HMP Exam 3

Magnet status

-a standard of nursing quality -deciding whether to commit to this journey should be based more on the vision of the board and management team and the facility's culture than on bed size or balance sheets -it measures the strength and quality of their nursing

3 developments explain departure from predicted nursing shortage

-annual output of US nursing education programs doubled in past decade -lingering slow economic growth following recession has kept some RNs in the workforce -given large contribution of baby boomers, the current size of the overall RN workforce is particularly sensitive to when those baby-boomer RNs choose to leave the workforce; may have delayed retirement due to recession; overall shift towards later retirement independent of economic effects

Pathway to excellence

-another less comprehensive credential -may be more realistic for smaller hospitals than magnet status -magnet requires nursing satisfaction, patient satisfaction and excellent clinical outcomes whereas pathway focuses on having a positive work environment as defined by nurses and supported by research

Standards of nursing practice

-assessment (understand and help the patient understand what is going on - their symptoms, what brought them there - whereas medicine would be focused on finding the diagnosis, but nurse things about what symptoms are getting in the way of the patients regular life; also determine if there is a positive outcome of implementation) -diagnosis -outcomes identification -planning -implementation: coordination of care, health teaching and promotion, consultation, prescriptive authority and treatment (mostly advance practice nurses) -evaluation

Trends impacting physician practice

-inter-related and focus on trying to push the system from a FFS model to one focused on accountability and value of care delivered (rather than quantity of service): population health focus; patient centered medical homes/ACOs; resource stewardship and appropriate care

Result of delayed retirement

-large increase in RN workforce -higher employment in non hospital settings -difficulty in recent surge of new RNs finding the jobs they expected -once this cohort retires, may lead to return of RN shortage

Physician shortage?

-no, it is a demand, capacity mismatch -should reallocate clinical responsibility, with help of current technologies, to non-physician team members and to patients themselves

Non-clinician licensed practitioners and non-licensed personnel

-non-clinician licensed: highly skilled professionals seriously underused to fill roles generally performed by clinicians -non-licensed: medical assistants, front desk staff, life coaches, patient navigators, etc.; equally underused

Future trends affecting physicians

-population health -value based strategies - relative cost and return on investment; want to value quality of care relative to quantity of care -patient centered medical homes/accountable care

FQHCs

organizations that receive federal funding, under section 330 of the public health service act, to provide comprehensive primary care services to uninsured and underserved populations

Instrumental activities of daily living (IADLs)

routine activities like shopping and housework

National practitioner data bank

types of adverse actions that must be reported: -adverse licensure actions -adverse clinical privileges actions (>30 days) -adverse professional membership actions -malpractice payments -DEA actions (drug enforcement admin) -Medicare/Medicaid exclusions -despite good intentions, little evidence exists that presence of data bank changes behavior -patients can't look at this - only available to the health system who is considering hiring someone -might be expensive physicians if they have many malpractice suits; however, also may not tell anything because sometimes patients with bad outcomes sue even when quality of care provided was good

Implementing regulation criteria

using broad guidelines to monitor transactions would seem to be much more appropriate than micromanaging the industry through the federal registrar

Central policy question

does government's role in financing graduate medical education increase the number of physicians trained and influence their specialty choices by subsidizing the cost of training?

Dramatic growth in number of US hospitals

due to advances in medicine and connection to the industrial revolution (large-scale, efficient production), hospitals became a symbol of progress

Who uses LTSS?

elderly and non-elderly with: -intellectual and developmental disabilities -physical disabilities -behavioral health, dementia -spinal cord, traumatic brain injuries -disabling chronic diseases -dual eligibles

Primary care practitioners perspectives on delivery system changes: physician views on effect of ACO and medical homes on overall quality of care are mixes

increased use of medical homes: -all physicians = 33% positive, 26% none, 14% negative, 27% not sure -those in PCMH/APCP = 43% positive, 24% none, 17% negative, 15% not sure increased use of ACOs: -all physician = 14% positive, 21% none, 26% negative, 28% not sure -those in ACOs = 30% positive, 20% none, 24% negative, 25% not sure

Growth in NCLEX-RN first-time test takers, 2001-2013

increasing greatly over time

Clinical integration

independent providers, such as hospitals or health systems, physician practices, individual providers, and outpatient diagnostic centers, integrate their services through shared electronic health record systems, clinical guidelines, unified practice management and other techniques -result is patient care that is coordinated across all conditions, diseases, providers, and care settings, and over time -ACA adopted comprehensive national strategy for quality improvement in health care whose foundation is clinically integrated, systems-based practice -goal to achieve optimal results in terms of efficiency, cost, safety, and timing, as well as overall quality of care

