Austin Holmes

HPM5001 Spring 2010

Professor Markenson
Final Exam

Describe the three major factors driving the change in our health
care system to a more primary care based system.
Due to its reliance on specialty care under an illness model, the U.S.
health care
system has become fragmented, quality has been compromised, and costs
have risen beyond any other country (AAFP, 2010) . This has caused a need
or demand within our country to shift focus to a more primary care system.
Studies have shown that systems reliant upon primary care have better
coordinated care, increases in utilization efficiency, and decrease in over-all
costs (AAFP, 2010). In-fact, states within the U.S. who rely more heavily on
primary care consistently show lower Medicare spending, lower resource and
input utilization and higher quality of care and health outcomes, than their
counterparts.
Studies have also shown that systems relying more heavily on primary
care cause an increase in access to care (AAFP, 2010). Certain
determinants detrimentally influence a person’s ability to access care, and
primary care clinics, including retail clinics and community health clinics,
have given people who would otherwise be unable to access care, the ability
to access care (RAND, 2009). Also, access to care can be as simple as
convenience of location and accommodation of patients needs, which retail
clinics offer. With over a 1,000 locations in department stores (target, wal-
mart, etc), grocery stores, or other locations, retail clinics offer the ability to
walk-in whenever care is needed, and they offer deep discounted prices for
those who do not have insurance or have an insurance they do not accept
(RAND, 2009). Accessing primary care through these clinics has literally
become as easy as shopping.
According to Shi and Singh (2008), Managed Care Organizations
are the single most influential force of change within the U.S. health care
system since the 90’s. As of 2006, over 90% of covered employees (those
who receive their insurance through an employer) were enrolled in a
managed care plan. MCO’s single largest contribution to the shift towards
primary care is the idea of gate keeping. All HMO’s require and some PPO’s
incentivize the use of gate keeping, which is where a PCP must first be seen
and authorization obtained prior to seeing a specialist. In HMO’s especially,
the PCP is the main physician in charge of coordinating the patients care.
Another contribution MCO’s have made to the shift towards primary care
occurred during the 80’s when MCO’s implemented a novel idea; coverage of
preventative check-ups and annual physicals.

Summarize the 4 “A” concepts that are significant to a discussion of

access to care.
 The four significant concepts determining access to care are
accessibility, affordability, accommodation, and acceptability.
Accessibility is the ease of being able to receive care from a health
professional for a disorder or disease (Shi & Sing, 2008). Both geographic
location and types of services influence accessibility (Markenson, 2010). For
instance, a person in a rural community would likely have lower accessibility
to many services taken for granted by those in urban areas; however, rural
individuals may have higher accessibility to some types of services due to
shorter wait times and greater availability in a doctors schedule.

Austin Holmes
HPM5001 Spring 2010
Professor Markenson

Affordability refers to the ability of individuals to pay for needed

medical service (Markenson, 2010). If deductibles, co-insurances and/or co-
payments are too high, access to care will diminish and utilization of care will
decrease in accordance with market theories and supply/demand curves (Shi
& Singh, 2008).
Accommodation is a measure of how well a business adapts its
policies and procedures to the needs of the population and/or its patient
base (Shi & Singh, 2008). For instance, if many of the patients work during
the weekday, a Saturday clinic could be opened to meet the needs of these
patients. An Inflexible schedule reduces accommodation, thus reducing
access to care and inversely, a flexible schedule increases accommodation,
thus increasing access to care.
Acceptability refers to the openness of patients to receive care from
health care professionals. For instance, some patients only like to receive
care by either a male or female provider, or by a provider of a specific race
(Shi & Singh, 2008). Also, wait times, and the doctors ability/desire to explain
the condition are both very influential factors in the patients acceptability of
care being offered (Shi & Singh, 2008).

