control. Financing is where the money flows from individuals/groups to health insurance plans, and payment is where the money flows from a health insurance plan to health care providers. Financing controls include regulatory and competitive strategies. Payment controls include price controls and utilization (quantity) controls, where price controls include regulatory and competitive controls, and utilization controls include aggregate units of payment, patient cost-sharing, utilization management, and supply limits.
2. Healthcare Quality
The factors causing an unsatisfactory healthcare quality include medical errors with or without negligence, overuse or underuse of medical services, and systematic errors at the hospital. We may find the solutions to improvement of healthcare quality if we could develop methods to standardize the medical procedures with proper guidelines and evaluate the performance of hospitals to reveal risk factors that decrease hospitals' healthcare quality.
2.1 Current Reasons Why Healthcare Quality Could Be Poor
2.1.1 Medical Errors
Fatal medical errors caused by medical injury and deficiency of disease management had occurred at a moderate rate during medical procedures and influenced the overall quality of healthcare. The errors are classified based on whether or not it was caused by medical negligence. The issues regarding negligence are associated with the competency of health care providers: patients need appropriate care or treatment from health practitioners with the necessary training. For instance, it is dangerous for general surgeons to deal with facial wounds that require a plastic surgeon’s professions. It is also critical for health practitioners to clarify prior allergies, comorbidity, and medical histories with the patients before the prescription. However, not all errors are avoidable by mechanical control of negligence. The unexpected or unmeasurable acute allergies after the first exposure to the treatment, wound infection, severe drug reaction, and the misdiagnosis of false-negative are hard to track down to their origins thus hard to improve accordingly.
2.1.2 Misuse of Clinical Services
The Cost-effectiveness of medical care utilization weighs heavily for hospitals. However, both overuse and underuse of healthcare procedures present frequently. The incentive of using health care services such as MRI, CT, and X-Ray sometimes are not necessarily associated with saving costs or increasing the diagnosis accuracy, yet rather the capitation payment with fee-for-service benefit. On the other hand, the lack of insurance coverage, the discrimination to insurances such as Medicaid and Medicare, and the discrepancy of facility availabilities lead to underusing health services for undertreated patients. In some cases, insurance companies will compensate the hospitals if they do not prescribe services and directly discourage service utilization.
2.1.3 Systematic Errors
Systematic errors at hospitals could also lower the quality of healthcare they provide. A practical problem is the nurses’ understaffing which could contribute to higher rates of patients’ mortality. The exhausted nurses may handle procedures incorrectly or even be absent when needed due to the shortage of availability. On the other hand, clinicians may make mistakes for diagnosis which may cause the complication associated with a higher hazard of death during prognosis. The varying factors such as the proficiency of surgery at a certain hospital, the level of support from other departments, and the collaboration of the surgery team may affect the quality of surgery yet remain non-transparent for patients. At the organization level, it is hard to compare and contrast the differences in performance within and between hospitals.
2.2 Possible Solutions and Their Complexity or Vagueness
It is suggested that clinical guidelines could standardize the discrepancy of negligence issues and handling errors to some extent. Education and regulation of standard workflow could ideally minimize the personal errors due to constraints of time and availability. Meanwhile, the EHR-based implementation of clinical decision support in forms of screening reminders, prescription proofreading, and tracking of patient treatment history could enhance the establishment of complete and longitudinal patient profiles and help clinicians keep track of patient records, especially for chronic disease management. Yet the complexity lies when the patient will is opposite to what the clinicians suggest. On the other hand, it was revealed that guidelines’ ties to industries and local bias may restrict hospitals to improve clinical outcomes with help from guidelines. Meanwhile, the quality of guidelines cannot be centrally managed and evaluated efficiently. It seemed that further “standardization for standardized guidelines” will be necessary.
