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Health Care Quality Model in the USA



Health Care Quality Model in the USA

During the last decades, the state of affairs in the US health care field and innovations to improve the quality of provided services are the subjects of numerous debates among journalists, policymakers, experts, and ordinary citizens. Basic health insurance plans, technological modernization, and legislative support precipitate the development of the national health care model, encouraging medical organizations to be high performance.

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The key goal of the US national health care system is the provision of health care services of high quality. The authorities adopted effective legislation to initiate the reforms and development of the national health care system.

The most popular health insurance plans are Medicare and Medicaid. They originated in the 1960s as the government initiatives to cover health care spending for the elderly and poor Americans. Medicare comprises four parts handling hospitalization payment, outpatient services, advantage plans, and medicament support. Currently, about 45 million US citizens have a Medicare plan (Healey & Evans, 2014, p. 133). This fact proves the popularity of the government initiative among US citizens, who have been enjoying the guaranteed medical services for five decades.

However, insurance plans did not completely embrace the US population until the recent time that demanded urgent reforms. The social structure of the insurance coverage owners demonstrates the substantial benefits of the programs. To illustrate, about 50% of Medicare owners are members of the poor layers of the community (Healey & Evans, 2014, p.147). They do not have the opportunity to pay for expensive medical treatment without governmental support. Therefore, initiating Medicare and Medicaid is an extremely important social matter. Taking into account their advanced age, many Medicare owners have failing health. According to the statistics, approximately 40% of the participants of the Medicare program suffer from four or more chronic diseases (Healey & Evans, 2014, p.148).

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Hereby, they need numerous advanced checkups and consulting high-qualified experts. The second vulnerable group of Medicare possessors includes individuals with disabilities. The handicapped category makes approximately 16% of Medicare respondents (Healey & Evans, 2014, p.149). They need social help and special equipment such as wheelchairs. Finally, the state of health of other individuals demands hospitalization to support their vital functions. To illustrate, permanent treatment at hospitals is necessary for 5% of individuals (Healey & Evans, 2014, p.151). The above-mentioned examples demonstrate the fundamental importance of services provided by Medicare and Medicaid insurance coverage.

Initiating them, the US government greatly contributed to the improvement of the domestic health care quality and maintenance of the nation’s health. The current reforms in the health care system are connected with the insurance programs as their integral part. Government spending on Medicare programs for US citizens will make approximately 14% of the federal budget during the period from 2010 to 2030, embracing from 46 million up to 78 million individuals (Healey & Evans, 2014, p.155). Therefore, the services provided by Medicare plans meet the needs of the major part of Medicare owners (Healey & Evans, 2014, p.155).

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Being originated in 1965, Medicaid is the government program helping children from the poor layers of the community and their caregivers. Currently, about 62 million Americans possess this health care plan. It embraces about 60% of children in nursing homes. The US federal budget covers 43% of the Medicaid value, developing the tendency to boost spending on health care programs. To compare, the government spending on Medicaid made $1 billion in 1965, while it increased up to $200 billion in 2014 (Healey & Evans, 2014, p.133).

In 2010, the fundamental reform of the health care system started, and it was directed at the basic support of the poorest layers of the US population and the elderly people. Being initiated by Barack Obama, the reform gets the second name as ’Obamacare’. The innovation targeted free access to high-quality health services for all citizens in the United States. Unlike the previous years, health insurance is saved in cases when its owner lost or changed a job. The reform protects low-income families if they fail to pay for health services. Moreover, patients obtained the right to choose doctors and select the insurance plans most attractive for them. The accent is made on boosting the quality of provided health care services and improving the current system (Edmonds, 2010).

In 2010, the Affordable Care Act (ACA) was introduced that initiated a compulsory introduction of health insurance plans (Healey & Evans, 2014, p.135). According to the document, employers are to pay the fine of $2,000 per worker if they do not possess health insurance coverage (Healey & Evans, 2014, p.136). ACA contributed to the improvement of the US health care quality, performing several functions except enhancing health insurance and access to medical treatment.

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  1. First, it originated as a national quality strategy that focuses on “federal, state, and local efforts to improve the quality of care and align public and private payers in their quality and safety efforts” (Morris & Bailey, 2014, p.8).
  2. Second, ACA founded a center for quality improvement and patient safety that examines and encourages studies of the best practices to improve the US health care quality model.
  3. Third, this legislation initiated the Patient-Centered Outcomes Research Institute (PCORI) that encourages patient-centered evidence to improve the assessment process.
  4. Fourth, ACA launched the Center for Medicare and Medicaid Innovation (CMMI) for checking the new payment and delivery samples. It is worth noting that their key units are health care quality measurement and development of the services in the above-mentioned field.
  5. Fifth, ACA initiated a mandatory physician quality reporting program in 2015. Being suitable for Medicare owners, software options were introduced to compare the quality of medical services and physician care.
  6. Sixth, ACA demands feedback on the quality of provided government health insurance plans.
  7. Seventh, the legislation provides the possibility to collect additional information about race, ethnicity, gender, financial status, and the native language of owners of health insurance plans. These data are used to facilitate the usage and outcomes of Medicare and Medicaid programs.
  8. Finally, ACA verified innovative payment and delivery models in the health care field such as “value-based physician payment, accountable care organizations (ACOs), and patient-centered medical homes that all use quality as a key metric of success” (Morris & Bailey, 2014, p.8).

