HPM Final

#28 According to "the Era of Delivery System Reform Begins" article by Song and Lee, what are the major problems of our delivery system? How can we address these problems?

#1- lack of coordination #2- Dawson model is not free flowing at all so it is hard to coordinate need a model that can coordinate info through different doctors, inefficient

Dawson Model

- primary-secondary-tertiary - gate-keeping - stepwise patient flow

#4 Who constitutes the largest group of beneficiaries in the Medicaid program? Which group accounts for the highest percentage of expenditure/cost?

-children!! -highest costing is the elderly

What kinds of changes has the ACA introduced in Medicaid?

-expanded eligibility in states that implement expansion (138%) and increased outreach and enrollment

#29 How is the British health care system financed? What is the role of government in the British health care system?

-financed but the state funded system NHS and paid for with payroll taxes that depends on your income

#1 What does Medicare Part D Cover? What kinds of changes are introduced to this program with the ACA? Has the Trump administration introduced any changes to this program?

-it covers specific prescription drugs in a specific plan that you can purchase at a pharmacy in your plans network -ACA changed Medicare because they left the DONUT HOLE in Medicare -Trump Admin. has not changed it

#6 Why did some states decide not to participate in Medicaid expansion? What are the concerns/problems in those states in the aftermath of the ACA?

-politics! -states don't want to have to fund it -creates a larger gap in those who are not funded and there is a ton of coverage in some states and barely any in others

#17 What additional steps did the ACA take to build up capacity in the primary care system? Mention at least TWO steps and discuss if you agree or disagree with these steps.

-primary care capacity , not enough providers so the ACA gave incentives and encouraged states, especially rural ones, to do it also -ACA did not change licensing requirements so more doctors would

Primary Care

A doctor who provides general medical care and coordinates other health care, general health care

What are the problems in Medicaid after the ACA?

ACA is expanding in certain states, making them the most successful in coverage, but it makes the gaps between different states so much more substantial for those who never expanded.

#32 What are the problems of British and German systems?

Both systems have extremely long waits and services are not immediate -certain drugs and doctors are not as good as U.S., innovation is not as good -not enough staff

secondary care

Care by a physician (specialist) who can perform out-of-the-ordinary procedures in outpatient facilities after consultation

#37 Why are costs higher in the American health care system compared to other industrialized countries? And why are these high costs a major problem?

Costs are higher because there's no restricition to price and most of it is private, so they can charge as much as they want -no one can afford it

#14 What is the difference between the Dawson Model and a free flowing model?

Dawson- very structured, pyramid w/ lots of primary. care and gets much smaller the more specific it gets, must get care near where you live Free- patient can go through the system as much as they want, more costly, lots of waste, PCMH interferes bc it is based on the market, minimal regulation on location of hospital

#21 what did the Flexner Report recommend and what were the consequences of these recommendations for the American health care system?

Flexner said medical schools needed to be more specific because they were not specialized enough, making med schools much harder to get in to

Sickness funds

German insurance programs offered by nonprofit groups to serve a given occupation, geographic location, or employer. Otherwise known as social insurance.

universal coverage

Health insurance coverage for all citizens.

#2 What is Medicaid and who funds it?

Medicaid is funded by a federal state system, meaning the states administers law but the government oversees it. It is also funded by payroll taxes.

What does Medicaid cover?

Moms, babies, children (largest) all under the poverty line, disabled, elderly

#31 Who owns the majority of hospitals in the UK? Where do GPs work and are they government employees?

NHS -GPs are independent practitioners that work for the NHS, usually work as part of teams in hospitals or w connections to hospitals

PCMH

Patient-Centered Medical Home A health care setting that organizes care around patients, working in teams and coordinating and tracking care over time.

#15 What are the benefits/advantages of primary care?

Primary care coordinates all care with other doctors and is there for basic needs.

coverage

The risks covered and amount of money paid for losses under an insurance policy

Physician Assistant

a licensed professional who works under the supervision of a physician -trained as a physician and can perform about 80% of the tasks a doctor can -MED SCHOOL

#35 Who owns the hospitals in Germany? What is the role of government in the German system?

a lot of them are university funded hospitals (public) and very few private

Nurse Practitioner

a nurse with graduate training who often works as a primary care provider -NURSING SCHOOL

National Health Insurance

a program—that has been proposed in a variety of ways over the last few generations—to provide the financing, policies, and regulations to guarantee all or almost all Americans' medical health insurance.