Justification for regulating private health care industry

redress market failure

Physicians not under salary

often conduct much of their business in private offices they own or rent

Open physician hospital organizations

open to all members of the medical staff who wish to participate -increase in market share of hospitals that had open physician hospital orgs associated with a small decrease in volume (lower rate of hospital admissions)

First institutions (history)

-first institutions to care for the sick were monasteries -provided shelter for the indigent -cared for health needs when sick -affluent got care at home

"Me-too" drugs

-"me-too" drugs are "new" drugs which consist of a minor modification to an existing drug -of 31 blockbuster drugs launched between 1992 and 2001, 23 were "me-too" drugs for common conditions such as allergies and inflammation -of the 20 drugs approved in 2005, 7 were "me-too" drugs -these drugs sometimes provide benefits for the consumer (e.g. take fewer or less often) -these drugs benefit the manufacturer because they are cheaper to develop and can generate new patents -emphasis on "me-too" drugs is problematic because it inhibits innovation -companies are spending their funds on this rather than new innovations, which is a bad thing for us; they don't actually benefit patients that much, lose out on opportunity to create new drugs to help new patients

Breakdown of devices by therapeutic area

-$159.4 billion spent in 2011 (5.9% of US NHE) -modest growth; from 1989-2011, spend on devices increased 7.2% annually vs. 6.7% annually for overall national health expenditures -big segment, not as big as pharma, and not growing as quickly

Rx expenditures

-$263.3 billion or about 10% of aggregate health spending in the US (2008); more than 5 times the $40.3 billion spent in 1990; projected increase to $515.7 billion in 2017; overall, substantial amount spent on drugs -annual rate of growth historically much higher for drugs than other medical expenses: some slowing in the near past (number of newly approved drugs has decreased; brand name drugs have lost patent protection; economic recession); growth increasing again due to new, high-cost drugs -annual growth on drugs much higher than other medical expenses (such as surgery) -ideal is that maybe with more drugs, you can decrease the need for other things such as surgery

Types of community benefits

-45.3% unreimbursed costs for means-tested government programs -25.3% charity care (hospital never expects to collect on this) -14.7% subsidized health services -community benefits consisting of direct patient care include charity care, unreimbursed costs for means-tested government programs and subsidized health services -community benefits consisting of community services include community health improvement, cash and in-kind contributions to community groups, research, and health-professions education

Provision of community benefits as a percentage of hospital operating expenses

-% of operating expenses that go towards these community benefits that keep them non-profit or exempt from taxes are actually very low -unreimbursed costs for means-tested government programs = unreimbursed costs for Medicaid patients; Medicaid doesn't pay 100% of the cost of the service, so the hospital has a loss for the service they provide; puts into tally of operating expenses that they consider community benefit -require that hospitals deliver community benefit if they are tax exempt; on average only 7.5% of cost of running the hospital -charity care=1.9% -unreimbursed costs for means-tested government programs=3.4% -subsidized health services=1.1% -community health improvement=0.4% -cash or in-kind contributions to community groups=0.2% -research=0.1% -health-professions education=0.4%

Nursing home resident characteristics

-1.369 million residents -86% of elderly residents >75yo and 50% >85yo -48% have dementia and 44% are depressed; 64% are on psychoactive medications (including antipsychotics, antidepressant and anti anxiety) up from 45% in 1997 -96% require assistance in at least 1 ADL (96% bathing, 57% eating, 87% toileting)

Depression in elderly

-10% of elderly have depression -depression in elderly commonly associated with declining function, reduced social networks and social isolation, often with other chronic conditions

Nursing home statistics

-15,650 nursing facilities -1,663,537 beds -1,368,986 residents -median facility occupancy rate = 85.6% -4.18 average ADL dependence -1.657 mil employees -63.5% financed by Medicaid, 14.2% Medicare and 22.3% other payer -nursing home expenditures represent: 11% total Medicaid expenditures and 6% total Medicare expenditures

Mental health insurance coverage: Medicare

-190 day limit for inpatient mental health services -50% co-pays for outpatient psychiatric services; reduced to 20% in 2014

