Definition of Serious and Complex Medical Conditions (1999) / Chapter Skim
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2 Challenges in Health Care Delivery for Patients with Serious and Complex Medical Conditions
2 Challenges in Health Care Delivery for Patients with Serious and Complex Medical Conditions
Pages 34-42
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From page 34... ...
Rising health care costs, rising consumer expectations, and national efforts to ensure access to care and improve and sustain the quality of health care in the United States are all contributing factors to the need for changes in the traditional health care delivery system. This chapter briefly reviews issues considered by the committee to have relevance to implementation of regulations concerning patients with serious and complex medical conditions.
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From page 35... ...
Quality of care has been defined as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (Institute of Medicine, 1990~. A number of initiatives including the Institute of Medicine's National Roundtable on Health Care Quality and the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry have focused on major sources of compromise in the quality of care delivered to patients (Institute of Medicine, 1999; President's Advisory Commission, 1998b)
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From page 36... ...
Health insurance status has also been cited as a predictor of variations in quality of care, with lack of insurance or inadequate coverage associated with lower quality of care (Aday, 1994; Aday et al., 1993b; Blazer et al., 1995; Brook et al., 1990; Elnicki et al., 1995; Erlich, 1985; Fox and Newacheck, 1990; Frenzen, 1991; Freund and Hurley, 1995; Freund and Lewit, 1993; Gibbons et al., 1991; Hofer and Katz, 1996; Imperiale et al., 1988; Ireys et al., 1996; Lave et al., 1995; Lillie-Blanton et al., 1993, 1996; Newacheck et al., 1996; Riley and Lubitz, 1985, 1986; Rogers, 1993; Rowland and Lyons, 1989; Stano and Folland, 1988; Starfield, 1992; Starfield et al., 1991, 1998; Van Nostrand, 1993; Vayda, 1973; Woolhandler and Himmelstein, 1988~. Provider Characteristics Characteristics of health care providers have also been identified as predictors of variations in quality of care.
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From page 37... ...
A recent meta-analysis of evidence comparing the performance of managed care plans with that of fee-for-service plans examined results from 37 peerreviewed studies (Miller and Luff, 19979. Operationalization of quality-of-care measures included hospital admission rates, patient outcomes, lengths-of-stay, hospital expenditures, use of costly procedures, physician visits, outpatient spending, home health care spending and use, total spending, and enrollee satisfaction.
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From page 38... ...
Current options include traditional indemnity plans, health maintenance organizations, preferred provider organizations, and other types of managed care plans with various options concerning benefits, premiums, copayments, and health care delivery systems (President's Advisory Commission, 1998b)
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From page 39... ...
Other studies have shown that Medicare beneficiaries enrolled in health maintenance organizations are more likely to disenroll when they are less healthy as measured by mortality rates, preenrollment health care costs, and selfreported health status (Hill and Brown, 1999; Riley et al., 1991, 1996; Rossiter et al., 1988; Sullivan, 1990~. In contrast, other studies do not yield support for the premise that vulnerable populations have limited access to specialized services, poor service, greater inconvenience in accessing care, and restricted choice of providers (Aday and Andersen, 1981; Aday et al., 1993a; DesHarnais, 1985; Dowd et al., 1992; Fama et al., 1995; Lust and Miller, 1988; Moy and Hogan, 1993; Newhouse, 1994; Schlesinger and Mechanic, 1993~.
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From page 40... ...
Medicaid reimbursements include nursing home care, intermediate care facilities for persons with mental retardation, home health care, personal care, and home- and community-based services. Medicaid also assumes financial responsibility for reimbursement of both acute and long-term health care services required by persons with disabilities.
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From page 41... ...
The Institute of Medicine Committee on Utilization Management by Third Parties defines utilization management "as a set of techniques used by or on behalf of purchasers of health benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision" (Institute of Medicine, 1989~. Utilization review or management focuses on a single episode of an illness, examines a large number of patients at a low level of intensity, and relies on prior authorization, concurrent review, and retrospective review to evaluate medical necessity (Kellie and Kelly, 1991~.
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From page 42... ...
For example, disease management programs and multidisciplinary teams for care management are used with increasing frequency to improve the efficiency and coordination of care for patients with serious and complex medical conditions. Efforts are also being made to better manage health care costs while ensuring access to quality services through the use of nurses, nurse specialists, and social workers to manage routine health care and respond to needs for ancillary services.
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