Identify which government agencies regulate the U.S. emergency

medical system and describe their responsibility.
The emergency medical system can be broken down into two main
categories; normal emergency response and disaster response. There are
agencies at the federal, state and local level to handle these responses, and
in many an agency may be responsible for both type of responses.
At the federal level, there are five (5) main agencies (NHTSA, 2009).
First, the Department of Transportation; National Highway
Transportation Safety Administration Department of Emergency
Medical Service is responsible for creating standards and guidelines for
everyday EMS practice. Most importantly, this department is responsible for
the educational standards for emergency services personnel from first
responders to paramedics and everything in between. Second, the General
Services Administration. deals with federal vehicle standards and is
responsible for all public emergency service vehicles, including ambulances.
Third, the Federal Communications Commission; Public Safety and
Homeland security, is responsible for regulating the communication
equipment used in emergency services vehicle and communication during
disasters. Fourth, the Department of Health and Human Services:
Centers for Disease Control and Prevention plays an advisory rule by
issuing studies related to EMS and published a widely used and accepted as
the gold standard “field triage decision scheme.” They are also responsible
for identifying biological and environmental threats and are responsible for
response to these threats. Lastly, the Department of Health and Human
Services: Office of Public Health Emergency Preparedness (OPHEP)
has the largest role in the regulation and implementation of the day to day
practice of Emergency Medical systems directly through its Emergency Care
Coordination Center (ECCC). It also plays a coordination role during disasters.
Each of the 50 states and the District of Columbia has its own,
independent Health Department (NHTSA, 2009). In fact, within the U.S., the
state health department is the main regulatory body for both normal
emergency response and disaster response. In the event of an emergency,
federal organizations will only assist if asked to by the state. State
departments are
Austin Holmes
HPM5001 Spring 2010
Professor Markenson

also involved in the creation of curriculums and training programs for EMS
personnel within their state and EMS personnel must be licensed to practice
in that particular state. In most cases, licenses are not transferable to other
states, and recertification is necessary if an individual moves to a different
state.
Within the U.S., there are over 150 local EMS agencies and these
agencies are responsible for their communities (NHTSA, 2009). As needed,
they add tailor EMS personnel’s scope of practice to the individual needs of
the community, and in-order to practice within that community, EMS
personnel must also register with the local agency.

The Medicare program (all parts) pays for a significant portion of

health care that is delivered in the USA. Describe who is covered by
this program, its major components how it is financed and
specifically what coverage each part of the program provides.
There are four parts to Medicare; parts A,B,C, and D. In-order for a
person to qualify
for any part of Medicare, they must meet one of the following requirements
as described in the Social Security Act of 1965 (Shi & Singh, 2008); 1). Be
over the age of 65. 2). Be a disabled individual who is entitled to Social
Security Benefits, regardless of age, or 3). Be an individual who has been
diagnosed with an end-stage renal disease.
Part A coverage is a premium-free insurance for in-patient care,
skilled nursing care, home health visits, and many other services. In order to
receive benefits, the beneficiary must have worked and paid taxes in the
U.S. for at least 10 years. If the beneficiary does not qualify for premium-free
coverage, they can pay a small premium for coverage. Part A is primarily
financed through special pay-roll taxes in which both the employee and
employer share equally in. This tax is specific to Medicare and is placed in a
trust fund. A portion of Part A is financed through the deductible, which as of
2007, was $992 per benefit period. A benefit period is defined as the time
between initial hospitalization and 60 care-free consecutive days after being
released from a hospital or SNF. Benefits include a maximum of 90 days in-
patient care and 100 days of SNF care. In order to qualify for SNF coverage,
a beneficiary must have been admitted to the SNF no later than 30 days
after being released from in-patient care (Shi & Singh, 2008).
Part B coverage is voluntary and even if a beneficiary does not qualify
for part A, they can still purchase part B coverage. As of 2007, approximately
75% of Part B was financed through general taxes and the other 25% was
financed through monthly premiums. The standard premium as of 2009 was
$93.50 per month and the annual deductible was $131. A beneficiary must
also pay a co-insurance of 20% of the allowed amount. Part B coverage pays
for many services including; visits to physician offices, outpatient procedures
(including outpatient surgeries), emergency department visits, speech
therapy, physical therapy, and some durable medical supplies (Shi & Singh,
2008).
Part C coverage, or Medicare advantage, was authorized under the
Balanced Budget Act of 1997, and allows private health insurance companies
to offer packaged plans which usually include coverage above and beyond
Parts A and B combined. Depending on the plan, coverage for medication is
also included. When a beneficiary signs up for Medicare part C through a
private insurance company, the government pays the insurance company a
capitated rate and the beneficiary also pays a monthly premium (Shi and
Singh, 2008).
Austin Holmes
HPM5001 Spring 2010
Professor Markenson

Part D coverage is also voluntary, and covers only CMS approved

medications. Anyone who has Part A or Part B can qualify for Part D.
Coverage for Part D is financed primarily through tax revenue, and partially
financed through premiums, payments from states and other non-specified
sources. Beneficiaries pay a premium of $37 per month and a deductible of
$265 per year. Co-payments are dependent on out-of-pocket costs and when
a beneficiary reaches $2,510, they reach coverage gap where they must pay
for 100% of the medication until total out of pocket cost reaches $4,350. At
this point, the beneficiary reaches catastrophic coverage, and is now only
responsible for 5% (Shi & Singh, 2008).