It was also recommended that healthcare practitioners should measure and evaluate the medical outcomes from the hospitals and provide patients with relative ranks for reference. Yet there lie two essential barriers for the patients to make the most out of it. First is that the unmeasurable metrics (e.g., the difference of handling the same problems in different departments/hospitals) and confounders (e.g., the severity of illness, age, sex, and comorbidity vs. mortality rate) may not be properly captured, weighed, or interpreted. Ranking brutally based on the measurable performance of clinicians may not improve the health outcome, or even encourage clinicians to make conservative (yet not necessarily the best) decisions in risky and acute cases. Secondly, the relationships between good outcomes and good procedures sometimes could be unpredicted. For instance, a patient having a clean and successful surgery may have a catastrophic prognosis due to surgical complications. We need a lot of clinical and research data for further analysis before we clearly define any “protocols of performance assessment” to enhance the quality of healthcare with no harm.
3 Healthcare Structure and Workforce
3.1 How Healthcare is Organized
Failures of the US health system to address health problems are not always cases of financial barriers; rather, these cases may be reflections of underlying organizational problems, such as the delivery of primary care or preventative services.
3.1.1 Primary, Secondary, and Tertiary Care
Health systems around the world are organized into three tiers of service: primary care, secondary care, and tertiary care. Primary care addresses common health problems – sore throats, diabetes, arthritis, depression, hypertension – and preventative measures, such as vaccinations and diagnostic tests. 80-90% of visits seek primary care. Secondary care tackles health issues that require specialized clinical expertise. An example of this care might be hospital care for a patient with acute renal failure. Tertiary care is responsible for the management fo rare disorders, such as pituitary tumors or congenital malformations.
There are two contrasting approaches for organizing a health care system that addresses each of these levels of care. First, there is the Dawson model of regionalized healthcare. This is a scaffold for a highly structured system that is based on the concept of regionalization. Here, regionalization refers to the organization and coordination of all health resources and services within a defined area. Different types of personnel and facilities are assigned to distinct tiers at each level (primary, secondary, tertiary). The flow of patients across levels occurs in an orderly, regulated fashion. Under this model, a base of primary care and population orientation is emphasized. A free-flowing model for health care organization gives a more fluid role for caregivers. Patients also move more freely across care levels. Here, the value of services at tertiary care is more emphasized than primary care.
Most health care systems embody elements of both models, but some may gravitate towards one extreme or the other. The US healthcare system as a whole traditionally follows the more dispersed, free-flowing framework, where some large integrated delivery systems resemble the regionalized approach. The British National Health Service (NHS) follows a highly regionalized model, with distinct levels corresponding to specific functions, roles, administrative units, and population levels. Patients move in a step-wise fashion across different tiers and are always seen first by a general practitioner (GP). They may then be steered into more specialized levels via referrals by their GP, but may not directly refer themselves to a specialist. GPs work closely with practice nurses (nurse practitioners), home health visitors, public health nurses, and midwives to provide comprehensive primary care. Teamwork, accountability, and universal coverage are the underlying tools that avert common problems such as missed childhood vaccinations.
The traditional US healthcare organization is much more dispersed, with a far less structured approach to levels. Insured patients are able to refer themselves and enter the system directly at any level. The result of this is that many people in the US are accustomed to taking symptoms directly to the specialist of their choice. A unique aspect of the resulting primary care system is the increased role of internists and pediatricians at the primary level – principally second-tier referral physicians in Europe and the UK. Primary care physicians (PCPs), including family physicians, general internists, and general pediatricians, have also assumed a number of secondary care functions by providing both outpatient and substantial amounts of inpatient care.
Around one-third of all physicians in the US are generalists, well below the 50% mark found in the UK. Physicians at the secondary and tertiary levels in the US fill the gap instead, in some cases acting as PCPs for their patients. Nurse practitioners and physician assistants are also more likely to work in primary care settings, and make up a key component of the clinical workforce.
