Cost, Quality, and Access Dilemmas in Healthcare - Case Study Example

Running Head: COST/QUALITY/ACCESS DILEMMA IN HEALTHCARE Cost/Quality/Access Dilemma in Healthcare Salem Said Al-Touby University of Phoenix Course: DHA 724 Instructor: Dr. Becky Brown Table of Contents Goals in Each Area 3 Areas of Higher Priorities 4 Extent of the Problem of Access, Cost, and Quality of Care 5 Solving Quality Access Cost Dilemma 8 Conclusion 10 References 12 Appendix A 14 Cost/Quality/Access Dilemma in Healthcare Health care purchasers are in a unique position to effect change and to guide the attempts to hold health care professionals responsible for giving and providing suitable and effective medical options. The paper discusses health care consumers must set the health care professionals responsible for the higher costs and the bad quality in health care. This paper evaluates how the United States and Oman are addressing the cost/quality/access dilemma. Goals in Each Area Cost is explained in a variety of studies inventoried as fixed cost per patient, cost for each patient day, net patient revenues, cost for each case, efficiency, profitability, mark up, or surplus. Cost presentation also comprises economic competence, price competence, and efficiency. (Davis, Schoen, Guterman, Shih, Schoenbaum, & Weinbaum, 2005). For idea of this systematic evaluation lower costs or better cost-efficiency were implicit to be favorable to higher costs. Quality is defined in quite a few different crossways studies. It includes lower unpleasant event rates, lower death rates, lower rebelliousness notification, lower disenrollment rates, a broader collection of services, a full range of health care, more patient teaching, or a higher Health Plan Employer Data and Information Set (HEDIS) gain from the National Committee for Quality Assurance (NCQA) (Davis. et al, 2005). Because inferior quality HMOs have been established to expend more on administration and less on definite medical care, a privileged medical failure ratio is taken to be a pointer of higher quality, though this is notorious (Cylus, 2007). Higher quality is implicit better to lower quality and to correspond to better performance. Access to care is typically alarmed with whether or not a supplier takes on their reasonable share of Medicaid and Medicare patients, and further more costly patients and cure. Access to health care is clear, as being able to get hold of “needed and successful health care services . . . despite of . . . health settings, dangers, or ability to pay”. A definition of donations care is not as simple, because some studies think charity care to be any voluntary services offered with uncompensated care (Cylus & Anderson, 2007, p.14). Others eliminate these, while keeping a definite definition. Relatively bigger access and more donations care are taken as favored and assumed to signify better performance. Areas of Higher Priorities The Regional Health System Observatory (2006) states that between 1970 and 1980 saw a manifestation of significant development in Omani healthcare system. One can get the modern history of the country Al Bulushi & West (2006) which states that the Sultan came to power in 23rd of July 1970 and part of the accomplishment in the decade from 1970 to 1980 is that the Sultan instituted the Ministry of Health and gave the citizens assurance of access to free medical services as a fundamental right. Growing proof indicates that the American health system falls undersized compared with other industrialized and developing countries, according to the Commonwealth Fund Commission on a High Performance Health System (The Commonwealth Fund, 2006). Even though the national health cost is considerably higher than the usual rate of other industrialized countries, the United States is the only nation that did not succeed to promise universal health insurance and treatment is deteriorating, leaving millions without reasonable access to definitive and necessary health care, the commission explained. Quality of care is extremely variable and brought by a system that is too often badly synchronized, lashing up costs and placing patients at danger (Schoen, Collins, Kriss, & Doty, 2007). The commission has created a National Scorecard on U.S. Health System Performance, which offers benchmarks for the countries and an instrument for monitoring modification over time crossways middle health care system goals of health results, quality, access, efficiency and equity (Appendix A). Extent of the Problem of Access, Cost, and Quality of Care Current health care initiatives focus on providing broader access to health care. The Oman healthcare system ensures that all citizens receive access to free healthcare. (Davis et al., 2007). Healthcare's benefits are somewhat less extensive than the norm for American private insurance (though perhaps, as healthcare adds a drug benefit and private employers reduce theirs, the gap will narrow). Other countries' coverage also tends to be more extensive. A number of countries only cover pharmaceuticals for some populations, but even then, as in the Oman., coverage for the elderly population tends to be more extensive than healthcare's promised drug coverage for U.S. elders. (Davis et al., 2007) Many countries have meaningful cost-sharing whereby the patient pays a portion of the bill; what’s truly abnormal is not the ostensible 20-percent co-payment under parts of healthcare but the fact that U.S. prices are so high and providers are allowed to game some rates, effectively raising the amount paid by the consumer. In Oman, there has been a dismantling of what was thought to be "the unique Omann settlement", involving restrictions on social expenditures, the development of market-like approaches, the vilification of dependence and the assertion of the obligations of people who access social welfare. As with a number of