Describe three (3) of the major stakeholders in the health care

system and for each stakeholder identify and discuss three (3)
reasons why they are a stakeholder in the system.
Patients are the driving force and the main reason why the health
care system exists. It is towards them that services are directed and who are
most directly concerned with the quality of care. In-fact, the concern for
quality (Markenson, 2010) has lead to the creation of several
groups/organizations specific for the monitoring of quality. Patients are also
concerned about and directly affected by the cost of health care and have
an incentive to keep health care costs lower (Markenson, 2010). Lastly,
access to care is a major concern for patients (Markenson, 2010). To
increase access to care, patient rights groups have attempted to increase
funding for and expand public health insurance.
The government plays a central role in the regulation, finance and
access to health care (Markenson, 2010). Through regulations at either the
federal or state level, the government is able to control the quality and types
of services provided (Markenson, 2010). This includes the licensing of health
care professionals and creating standards for and monitoring the operation
of hospitals and other health care facilities (Shi & Singh, 2008). The
government is the single largest payor of health services in the U.S. and as
such, has large incentives to decrease expenditures and ensure efficient
utilization of resources (Shi & Singh, 2008). To increase the over-all health of
the community/country, the government must ensure that health services
are accessible. For instance, rural areas are currently experiencing a
shortage in physicians, where as in some urban areas, there is a saturation
of the market. The government has recently proposed incentives to balance
this disparity (Shi & Singh, 2008).
Providers include both individual health professionals and facilities,
such as hospitals, where health services are rendered (Markenson, 2010).
Health facilities and individual providers are both concerned about their
profit margins (Markenson, 2010). Providers are adamantly against any
changes in the system that adversely affect reimbursements and tend to do
procedures or exams that have the higher “pay-out.” Most providers are
concerned with advancing their professional standing /career or increasing
market share (Markenson, 2010). Especially in academics, the way to
accomplish this is by performing studies or creating new treatments. Also a
way for facilities to gain prestige and market share is by sponsoring studies
and creating new technology (Shi & Singh, 2008). Lastly, providers are
interested in regulations that either make it easier for them to practice or
will cost them money to be compliant (Markenson, 2010). For instance, when
HIPAA was created, providers had to spend large amounts of money to
become compliant with the privacy regulations.
Austin Holmes
 HPM5001 Spring 2010
Professor Markenson

Explain three of the aims for improving quality that were addressed
in the IOM report “Crossing the Quality Chasm” which followed the
1999 IOM report “To Err is Human.”
In “Crossing the Quality Chasm”, the Institute of Medicine created six
aims by which
quality of health care delivery within the U.S. could be improved (Stier,
2010). Three will be discussed here.
First, care should be patient centered. Care that is patient centered
focuses on and respects the idea that patients are free-willed individuals able
to make choices for themselves. As such, patients are involved in every
aspect of the management of their condition and are entitled to informed
consent for any and all procedures or tests (Shi & Singh, 2008). Treatments
plans are created with the patients input and tailored to each individual
patient’s needs. In a patient centered environment, questions are never
frowned and a patients desire to educate themselves on their condition is
encouraged (Shi & Singh, 2008).
Second, care should be equitable. There are many factors that
underlie the cause of some people’s inability to access care or the disparity
of care received by those who are able to access care. According to the IOM,
the same level of care should be rendered to any individual regardless of
their socio-economic statues, type of insurance they carry, what race they
are, or which religion they associate themselves with (Stier, 2010). In other
words, care should be blind to all else except the condition present.
Lastly, care should be effective. In other words, did the treatment do
what it was intended to do. Realistically, most conditions will never have a
100% treatment success rate, however understanding the factors causing
variability in outcomes and creating more uniformity in the variables that can
be controlled will lead to more effective treatments (Stier, 2010).

