Population Health Question

1. Politics
2. Legislation
3. Structure
4. Resources/Funding/Reimbursement
5. Socio- demographics
6. Technology

What other influences do you feel might exist?

Chapter 3 in your Ledlow and Stephens (2018) text identifies and defines each of these influences in detail. Here, we will review these individually and in summary.

Politics & Legislation

Politics drive change by means of influencing people in powerful positions. Legislation is the tool through which those in political office shape and change policy. Changes are enacted through statutes, and in healthcare these are connected to decisions and actions planned to achieve societal health care goals (Ledlow & Stephens, 2018).

Once a health policy has been accepted and enacted then it is up to government agencies to make things happen. Regulations are put in place so that laws can be followed. The Centers for Medicare and Medicaid services enforce the regulations.

Decisions related to health policy should take into account three areas of impact: quality, cost, and access. Early theoretical models describe that these three areas exist in opposition of another in what is considered the Iron Triangle. Through the lens of the model, if two areas of impact are moving in one direction, the third moves in the opposite direction. For instance, if quality and cost are high, then access is typically low. This is important to you as a future leader in health care. You should be aware of both the politics involved in health care decision making, as well as the overall impact. Cost, quality, and access will be very much part of the conversation for you as member of a healthcare organization no matter what your role (Ledlow & Stephens, 2018).

Structure

Our public health system has a very important role in assessing and assuring some of the major components of health delivery as well as contributing to the development of health care policy. Public health is best defined as the collection of publicly available healthcare related services that seek to address population-level health (Ledlow and Stephens, 2018, p. 43). While physicians manage individual health, the public health system aims to not just promote overall wellness but also to influence change where risk to healthfulness might exist (education, vaccination, environmental hazard etc.).

Delivery of health care in the United States is considered to be highly complex in comparison to other countries. We have a large number of care providers in addition to a complicated system of insurance organizations and mechanisms of payment. Funding and reimbursement are a big part of the conversation for both health care leaders as well as the providers. Cost, quality, and access are very much part of this conversation as well (Ledlow & Stephens, 2018).

Resources/Funding/Reimbursement

The United States spends more on health care delivery than most other countries. Why? There may be several reasons for this. The complicated nature of our system could be one factor (Ledlow & Stephens, 2018).

Insurance

For most of us, care is provided for and then reimbursed later by the insurance companies. The process by which this happens can be different depending on the insurance company, but typically occurs through some level of negotiation with the provider. Medicare follows an Inpatient Prospective Payment System (IPPS) by which they reimburse on discharge from an inpatient stay. On discharge a patient is given a classification based on a diagnosis or several diagnoses (Diagnostic Related Group, or DRG). Medicare will then use the DRG and other patient factors (age, gender etc.) to determine how much they will reimburse. Most insurance companies follow this same or similar system of reviewing care provided and determining reimbursement (Ledlow & Stephens, 2018).

Private insurance can be accessed either individually or through the workplace. Each insurance company is required to be accredited by the state where they sell their services. When provided through an employer, cost is typically shared by you and your employer (Ledlow & Stephens, 2018).

In 2010, the Affordable Care Act was passed with the purpose of increasing access to health care coverage by making health insurance more affordable for all. They did this by incentivizing employers to provide insurance. At the same time, individuals who did not obtain insurance were penalized. In addition, standards and procedures were set up through the ACA for each state to create their own insurance markets (Ledlow & Stephens, 2018).

Self-Pay

For those who have the resources, self-pay can be an option to pay for services not covered by the insurance company. Self-pay would include flexible spending (FSA) and health savings (HAS) as well as cash and credit card payment. As you might imagine, individual charges are often much higher than what would be billed to insurance because of the ability of insurance companies to negotiate cost from a volume discount perspective.

Medicare & Medicaid

Lastly, there are additional government programs for insurance. These include Medicare, Medicaid, Military and Native American programs. Medicare coverage focuses on the disabled and elderly populations (with the addition of patients who require dialysis), while Medicaid is intended to cover people below a specific income level and other specified disabilities. The ACA provides additional government funding to State Medicaid services (Ledlow & Stephens, 2018).

Socio-demographics

There is increasing research that shows that not only can one be judged and influenced by these, but several of these factors strongly influence health care outcomes. Do you think it matters where your clients live and whether they are a high-risk population? It does. In fact, at a large healthcare leadership conference in 2015, ZIP code was identified as the biggest predictor of health. How is this determined (Ledlow & Stephens, 2018)?

Technology

Health care analytics are utilized to provide information to public health leaders, insurers, the government, and other health care leadership. Using large data from many sources, models are created to both evaluate and predict the trends and outcomes of health issues, services, delivery, and outcomes. Patient and population data are used to evaluate both individual and community demographics, health, diagnoses, access and service utility. Processes and profitability for institutions that deliver care and agencies that cover it are also evaluated using data analytics. These outcomes, in turn, influence many of the factors previously mentioned: policy, structure, and reimbursement. Data will also be utilized to challenge the efficiency of the system. As a leader in health care, you will need to understand how to utilize outcomes data to help you balance resources, cost, outcomes and efficiency in your organization (Ledlow and Stephens, 2018).

So, given these influences, what does it take to be a good leader in healthcare?

Make good choices; informed choices. Consider the details but also the bigger picture. Be knowledgeable and compassionate but at the same time understand the business and politics involved in healthcare.