Brief history of long term care

-1930s: beginning of nursing home industry -1950s: state licensure of nursing homes -1965: Medicare pays only for acute care; Medicaid coverage of LTC in institutions only -1975: emphasis on community-based services (Medicare/Medicaid started to cover community-based care) -1980s: quality standards for Medicare and Medicaid certified nursing homes (certified at state and federal level); protections against spousal impoverishment -2010: ACA established CLASS act, voluntary long term services and supports insurance - then repealed in 2013 because not financially sustainable; commission on long term care established in the mean time until it is solved

Growth in FQHCs

-1965: first 2 health centers were established in the US -in 2014: US has 22.9 million individuals receiving care at more than 9,200 FQHC delivery sites; MI has 595,000 individuals receiving care at 220 FQHC delivery sites

Reimbursing home health care

-1997 BBA decreased per visit payments to stem rise in spending (from 1997-2001, home health visits dropped 72%) -home health prospective payment system was implemented in 2000: reimbursements is per episode of care; from 2001-2010, visits increased 69% -decided we were spending too much for home health care; wanted to stop the growth in payment through putting in a prospective payment for home health care

FQHCs in Michigan

-2014: 220 FQHC delivery sites in Michigan -many sites in SE Michigan and south/western part of the state -compared to UP where there are few FQHC delivery sites

Nursing care facilities expenditures by source

-30% Medicaid -29% out of pocket -25% Medicare -8% private insurance -7% other third party payer -3% other health insurance program

FQHC statutory requirements in order to receive federal funding

-4 basic categories: need, services, management and finance, and governance -are located in a high-need community (serve medically underserved area/population - HRSA designates these areas based on many different things) -provide primary care and supportive services (service requirements: must provide primary and preventive services and enabling services such as translation and transportation; must staff their center to meet required needs; have accessible hours; providers have admitting privileges; quality improvement and quality insurance programs) -provide services based on ability to pay -majority of board (51% or more) represent the population served -management and finance: having key management staff oversight for all contracted providers and services; auditing and billing compliance; data reporting, etc. -medically underserved area or population: primary care to population rate, infant mortality rate, % aged over 65, etc. -also provide enabling services (translation, transportation), etc. -must have accessible hours -must report their data to HRSA - include clinical services, demographics, type of services the population receives; required on annual basis

Sharp increases in the clinical pipeline: opportunity and danger

-4 key health care clinicians: NPs, pharmacists, PAs, and RNs -increase in education capacity for each of these currently; danger that this rapid growth could lead to significant surpluses -NPs increasing greatly; however, not all will be NP; some will remain RN, some may go into administrative position; increase 142% over decade -# of PAs measured by those passing exam for certification, so good measure; 52% increase -pharmacy graduates increased by 78% -# of RNs taking NCLEX-RN exam increased 102% -although the increasing need is temporary, will have many entering the careers for 30-35 years, even if need ends -increases have potential to help the nation meet its health care needs over the next few years; but could lead to large surplus -in early 80's and 90's, nursing job market became saturated and new RNs had a difficult time finding jobs; as a result, applications and enrollment plummeted significantly, contributing to new round of shortages; cycle of over- and under-production is very costly to individuals and institutions

Sources of payment for formal home health care

-44% Medicare -29% out of pocket -28% private health insurance -14% Medicaid -12% other third party payers

Access to mental health care

-55% of counties in US have no psychiatrists, psychologists or social workers -2000-2008: 14% decline in graduates from psychiatry training -psychiatrists are needed to give medications; may see a psychiatrists occasionally to monitor their medication, but then more frequently see a psychologist or social worker -psychiatrists aren't paid as well as other physicians - stigma associated with them too - leading to shortage in them -in 2009-2010, of all psychiatrists: 50% did not accept private insurance; >50% did not accept Medicare and Medicaid -many end up paying a lot of disposable income on this because they don't accept insurance; no other specialty where this many don't accept insurance -57% primary care physicians report inadequate availability of mental health services for adults -68% reported inadequate availability for children (this is bad because many of adult symptoms would be less severe if it were addressed when they were children) -Michigan ranks 42nd in the US in availability of inpatient psychiatric beds

Medicaid nursing home patients

-60% of nursing home residents stays paid for by Medicaid (almost all also Medicare beneficiaries) -Medicaid stay of unlimited duration -benefits cover, in addition to residential services and personal care, only limited nursing and therapeutic care -Medicaid resident with acute illness routinely transferred to hospital or ER where Medicare will pay