Identify the major elements of the “Pay for Performance” concepts

that are now taking hold in the US health care system. Briefly
discuss what concerns they are designed to address.
Pay for Performance (P4P) is a concept that links the quality of health
care provided with reimbursements paid to the provider (Shi & Singh, 2008).
The idea of quality is hard to define, and though logically health outcome
should be the main measure, this is not necessarily so; rather quality is
defined as doing the right thing, at the right time, the first time (Stier, 2010).
Therefore, even if a patient does not have the intended outcome (getting
better), yet the physician did everything correct at the right time, than the
physician would still be reimbursed under the pay for performance method
(Stier, 2010). Conversely, reimbursements would not be paid to the provider
if medical errors were found, the care did not meet standards set by the
plan, or if unnecessary tests or procedures were done.
 Currently our system in a way rewards mistakes. Extra procedures to
correct errors are fully reimbursed by insurance/MCO companies (Shi &
Singh, 2008). This is turn leads to an increase in health care expenditures
and lower quality of care. As an example, an Ophthalmology practice in the
west coast deals with a retinal detachment in the following way; first, the
patient receives an in clinic treatment that has a success rate of about 40%.
If the first procedure fails, they take the patient to the operating room and
do Vitrectomy (removing the jelly like substance in your eyes) based surgery,
which has a success rate of 80%. If the second procedure fails, they then
take the patient back to the operating room to perform a different type of
procedure, which
Austin Holmes
HPM5001 Spring 2010
Professor Markenson

has a first time success rate of over 90%. Of note, the last procedure has the
lowest reimbursement rate. Under a P4P system, this group would be
penalized for using the above method of treating a retinal detachment and
would only be reimbursed if they used the 90% success rate surgery first.

Briefly discuss whether an individuals level of education is a

determinant of health based on research presented in the course.
According to Arno and Figueroa (2000), if a person is in the lower
distribution of several factors, including education, than their risk of death
between the ages of 25-64 is two to three times higher than a person in the
upper distribution. Unfortunately Arno and Figueroa link educational level
with other determinants of Social-Economic Statues (SES) such as income
level, occupation, and social class, and fail to tease these factors into their
individual components. They however do describe that there is a relationship
between SES and mortality and that “each increase in the level of income,
education or occupation status” causes a subsequent reduction in the risk of
death between 25-64.
Professor Markenson’s lecture on “Access to Care” (2010) gives us a
better insight into how education and health are linked. Though health
outcome and education are not directly linked together, education and the
use of certain medications/services are examined. Making a logical
inference, higher utilization of preventative services or use of medication
leads to better health outcomes. According to professor Markenson’s lecture
(2010), there is a lower utilization of every service/medication usage
measured among Medicare beneficiaries who have low education. As an
example, one of the leading causes of blindness among people with diabetes
is diabetic retinopathy and early detection and treatment of this condition
significantly reduces the occurrence of blindness. Therefore annual eye
exams are essential. Only around 40% of diabetic beneficiaries with low
education, received eye exams whereas over 50% of diabetic beneficiaries
with high education received eye exams. To make the next step, a study
should be done to see the prevalence of blindness caused by diabetes
among beneficiaries of low and high education.
In conclusion, there is a statistically significant correlation between
level of education and health. However, this is only one of many
determinants of health; with some determinants more influential on health
than education level.

Austin Holmes
HPM5001 Spring 2010
Professor Markenson

References

American Academy of Family Physicians (AAFP) (2010). Health Care for All: A
Framework for
Moving to a Primary Care-Based Health Care System in the United
States. Retrieved May 1, 2010, from
http://www.aafp.org/online/en/home/policy/policies/h/healthcare.html

Arno, P., Figueroa, J. (2000). The Social and Economic Determinants of

Health. Madrick, A.
(Ed). Unconventional Wisdom: Alternative Perspectives on the New
Economy (93-104). New York, NY. Century Foundation Press.

Shi, L., & Singh D. (2008). Delivering Health Care in America: A Systems
Approach. (4th ed.).
Sudbury, MA. Jones and Bartlett Publishers.

Markenson, A. (2010). Access to Care: Spring 2009 HPM5001. [PowerPoint

slides]. Retrieved
from New York Medical College moodle website: nymc.mrooms.org

Markenson, A. (2010). Stakeholders in the U.S. Healthcare System. Spring

2009 HPM5001.
 [PowerPoint slides]. Retrieved from New York Medical College moodle
website: nymc.mrooms.org

National Highway Transportation and Safety Administration (NHTSA) (2009).

Department of
Emergency Medical Services Website. Retrived on May 1, 2010, from
www.ems.gov

RAND Corp (2009). Research Highlights: Health Care on Aisle 7. Santa

Monica, CA. RB-9491

Stier, J. (2009). Quality in Health Care. [PowerPoint slides]. Retrieved from

New York Medical
College moodle website: nymc.mrooms.org

Stone, R. (unknown date). Public Hospitals/Primary Care. [PowerPoint slides].

Retrieved from
New York Medical College moodle website: nymc.mrooms.org