The Measurement of Organization Performance

Numerous factors influence an organization's performance in the health care field. Experts developed a range of quality measurement that evaluates the current state of affairs, decreasing the influence of negative factors and boosting the beneficial ones.

In the US health care field, quality measurement can be defined as “the process of using data to evaluate the performance of health plans and health care providers against recognized quality standards” (Morris & Bailey, 2014, p.2). Experts offer a great variety of quality measures to assess health care according to the vast range of attributes such as health care offices, facilities and equipment, and hospital structures. The precise quality measurement plays an essential role in the development of the health care model, revealing current shortcomings to eliminate them (Morris & Bailey, 2014, p.3).

The basic quality measures evaluate the health care model according to its structure, process, outcome, and patient experience. Structure quality measures analyze medical equipment, staff, and policies connected with care delivery. To illustrate, it may reveal the absence of a critical care expert on staff in an intensive care unit. Process quality measures ascertain whether the provided health care services are permanent and meet the current requirement of everyday clinical care. For instance, process quality measures can determine if a physician checks the fact of their patients’ obtaining prescribed cancer screening. Outcome quality measures assess the state of patient health according to the results of the obtained treatment.

For example, evaluating means analyzing the survival rate among the patients that have undergone a heart attack. Patient experience quality measures evaluate the feedback on patients’ reports on the obtained medical care. To illustrate, measures of this type assess if patients consider their provider’s explanations of their treatment options understandable (Morris & Bailey, 2014, p.3).

Government agencies, private non-profitable organizations, and for-profit companies contribute to the development of national quality measures. Government agencies include the Centers for Medicare and Medicaid Services and the Agency for Health Care Research and Quality that create the possibilities to get feedback on the launched innovations and share the information nationally. The Joint Commission on Accreditation of Health Care Organizations and the National Committee for Quality Assurance represents private nonprofit institutions participating in the national health care program.

Healthgrades and U.S. News and World Report are for-profit organizations. Notwithstanding their active involvement in the process of boosting the quality of health care services, these organizations are sometimes accused of a low “level of transparency in their measure development processes” (Morris & Bailey, 2014, p.10). Despite inevitable criticism, the existence of numerous organizations that control the quality of the national health care states about the positive changes in the above-mentioned field.

There are several constituents in the current health care system such as health care experts, consumers of services, payers represented by insurance companies, employers, medical institutions, and health care coverage. The controlling organizations obtained due information from different sources such as the bank of administrative data, disease registries, medical records, and the information from patients’ feedback. The current reform imposes the responsibility to gather patients’ opinions on the provided health care services on insurance companies and their agents. This information is to be shared in public. Accreditation and certification are additional quality measures that greatly contribute to the improvement of the level of modern US health care services. Being the seal of high quality, these characteristics influence consumers’ choice of their insurance plans and doctors (Morris & Bailey, 2014, p.11).

My Agency Performance

My agency is C. L. Brumback Primary Care Clinic situated in Health Care District Palm Beach County, 1250 Southwinds Drive, Lantana, FL 33462.

As it was said above, structure, process, outcome, and patient experience make excellent agency performance. According to the structure, Brumback Primary Care Clinic complies with all the current requirements. Its medical equipment, staff, and policies handling care delivery are up to the level. Being high-performance, the clinic contributes to the provision of high-quality dental services for the great range of district inhabitants, including vagrants and migrants. In due time, both adults and children can obtain urgent medical services such as checkups, cleaning, filling, and teeth extractions.

The clinic staff comprises a dozen fully-fledged experts such as dentists, administrative personnel, and dental assistants. The clinic administration takes into account the financial status of patients while developing the price policy. Despite the ability to pay for the obtained dental services, all the suffering individuals get urgent help. Except for dental treatment, the Brumback Clinics provide a great range of medical services such as “yearly physicals, medical evaluations, laboratory services, diabetes and hypertension screenings, general and preventive dentistry, mammogram and specialty care referrals, mental health counseling, immunization, pharmacy services, and hearing and vision testing” (Miller, 2016).

The working process is described on the official websites and in clinics, stating that patients have the right to visit health experts five days a week from Monday until Friday, from 8 a.m. until 5 p.m. On Saturday, the clinic is open from 9 a.m. until 1 p.m. This schedule is suitable for the great majority of patients and the clinic personnel that makes the agency high performance. The outcome and patient experience are excellent as well due to the effective relationships between the clinic administration, its staff, and people visiting the institution. Doctors can have access to the data connected with appointments, tests and laboratory results, and prescription refills. Being protected, secure information includes data about patients’ “medical conditions, medications, allergies, immunizations, test results, and vitals” (Fall, 2015). Therefore, the feedback on the Brumback Primary Care Clinics is positive.


The state of affairs in the national health care system is the burning problem of the current time. The US authorities pay due attention to the issue while initiating effective health insurance programs and the legislation supporting reforms in the field. Organizational performance is dependent on many constituents such as structure, process, outcome, and patient experience. According to these criteria, C. L. Brumback Primary Care Clinic is truly considered to be high-performance since it meets all the requirements.

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