Shifting resources

-61% of LHOs reported shifting resources among population groups very little or not at all -officials in small departments reported less shifting of resources than larger departments -reporting little shifting of financial resources from one population group to another (may not be able to due to restrictions on funding) but reported a greater capacity to redirect staff time -may spur more cross-training of staff for various roles, as has happened in some LHDs because of increased demand for staff with emergency preparedness and response skills -small health departments reported less shifting of resources and redirecting staff than large departments; may be lower funding and less capacity within staffing pool to perform variety of tasks

Community hospitals rural vs. urban

-62% urban hospitals -38% rural hospitals -about 15% of the US population is rural

Community hospitals system affiliated vs. independent

-65% system-affiliated community hospitals (have a relationship with other hospitals in some way; allows them to provide wider care or economic sufficiently to stay afloat) -35% independent community hospitals

Nursing home ownership

-69% for-profit (have different incentives; pay shareholders the profit rather than put profit back into system/institution) -25.3% not for profit -5.7% government

Living arrangements by sex, age 65+

-71% men live with spouse; 19% live alone, 10% other -only 35% women live with spouse; 45% live alone; 20% other -living alone sets someone up for the need for LTSS

Concept of delegation of physician tasks

-80-85% of primary internist care and 90% of primary pediatrician care is preventive or consists of problems which are: self-limiting and not severe (ex. mosquito bite or head cold, often require no treatment, often delegates to those with less training and education), readily identifiable (protocols for how to treat) and/or able to be handled in a straightforward manner -NPs and PAs both quite capable of doing these tasks; very common tasks which is why many people think that the shortage can be addressed by having more NPs and PAs

Nursing home general facts

-92% of nursing homes certified for Medicare and Medicaid -most are for-profit -very small % government-owned -on average, about 100 beds -most are free-standing (not within a hospital)

Questions regarding retail clinics

-ability to coordinate care with other providers and networks? -ability to extend programs to children such as vaccines? -ability to extend emergency response systems? -don't know any of these things about retail clinics yet; could potentially help in all of these areas though

Mental health and the ACA

-ACA calls it behavioral health (mental health more reference to biologic disease, whereas BH refers to biological, substance abuse and behavioral problem); some don't like use of behavioral health - make it seem like it is up to the patient -first federal law to mandate mental health coverage; those being sold on exchanges and that have to include essential benefits now include mental health services and include them equally -ACA completing parity law by forcing MH to be included -plans no longer able to deny coverage for pre-existing physical or mental health condition -mental health, substance use disorder services, and behavioral health treatment considered an essential health benefit -most plans will have coverage for preventive services (e.g. depression screening and behavioral assessments for children) -builds on the mental health parity rule

Accountable care organizations

-ACA encouraged formation of ACOs -networks of physicians and health systems take on responsibility for a patient population, with goals of coordinating care and reducing costs, meeting the triple aim of improving the experience care, improving the health of populations, and reducing per capita costs of health care; include quality measures for systems; share savings with Medicare -Medicare shared savings program and pioneer ACOs -worries about ACOs: won't achieve expected savings; reduce competition, leading to higher prices for services -number of ACOs has grown a lot from 2011-2015 -number of people in/covered by ACOs is growing as well from 2011-2015 -Michigan has a lot of ACOs; university health system can be in multiple ACOs

Reporting of data

-ACA imposes new reporting requirements designed to make hospitals used system-based approaches to improve quality, with many focusing on physicians -increased reporting required of physicians will affect hospitals that employ or are affiliated with physicians thereby increasing the pressure to raise the institutions quality -public reporting of quality data is good for increasing quality of care

5 reasons ACA has made reinventing mental health and substance abuse care in the US more likely now

-ACA provisions enable states and federal agencies to test and evaluate improved financial and organizational tools in order to address the fragmentation of services that lead to poor quality and high cost -many provisions (such as health homes) are directed toward chronic disease comorbidities -allows providers to better coordinate Medicaid behavioral services with social service and housing programs that seek to prevent and manage homelessness among people with serious mental illnesses -encourages the use of preventive services and substance abuse education, evaluation, and treatment, and it allows providers treating people with serious mental illnesses to pay more attention to substance abuse problems -by extending the concepts of treatment and related supportive care to such entities as health homes, ACA provides new pathways for incorporating evidence-based treatments, such as supported employment, that are commonly neglected

Hospital bundled payments

-ACA will provide these for hospital "episodes of care" -CMS will bundle payments for entire episode of care for one or more of 10 selected medical conditions -covers the period from 3 days prior to a qualifying hospital admission through 30 days following discharge -covers cost of acute care inpatient services, physicians' services delivered inside and outside of an acute care hospital setting, outpatient hospital services (including ER services), post-acute care (including home health services, skilled nursing services, inpatient rehabilitation services, and inpatient hospital services furnished by a long-term care team), and other services that CMS deems appropriate

