Health Access

and Quality
Determinants
Mathew Kiio
 Overview of the health care payment system in the United States.

How the current (2017) changes in the ACA impact the patient
profile? How do these policy changes impact the provision of care
you provide?

Objectives
The concept of quality determinants in relation to care provision and
management. How is quality determined, measured, and
documented?

What are the barriers to accessing healthcare in the United States?

Identify one policy issue related to psychiatric and mental

healthcare that is currently being addressed by your national
professional organization and discuss how NPs can become policy-
aware, as well as act as patient advocates.
The U.S Health Care System-Payment

 The U.S. health care system can best be described as a hybrid system . It does not have
a uniform health system, has no universal health care coverage. It has an operating
national health service, a single-payer national health insurance system, or a multi-payer
universal health insurance fund(https://dpeaflcio.org/programs-publications/issue-fact-
sheets/the-u-s-health-care-system-an-international-perspective/)
 Sources of funding
 Private funds- American households and private businesses
 The federal government, state and local governments
The U.S Health Care System-Payment
2017 changes in the ACA impact on patient
profile
68yr old patient, diagnosed 34yr old patient,
with depression, who has diagnosed with
Medicare Schizophrenia, who
has Medicaid

• Access to more care • Scope of services

preventive at no additional covered to this
cost. patient will reduce
• Wellness exam every year
at no cost
2017 changes in the ACA impact on patient
profile
43yr old patient, diagnosed 22yr old patient,
with bipolar disorder, undocumented immigrant
private/work-provided diagnosed with PTSD and
health insurance anxiety, who is uninsured

Upward trajectory
Might have to
to the premiums,
forego needed
deductibles and
care
out of pocket cost.

High cost of
access to
healthcare
How the policy changes impact the provision
of care to patients
1. Rise in the numbers of uninsured patients
2. Deprivation of the resources needed to care for patients
3. Hospitals and other safety net providers forced to bear more unreimbursed
costs as a result of people being afraid to access coverage for which they
are eligible
4. Fragmentation of care across settings and populations due to
reimbursement hurdles.
Concept of Quality Determinants

Definition:
The concept of quality determinants takes into
consideration the process of using data to evaluate
the performance of health plans and health care
providers against recognized quality standards.

55%
(Morris, & Bailey, 2014).
Patients receive proper diagnosis and
care only about 55% of the time
Concept of Quality Determinants

How it improves health care quality

1. Preventing underuse, overuse, and misuse of health care services

2. Identify what works in health care and what doesn’t to drive improvement
3. Holding health insurance plans and health care providers accountable for providing quality health care
4. Helping consumers make informed choices about their care
How is quality determined, measured and
documented?

 Quality is determined using various measures which assess the full

continuum of health care delivery.
 This assessment is done from the level of individual physicians all the
way up to the health insurance plans
 There are four main categories of measures for quality determinacy:
1. Structure
2. Process
3. Outcome, and
4. Patient experience
How is quality determined, measured and
documented?
Quality Measure How it’s Documented
Structure This measure makes an assessment of the care setting. This includes
facilities, personnel and policies which are related to delivery of care.
Process This measure is documented through the determination of whether
there is consistency between the services provided to the patients and
routine clinical care.
Outcome This measure is documented through the evaluation of patient health
as a result of the care received.
Patient Experience Quality is determined and documented using this measure by getting
feedback from the patients on the quality of care received.
Barriers to accessing healthcare in the
United States

1. Affordability
2. Accommodation
3. Availability
4. Accessibility
5. Acceptability
Source: Douthit., et al, 2015)
Policy issues related to psychiatric and
mental healthcare

 Policy issue:
 The need for inclusion of mental health and substance
use services in the policies promoting a healthy nation

 National professional organization addressing this

policy:
 The American Psychiatric Nurses Association (APNA)
Importance of this policy

 Drive down costs

 Produce better outcomes
 Encourage a healthier more
productive society “Whole Health begins with Mental
Health”

56M
56 Million American adults
experience a mental illness
and/or substance use
disorder (Abuse, 2015)
Importance of this policy

 True health reform cannot and will not succeed without a comprehensive,
committed focus on the mental health of all Americans.
 Professionals in mental health and public health must work in collaboration
with concerned citizens.
 This will help all Americans understand that mental health is essential for
overall health.
 Together, we can cultivate strong, enlightened leaders who acknowledge that
the mental health implications of public policies are as important as their
political or economic impact.
References

 Abuse, S. (2015). “2015 National survey on drug use and Health”

 Douthit, N., Kiv, S., Dwolatzy., & Biswas, S. (2015). Exposing some
important barriers to health care access in the USA. Public Health,
129(6), 611-620
 Morris, C., & Bailey, K. (2014). Measuring health care quality; an
overview of quality measures. Families UA issue brief May
 LeCuyer, Nick A. and Singhal, S. (2015). Overhauling the US healthcare
payment system. The McKinsey Quaterly
End