countries around the world, Oman is looking at American care management strategies to assist in containing costs and improving access to services. And, predictably, in the US, the recent programme of welfare reform represents a move even further away from a sense of community responsibility for responding to social needs. Other major differences include health and welfare systems. (Cantor, Schoen, Belloff , How, & McCarthy, 2007). These "consumer choice" proposals are favored by many. The proponents of health care reform sometimes muddy the debate by suggesting that their favored option, be it managed competition or one payer or something else, is necessary for giving everyone access to health care (Collins, Schoen, Davis, Gauthier, & Schoenbaum, 2007). That is incorrect. Access does not require managed competition or any other reform. It requires only that the unemployed, self-employed, poor, and sick be provided with the money to obtain the health care services they need. The society is able to decide whether it wants to spend the considerable sums required to achieve this important goal. But that is quite a different issue from the public policy decision of how to control the costs of the health care system. A variety of other factors such as economic pressures, geopolitical change and demographic shifts, can create new challenges for hospital management. In Oman's publicly funded health care system, public policy and economic conditions bear directly on hospitals. In recent times the experience has been unfavorable, and most Omanian hospitals are counting on continuous quality improvement to maintain progress in health care (Schoen et al., 2007). Without the factor of market competition, discussions of quality improvement in Omanian hospitals tend to focus on service access and customer satisfaction. Americans are becoming much more critical of health care access under their present system, and comparisons between systems in Oman and the U.S. are common (Lindenauer, 2007). Omanian health care professionals are keenly interested in performance and management practice data for purposes of benchmarking. Oman is also benchmarked with similar healthcare systems such as that of Germany that provide Universal healthcare. Continuous quality improvement is not a big item with Germany’s physician-dominated hospitals, however, and is not being applied as a management philosophy in Germany’s uncompetitive health care system. Government regulation controls most personnel practices within each state-run hospital, making it more difficult to introduce new management methods that focus on continuous quality improvement (Schoen et al., 2006). The progress in the European Community unification has not affected German hospitals to the extent it has other industries, but there has been one interesting development -- the emergence of the 'medical tourist', who is an individual who seeks treatment abroad if dissatisfied with services available at home. Greater access for medical tourists may need to be addressed if the current trend continues. Solving Quality Access Cost Dilemma The public hospitals we know today, and their relationship to general practice, are based on an antiquated structure known as 'hierarchical regionalism'. In the 1950s the tertiary hospital formed the backbone of medicine in terms of care delivery, training and research, whereas general practice was in its infancy. (Schoen et al., 2008). Infectious disease was still a major cause of morbidity and if hospitalization was required it was for severe, acute illness or surgery, not the chronic diseases we see today. The position of the public hospital has changed little but the landscape of medicine is vastly different. What is needed now is a strong focus on primary care and preventive medicine, sufficient GPs to provide long term care plans for the chronically ill and high quality residential aged care facilities that can care for the elderly. Public hospitals cannot adequately provide these services. Their focus is on throughput, an overwhelming desire to discharge patients in the shortest possible time to make space for overcrowded emergency rooms. They are not the best places for rehabilitation of the elderly and yet at any one time between 800 to 2000 Omanns are waiting in hospital beds for aged care services. (Schoen, McCarthy, & How, 2008). There is no evidence that such a delegation would reduce hospital quality. Indeed, quality might actually be enhanced: in the absence of a direct federal role in ensuring hospital quality, states would receive considerable political pressure to assume a more active role in monitoring hospitals for licensing purposes. Oman, whose government and healthcare system are largely similar to America's, seems to have had positive results from delegating this regulatory function to its states. And American healthcare consumers are in dire need of some positive news. They cost millions of dollars in hospitalisation of Omanns with chronic disease yet play absolutely no part in the prevention of those same diseases. In political terms state governments in Oman have no incentive to change the way public hospitals work. This is due in part to public and media perceptions of the 'health care crisis' which is vastly different to that of clinicians and bureaucrats. It is indisputable that investing in preventive medicine in political terms state governments in Oman have no incentive to change the way public hospitals work. (Schoen et al., 2007). Conclusion The International Quality Study shows a global concern for quality patient care that is aligning practices in several areas. For example, both the US and Oman are planning to: •Use more information technology in the management of hospital affairs, •Get tougher on supplier quality, •Provide cross-training to employees, •Further restructure the nursing functions and staff