Quality measurement in health care has moved away from assessing care according to quality criteria and toward capturing compliance with practice guidelines. The HEDIS score, for example, consists of process measures and clinical indicators. Diabetic providers measure the reliability of hemoglobin A1c levels and LDL cholesterol checks. In addition, patients are concerned with risks of amputation, dialysis, and vision loss. These are not necessarily measures of quality or service.
Rather, stakeholders have a duty to improve value for patients. Value is health outcomes versus cost. Increasing value means improving health outcomes without compromising cost or outcome. Failing to achieve these goals is failure. But achieving value means rethinking the system. We need to move beyond the current dysfunctional system. We must start by re-engineering our health care system and recognize that the current model is no longer working.
Medicaid and CHIP are two examples of government-run health plans. Medicaid is largely tax-funded. Federal taxes pay about 63 percent of the costs, with states and local governments covering the rest. Medicaid expansion under the Affordable Care Act (ACA) was fully funded until 2017, but this share gradually reduced until it reached 90 percent in 2017. CHIP, on the other hand, is funded through matching grants given to states. In most states, people under 65 with long-term disabilities or end-stage renal disease must pay premiums.
The existing cost-accounting systems are fine for overall budgeting, but they only provide a crude idea of how much a medical condition costs. Often, these systems are based on charge instead of outcome. That makes them ineffective for improving the value of health care. Ultimately, health care organizations need a better way to understand the costs associated with a condition. They need to understand the resources used in treating the condition, the capacity costs of supplying resources, and the support costs of the staff providing care. This will help them compare outcomes with costs.
The U.S. health care system differs from those of other advanced industrialized countries. Compared to the OECD average, the U.S. system is inequitable, overspecialized, and neglects preventive and primary care. The Commonwealth Fund Commission has ranked the U.S. health care system as the world’s worst in terms of equity, healthiness, and efficiency. Its health care costs are higher than in any other country.
Global capitation has been shown to reduce the costs associated with health care. Under this system, providers are paid for providing services to a defined population in exchange for quality improvements. These organizations are then awarded a percentage of savings in health care costs between the actual and forecasted costs. A global capitation system rewards performance, while fee-for-service systems reward volume. In other words, they are paid to deliver services, but they do not necessarily increase value.
The health care system is complex, and patients have many choices when receiving care. Understanding the types of health care facilities available is important to making an informed decision about which one to choose for medical care. This information will help patients determine which facility is best for their needs. It is also important to note that patients can opt to pay out-of-pocket or with a small annual retainer. The type of insurance coverage you have will also influence your decision.