Hospitals, by this system, are not constrained by rigid secondary and tertiary boundaries. The lack of a pyramidal system – where a large number of hospitals are general community hospitals, with a limited number of tertiary referral centers – has resulted in a structure that more resembles a diamond. Every hospital in the US aspires to offer the latest in specialized care, with several often competing with each other in well-populated areas. Thus, the US sees a small number of hospitals lacking in specialized units, a small number of elite hospitals with super specialized referral services, and the bulk providing a wide range of secondary and tertiary services somewhere in the middle.
Critiques of this system revolve around the 'top heavy' specialist and tertiary care orientation. They highlight the lack of organizational coherence and generally describe the existing health care structure as independent, uncoordinated, fragmented, and uncontrolled in growth and pluralism. The high cost of health care is often attributed in part to this disarray, and in some cases quality of care may suffer. Certainly, mortality rates are higher when many hospitals perform small numbers of surgical procedures, rather than when they are regionalized in a few higher-volume centers.
Defense of the dispersed model maintains that pluralism is a virtue and promotes flexibility and convenience. Advocates for a stronger role of primary care believe it is too important to be considered an afterthought in healthcare planning. In this view, overemphasis of tertiary care creates a system where healthcare resources are not well matched to the prevalence and incidence of health issues in a community. Prevalence of illness generally follows that the majority of the population will suffer from minor ailments, chronic conditions, and behavioral conditions, while the incidence of acute conditions such as cancer will be rare, and very few patients will suffer from complex illnesses (see Figure 3.1.1). This is a very different pattern of disease than is seen from the emergency department or intensive care unit, where distinct subsets of patients are encountered. This breakdown of illness prevalence, however, does not on its own imply most health care resources should be devoted to primary care. Rather, the minority of patients who do require secondary or tertiary care will require a larger share of resources per capita than those who only need primary care.
Figure 3.1.1 Monthly prevalence of illness in the community and the roles of various sources of health care. Each box represents a subgroup of the largest box, which comprises 1,000 persons. Data are for persons of all ages. (Source: Green LA et al. The ecology of medical care revisited. N Engl J Med. 2001;344:2021.)
Three core forces have historically driven the organization of the US healthcare system as we see it today: the biomedical model; financial incentives; and professionalism. The biomedical model of education was introduced early among medical educators. This training consolidated medical education in academically oriented medical schools, and thus the biomedical paradigm was embraced. Under this model, physicians were trained to master pathophysiological changes within a particular organ system. This training gave way to the development of specialization. Advocates for a larger role of generalism have since attempted to broaden the interpretation of professional specialism, calling for a more integrated scientific approach to understanding health and illness. The generalist approach incorporates information about an individual's experiences and family, cultural, and environmental contexts into their diagnoses and care. This approach contributed to the emergence of family medicine in the 1970s as its own specialty discipline.
Financial incentives have primarily propelled physician specialization and hospital expansion. In the early days of insurance, benefits offered by Blue Cross covered hospital costs, but not physician visits or other outpatient services. Physician services were later covered under Blue Shield and other plans, but this disparity created a growing differential in payment between generalist and specialist physicians. Higher fees for new technologic and other hospital procedures were justified given the required time investment from physicians. As these procedures became routine, the fees remained high but the time and effort to perform them declined. Thus, the disparity in income between PCPs and specialists only widened. In the mid-1980s, PCP income was 75% of the average specialist's income. By 2006 this dropped to 50%. The percentage of graduating medical students planning to enter careers in primary care tracks this income gap closely; the proportion is actively decreasing as relative earnings decline.
Professionalism refers to the nature of control over health planning. Unlike many other countries with advanced healthcare systems, the US government is uniquely lax in its public regulation of healthcare resources. The government provides financing for healthcare, but without a perhaps expected significant degree of control. Professional 'sovereignty' of physicians emerged as the preeminent authority in healthcare in its place. Thus, a social contract was created: in return for the privilege of autonomy, physicians bear responsibility for acting as their patients' agents. As professionals, physicians must regulate themselves to preserve public trust. They are vested with special authority to guide the development of the US healthcare system. Thus, their judgment about the need for technology and greater inpatient capacity drove the wide-spread expansion of hospital facilities.