structures. Hospital customers include patients, payors, referring physicians and employees. Yet, in both the US and Oman, these customers seldom factor into what services a hospital provides or how a hospital assesses its quality performance. These matters are still locked up in the executive board rooms or the medical chambers. The International Quality Study (IQS) found that Oman and American hospitals intend to involve more customers, especially employees, from all levels of the hospital in the quality movement (Schoen et al., 2008). Quality of patient care and customer satisfaction are capturing higher priority in hospital strategic plans. This emphasis on quality is directly modifying hospital operations and structures according to IQS findings. Yet somewhat ironically, quality management principles are rarely used to communicate these plans to others. The lack of involvement in strategic planning by human resources management is a legitimate cause for concern. This may prove to be a major obstacle for hospital leaders who want to empower employees to participate in cultural change. The IQS also revealed an astonishingly low involvement of hospital trustees in strategic planning. Many contemporary hospital strategies are emphasizing process improvement in their strategic plans, but hospitals are enormously complicated networks of interlinking systems that span patient care and management functions. As the complexity of these systems increases, continuous quality improvement will have to rely on process simplification. Process simplification and improvement can upgrade patient care, increase efficiencies and reduce costs. The idea is to provide for stronger regulations and policies that support consumer choice in healthcare for both Oman and the U.S. References Al Bulushi, H,. & West, D. (2006). Health System Reforms and Community Involvement in Oman. Journal of Health Sciences Management and Public Health. Retrieved January 4, 2010 from http://medportal.ge/eml/publichealth/2006/n1/2.pdf Cantor C.,, Schoen C., Belloff, D., How, H., &McCarthy (2007). Aiming Higher: Results from a State Scorecard on Health System Performance. The Commonwealth Fund Commission on a High Performance Health System, June. Collins R., Schoen, K. Davis, A. K. Gauthier, and S. C. Schoenbaum (2007). A Roadmap to Health Insurance for All: Principles for Reform, The Commonwealth Fund, October Cylus J. and Anderson G. F. (2007). Multinational Comparisons of Health Systems Data, 2006. The Commonwealth Fund, May. Davis K., Schoen C., Guterman S., Shih T., Schoenbaum S. C and Weinbaum I. (2007). Slowing the Growth of U.S. Health Care Expenditures: What Are the Options? The Commonwealth Fund, January. Davis K., Schoenbaum S. C., and A. Audet J., (2005). A 2020 Vision of Patient-Centered Primary Care. Journal of General Internal Medicine 20(10), 953-957. Kahn J. G., Kronick R., Kreger M., Gans and D., (2005). The Cost of Health Insurance Administration in California: Estimates for Insurers, Physicians, and Hospitals. Health Affairs 24(6), 1629-1639. Lindenauer P. K., Remus D., Roman and S. et al., (2007). Public Reporting and Pay for Performance in Hospital Quality Improvement. New England Journal of Medicine 356(5), 486-496. Regional Health System Observatory-EMRO. (2006). Health Systems Profile-Oman, World Health Organization. Retrieved January 10, 2010 from http://gis.emro.who.int/HealthSystemObservatory/PDF/Oman/Full%20Profile.pdf Schoen C., Collins S. R., Kriss J. L., and Doty M. M., (2007). Insured but Not Protected: How Many Adults Were Underinsured Globally. Health Affairs, 37(2), 65-68. Schoen C., Davis K., How S. K. H., and Schoenbaum S. C. (2006). U.S. Health System Performance: A National Scorecard. Health Affairs Web Exclusive: W457–w475. Schoen C., Osborn R., Doty M. M., Bishop M., J. Peugh, and Murukutla N. (2007). Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007. Health Affairs Web Exclusive 26(6), 717-734. Schoen, McCarthy D., and How S. (2008). Why Not the Best? Results from the National Scorecard on U.S. Health System Performance. The Commonwealth Fund. The Commonwealth Fund. (August, 2006).The Commonwealth Fund Commission on a High Performance Health System, Framework for a High Performance Health System for the United States. Appendix A Scores come from ratios that compare the U.S. national average performance with benchmarks, which represent top performance. If performance was uniform for each of the goals, and if, in those instances in which U.S. performance can be compared with other countries. The United States was consistently at the top, the average score would be 100. But, the United States as a whole scores an average of 66. Some major findings include: • Long, Healthy, and Productive Lives: Total Average Score 69. The United States is one-third worse than the best country on mortality from conditions "amenable to health card"--that is, deaths that could have been prevented with timely and effective care. Its infant mortality rate is 7.0 deaths per 1,000 live births, compared with 2.7 in the top three countries. • Quality: Total Average Score 71. Only 49 percent of adults received preventive and screening tests according to guidelines for their age and sex. In addition, the current gap between national average rates of diabetes and blood pressure control and rates achieved by the top 10 percent of health plans translates into an estimated 20,000 to 40,000 preventable deaths and $1 billion to $2 billion in avoidable medical costs. • Access: Total Average Score 67. In 2005, one-third of adults under 65 (61 million) were either underinsured or were uninsured at some time during the year. • Efficiency: Total Average Score 51. As a share of total health expenditures, U.S. insurance administrative costs were more than three times the rates of countries with the most integrated insurance systems. Read More