delivery. b) From the perspective of consumers and financiers,
2. Why should the United States control the rising costs of health care?
• Rising healthcare costs consume greater portions of the total economic output. Since economic
resources are limited, rising healthcare costs mean that Americans have to forgo other goods and
services.
• Insurance coverage insulates consumers from the cost of health care, and there is a tendency to
3. How do findings of the Rand Health Insurance Experiment reinforce the relationship
between growth in third-party reimbursement and increase in healthcare costs? Explain.
Third-party reimbursement shifts the burden of healthcare costs from the patient to the insurer by
4. Explain how, under imperfect market conditions, both prices and quantity of health care
are higher than they would be in a highly competitive market.
In an imperfect market, utilization of health care is driven by need rather than demand.
Utilization is increased when patients are insulated from having to bear the cost of health care.
Providers are able to induce demand to increase their own incomes. Higher utilization means
5. What are some of the reasons for increased healthcare costs attributable to the providers
of medical care?
• Providers in many instances set their own charges, which are higher than what the same
charges would be under free-market conditions.
6. What are some of the main differences between broad cost-containment approaches used
in the United States and those used in countries with national health insurance?
The main approach used in the United States is referred to as the “bottom–up” approach, in
which insurance companies and MCOs compete to provide the most favorable premiums to
employers. MCOs, in turn, try to obtain the most favorable fee arrangements from providers. The
7. Discuss the effectiveness of CON regulation in controlling healthcare expenditures.
The main objective of CON regulation was to put limits on the expansion of facilities through a
state approval process that would allow expansion only if a need was demonstrated for additional
8. Discuss price controls and their effectiveness in controlling healthcare expenditures.
To be successful, regulatory cost-control initiatives must influence the cost of production as well
as the quantity of services utilized. The experience in the United States has shown that price
9. Discuss the role of Quality Improvement Organizations (QIOs) in cost containment.
Peer review organizations emphasize control of utilization. These organizations are charged with
10. What are the four competition-based cost-containment strategies?
a. Demand-side incentives—cost-sharing provides incentives to the consumer to be more cost-
efficient in the selection of a plan and in the utilization of services.
11. What are the implications of access for health and healthcare delivery?
• Access to medical care is one of the key determinants of health status, along with environment,
lifestyle, and heredity factors (Blum’s model).
12. What is the role of enabling and predisposing factors in access to care?
Predisposing and enabling conditions result in some individuals using more medical care
services than others. Predisposing conditions include an individual’s sociodemographic
13. Briefly describe the five dimensions of access.
a. Availability refers to the fit between service capacity and individuals’ requirements. For
example: Are primary and preventive services available to patients? Are enabling services such
b. Accessibility refers to the fit between the location of a provider and the location of patients.
For example: Are services convenient to patients (can the provider location be reached by public
or private transportation)? Is the provider site designed so that disabled or elderly patients are not
e. Acceptability is based on the attitudes of both patients and providers and refers to the
compatibility between patients’ attitudes about the personal and practice characteristics of
providers, and providers’ attitudes about the personal characteristics of the clients. For example:
14. What are the four main types of access described by Anderson?
a. Potential access refers to healthcare system characteristics such as its capacity, organization,
and financing, and enabling characteristics including personal income, insurance status, and
accessibility factors such as transportation.
b. Realized access refers to the type, site, and purpose of health services. The type of utilization
15. Describe the measurement of access at the individual, health plan, and delivery
system levels.
Access indicators at the individual level include (1) measures of medical services utilization
relative to enabling and predisposing factors while controlling for need for care and (2) the
patient’s assessment of the interaction with the provider. Examples include differences in
physician visits by race/ethnicity, gender, age, income, or insurance. Patients’ perceived level of
access is closely related to patient satisfaction with care and is part of the access framework.
At the health plan level, indicators include aspects of plan characteristics that affect access, such
16. What are some of the implications of the definition of quality proposed by the
Institute of Medicine? In what way is the definition incomplete?
The Institute of Medicine (IOM) has defined quality as “the degree to which health services for
individuals and populations increase the likelihood of desired health outcomes and are consistent
17. Discuss the dimensions of quality from the micro- and macro-perspectives.
The micro level is associated with the performance of individual caregivers and healthcare
organizations. The macro level looks at quality from the standpoint of populations. It reflects the
performance of the entire healthcare delivery system. The micro-dimension of healthcare quality
encompasses (1) the clinical aspects of care delivery, (2) the interpersonal aspects of care
18. Discuss the two types of health-related quality of life (HRQL).
Disease-specific quality of life is associated with the potential quality-of-life impacts of a
specific disorder and its treatment. Disease-specific HRQL focuses entirely on impairments that
are due to a specific disorder, and the effects and side effects of treatments for that disorder. For
example, arthritis quality of life is concerned with joint pain and mobility and the side effects of
anti-inflammatory agents; depression quality of life deals with the symptoms of depression (such
19. Distinguish between quality assessment and quality assurance.
Quality Assessment
• Defining quality, setting of standards, and measurement of performance against those standards
• Foundational to quality assurance
20. What are the basic principles of TQM (or CQI)?
TQM encompasses five main elements:
a. Quality is an integrative concept. It must permeate everything that a health delivery
organization does. In other words, it is not simply confined to the delivery of health services to
21. Give a brief description of the Donabedian model of quality.
The Donabedian model consists of three domains in which healthcare quality should be
examined: structure, process, and outcomes. All are equally important in measuring the quality
of care. All three domains are also complementary and should be used collectively to monitor
quality of care. Structure, process, and outcomes are closely linked, and are also hierarchical.
available per 1,000 population; the geographic distribution of physicians, hospitals, and nursing
home beds; and the mix between primary care and specialist physicians. Structural measures
indicate the extent to which healthcare organizations have the capability to provide adequate
levels of care. Hence, structure provides an indirect measure of quality. Process refers to the
actual delivery of health care, including both technical and interpersonal aspects of delivery.
22. Discuss the main developments in process improvement that have occurred in recent
years.
Some of the main developments in process improvement are clinical practice guidelines, cost-
efficiency, critical pathways, and risk management. Clinical practice guidelines are standardized
guidelines based on scientifically established protocols to guide physicians’ clinical decisions.
1.
In terms of health care access, ACA increases access to affordable insurance coverage and
high-quality care, eliminates cost sharing for preventive services, and supports improvements
in primary care and wellness.