Components of Healthcare and Role of Data at Each Level
In this blog, I will discuss the healthcare system of the US and how data captures at each level. Let’s start with stakeholders of healthcare, how they are involved, and how they generate data in the healthcare delivery system.
Consumers are the ones who buy and use healthcare services. They have a sense of entitlement and the right to healthcare. They are the individuals who choose the type of health care they want, where and when they want, and how much they are inclined to pay for it. This process is known as Consumerism. They have expectations of how much to spend on insurance coverage and healthcare services. Data has been becoming their part of decision making. Greater visibility of data offers independence to consumers. Their choices drive the market based on cost and quality of healthcare services.
Doctors and hospitals are the Providers who deliver healthcare services for payment. It’s business, revenue source, job, or means of income for some providers, while it is a personal motivation for some. They run consumerism because of the ability to decide to care on behalf of consumers. The reasons behind the choices of care for providers may not be the same as the consumers. Having data on how providers delivered care influence other aspects. Their services and quality of care become factors in payment.
Employers and Government Agencies help to pay for and purchasing healthcare services. Examples are employer-sponsored group coverage and government-sponsored Medicare and Medicaid. For employers, healthcare is an aid to maintain the workforce. Their aim is on recruitment, retention, and productivity. They focus on the cost of services. Data plays a role for them to deicide benefit coverage and price to manage employee healthcare coverage.
Government agencies are committed to serving a vulnerable population, maintaining comprehensive health status, and accessing care for those who can’t afford it. They generate rules and regulations for safe healthcare delivery and protect consumers. They use data to institute payment schedules and ensure best practices through quality programs. Data helps analyze the impact of healthcare services on population demographics. They play a crucial role in maintaining affordable healthcare.
Payers are administrators of services and payment on behalf of employers, consumers, and government agencies. Payers decide fee schedule and support regulatory compliance, claim payment, utilization review, and care management. For them, healthcare is a business and revenue source. For some providers, it is for profit, and for some, it is not for profit. Data plays a role for them in recruiting and retaining providers, identifying high-risk/high-cost members, reaching out to adequate members through target programs and information, and keeping track of the cost of healthcare services and pharmaceuticals.
Now let’s move forward to a different type of care settings (place of services) and how data is being gathered at each type of care.
Inpatient care can be critical/less critical, planned/unplanned, optional/given. It means the patient is staying in an institution. This type of care is the most expensive one. Data capture for this level is a facility claim with standardized code. Examples are diagnosis and procedures and Diagnosis-Related Grouping (DRG) if applicable to frame payment.
Outpatient or Ambulatory Care is the one where the patient is in a hospital setting or free-standing building. The patient gets a service and go home on the same day. This care is much less expensive than inpatient care. Data seized here is procedural driven. Current procedural terminology(CPT) codes are used to frame payment.
The Physician’s Office is for initial non-critical healthcare concerns. Examples are some routine care/checkups and minor procedures. Data that bounds here are ICD-10 (International Statistical Classification of Disease and CPT codes.
The Emergency Room is for short term critical problems. This care is used when the physician is not available, or the case is too severe for the doctor’s office. This type of care is costly for consumers as well as the healthcare delivery system. Hospitals are committed to providing service for this type of care and creating problems when individuals don’t have insurance(also known as uncompensated care). Data capture at this level is a combination of outpatient care and physician’s office. This care requires procedural codes and diagnosis to frame payment.
Community Care involves home care services to support individuals at home. Hospital care or hospice settings are provided for end-of-life care or long-term custodial care with activities of daily living (ADL). Data is collected here through diagnosis and procedural codes or healthcare common procedural codes(HCPC).
Regulatory entities provide oversight at federal, state, and local levels via public policies. Federal and global regulatory agencies enforce and develop standards for proper care. State departments of insurance manage insurance companies and protect consumers from financial problems if the insurance company fails. Some self-governing entities such as AMA(American Medical Association) also set standards for medical practices. The following are some agencies, and their links have the primary responsibility of healthcare delivery, healthcare technology, and healthcare quality.
CMS(Center of Medicare and Medicaid Services)
ONC(Office of National Coordinator)
AHRQ(Agency of Healthcare Research and Quality)
WHO(World Health Organization)
The Institute of Healthcare Improvement has developed the Triple Aim to improve health system performance. According to it, new designs must enhance the following three dimensions, which we call Triple Aim and compass direction that tells what success is:
Better Population Health
Better Experience of Care
Reducing per Capita Cost
Cost is a crucial variable in the evaluation of the quality of care. Quality of care in health services includes applying evidence-based practice, measuring outcomes, using technology to reduce human error, and enforcing consistency. The cost can be what consumers pay for insurance and services, cost of producing healthcare such as employee wages, cost of supplies and equipment for providers, administrative cost and cost of technology for advancement of medical care.
The amount nation spends on healthcare determines the country’s healthcare delivery system’s efficiency and efficacy. The current model of the United States healthcare focuses on treating sickness and less focused on prevention and lifestyle behavior change.
Enhancement of quality in health care fuels the continuous learning process. The virtuous cycle of learning health care systems is a cycle based on exchanging information between practice and research. The steps of the cycle that I will discuss must go in both directions to attain the triple aim of better care, lower costs, and improved population health.
Let’s also understand this cycle with an example. Suppose you want to study how long it takes to get an X-ray in a hospital? As a part of collecting and analyzing data, you include the number of patients needing an x-ray, time delay, and radiology department location. Then you interpret if it takes longer to get an X-ray at certain times of the day? or Is there a lack of experienced technicians available? Once your data is interpreted, you need to communicate with stakeholders about findings. You might want to hire more technicians for busy times as part of taking action.
The ability to analyze data and translate into actionable insights to influence healthcare drives quality improvement in healthcare.
The use of demographic and population health data is essential to shape healthcare and make sure that our approach to treatment and programs can meet individual needs. This includes information related to nations, communities, ethnic groups, etc. This information can also be categorized by race, gender, income, and education, as well as includes individuals and employees with specific diseases and disabled persons. Social, physical, biological, and geographic environments are also factors in the study. Three main elements of population change are birth, death, and migration. Migration can lead to a shift in how and where services are needed. Longevity is also a factor in demographic change. Suppose lower birth rates and lower death rates are signs of greater longevity, meaning our population is aging. The healthcare needs of the aging population are different than the young population.
Demographic data is collected in the form of EHR(Electronic Health Record) or other standardization mechanisms through individual physicians’ offices or hospitals. Data associated with demographic includes morbidity, mortality, ADL(Activity of daily living), Life expectancy, etc. You can check here my work about some insights on demographic data provided by WHO on life expectancy. The US Census, which is conducted every ten years, is the primary source of this data.
EHR is a common platform to collect, store, and transmit healthcare data. As EHR expands, it is possible to access individual records online for many separate automated systems. E-health portal, M-health (mobile health support), E-therapy, Virtual Physician, Telemedicine, and Monitoring in Home are some healthcare technologies to improve efficiency and quality of care.
Though these technologies come with challenges, such as:
- Compensation for services because spending is limited.
2. Consumer technology experience is not always fair since not all people have access to the latest technology.
3. Maintaining patient confidentiality
There needs to be a balance between the high cost of research and development and caution to using technology that adds no value.
I hope this knowledge helps the people who are trying to set their feet into healthcare or want to enhance their career in Health Care.