Effectiveness

accomplishing tasks that help fulfill organizational objectives

ACO

accountable care organization healthcare organization characterized by a payment and care delivery model that works with a network of providers ex: car garage

access

admittance to all patients

What are the advantages and disadvantages of work requirements?

advantages- boost economy because more people will work and work makes you healthier, will get rid of people abusing the system disadvantages- people w irregular work requirements can't meet the requirements, people taking care of kids can't work, elderly and disabled cant hit limit, messy administration issues

effciency

avoiding waste, including waste of equipment, supplies, ideas, and energy

#5 What were the problems with Medicaid before the ACA?

before the ACA to receive Medicaid, individuals must be poor and either aged, blind, pregnant, or a parent of a dependent child *(safety net- the providers and payers that ensure people who do not have access to traditional coverage options)*

quality

consistently producing what the customer wants while reducing errors before and after delivery to the customer, being well developed

#10 does Medicaid coverage make any difference in terms of access to care, use, unmet needs or mortality trends?

decrease in mortality rates, doctors can still refuse Medicaid patients, 16% reduction in mortality rates for those with Medicaid, more people have access to care

#33 How does the German health care system ensure that everybody is covered and everybody is entitled to the same package of benefits?

employers must pay and it is also taken from taxpayers, both public and private (sick funds)

#9 Who are the dual eligibles?

individuals entitled to Medicare who are also eligible for some level of Medicaid benefits. -also end-stage renal disease

#7 According to your readings what is the reason for introducing work requirements in Medicaid?

introduced because states thought you should be working to earn it and wanted to get rid of people abusing the system

#3 What are the mandatory benefits that must be covered in all states?

mandatory benefits include inpatient hospital services Outpatient hospital services Nursing Facility Services Home health services Physician services Rural health clinic services Federally qualified health center services Laboratory and X-ray service

What is Medicare Part D

medicare prescription drug benefit

What is the donut hole in Medicare Part D?

patients reach one limit of services covered and must reach catastrophic limit until insurance covers it again

outpatient services

patients recieve care without being admitted to hospitals or other care facilities

#34 How do Germans pay for health care? Do you think this is fair and redistributive?

pay a certain percent of their income into their sick funds and is also covered by their employer

Value Based Payment

paying health care providers for the quality of care they provide and the outcomes they achieve for patients

Tertiary Care

services requested by a specialist from another specialist

inpatient services

services that involve an overnight stay of a patient

Fee-for-service (FFS)

set of fees for services established by a health care provider and paid for by the patient

#19 what are the issues facing our rural health care system? How effective would Medicaid expansion be in order to help accessibility and affordability in these rural states?

shortage of professionals, 14 states that declined Medicaid expansion had big rural populations

#16 If you consider the impacts of the Affordable Care Act on primary care services, would you say we currently have the capacity to respond to population need for primary care?

the ACA has added incentives to get doctors to work in primary care places and introduced gateways to primary care right out of medicare so maybe in the future but we still have a shortage.

contribution

the act of giving or doing something

Coverage gap medicaid

the gap between medicaid and marketplace subsidies

#22 What are the defining characteristics of Physicians Assistants (PAs)? What do they do?

they do everything -can do 80% of what doctors do -trained in multiple settings -can order labs and imaging studies

#30 How does the British health care system ensure that everybody is covered and everybody is entitled to the same package of benefits?

universal health care provides coverage for everyone and as long as you pay in, you get it primary care is extremely effective and covers about 70% of the population

gate keeping

when someone is in charge of authorizing the patient's referrals, hospitalizations, and lab studies

#8 Has the Supreme Court's 2012 ruling on Independent Business vs. Sebelius impacted Medicaid?

yes, gave states the option to expand Medicaid because it is state funded, ACA cannot force states to participate

#12 Given that 14 states have not yet implemented Medicaid expansion, what incentives would you provide to states to encourage participation?

you could provide incentives to: give block grants (pay for first year, 90% the rest of the years) lower threshold for private insurance