Differences between HMO and ACO

-ACO patient not required to stay in their network -ACO aims to hold down the cost of care while avoiding the structural features that give the HMO control over patient referral patterns, limiting patient options and resulting in consumer backlash -ACOs must meet a long list of quality measures to ensure they are not saving money stinting on necessary care -ACO gives doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services

3 waves of health center expansion

-Bush administration: pledged to double the reach of the nation's health center- expansion through budget increase -the american recovery and reinvestment act: provided money to health centers - most earmarked for capital expenditures including purchase of additional equipment, renovation, and construction of new facilities; remaining funding expanded operations to meet increased demand for care due to recession and loss of insurance -ACA: established money mandatory for HCTF most which would be spend on expanded operations, and the rest on capital expenditures; expand national health service corps; expand Medicaid and private coverage

Conclusions about nursing homes from star ratings

-CMS should impose and enforce higher standards to improve the quality of care for residents, but also have cost implications for nursing homes and payers -some think nursing homes will develop with time and could provide more complex care to reduce hospitalizations; others caution that many nursing homes may not be well-equipped to care for patients with complex medical needs, given concerns about staffing levels and other issues -limited on-site capacity and other factors may be associated with relatively high rates of preventable hospitalizations and ER visits among nursing home residents

Examples of retail clinic services

-CVS/MinuteClinic supports diabetes management including biometric screenings such as glucose, hemoglobin A1c, blood pressure, weight and foot exams, weight management counseling programs and asthma maintenance therapy education -Walgreens Take Care Clinics include assessment, treatment and management for hypertension, diabetes, high cholesterol, and asthma; providers can evaluate, recommend and order preventive health services, such as screenings or lab tests, based on a patients age, gender and family history

Primary care practitioners perspectives on delivery system changes: method of physician payment

-FFS only = 34% -capitation or salary, with/without FFS = 64%

Take aways about FQHCs

-FQHCs provide comprehensive care to high need, low resource communities -services are based on the needs of the community and extend beyond primary care -ACA played critical role in expanding scope and reach of FQHCs

Take-aways for FQHCs

-FQHCs provide comprehensive care to high need, low resource communities -services are based on the needs of the community and extend beyond primary care -ACA played critical role in expanding scope and reach of FQHCs -board members have a good understanding oft he needs of the communities, and can make decisions on what additional services need to be provided

Growth in the US nurse workforce

-LPN had 15.5% growth -RN had 24.1% growth -create special programs for people to increase nursing workforce - created accelerated programs to get people with some experience up to a pace where they have bachelor's degree in nursing -other accelerated programs for people without experience in nursing, but have a bachelor's in something else

Michigan department of mental health (MDMH) and CMHs

-MDMH created shared and full management contracts with CMHs -shared responsibility for planning and coordinating mental health services in a county -CMHs would take full responsibility for administering mental health services in their area; previously, state was responsible for all; shift responsibility for public mental health services to CMHs from MDMH -CMHs given more funding, but assumed more responsibility for mental health care; responsible for allocating state funding for services at state-run hospitals and centers and at community-based organizations

Michigan community mental health (CMH)

-MI has publicly funded mental health system -permitted counties to form CMH boards to support and treat people with severe mental illness, developmental disabilities and substance abuse disorders outside of psychiatric hospitals and institutions -can create CMH in conjunction with other counties or on their own -funding: 60% local, 40% state -have Michigan Mental Health Code that is basis for creating these; increased state matching funds to 90%

Primary payer for long-term services and supports

-Medicaid (51%) -other public (21%) - this can include Medicare -out of pocket (19%) -private insurance (8%) - most don't have this because it is very expensive and benefit that it pays out is not great

Prepaid inpatient health plans (PIHPs)

-Medicaid behavioral health managed care organizations that administer captitated funds, bear risk for Medicaid patients, and manage Medicaid patients' behavioral health care -funds allocated based on # of beneficiaries in PIHP service area -PIHPs pay providers directly -providers include CMHs as well as community-based providers under contract with CMH or CA -receive monthly capitated payments from MDCH -issue Medicaid payments to doctors, hospitals, and other community providers and CMHs -perform gatekeeping and authorization services and monitor health outcomes and standards of care -each affiliated with at least one CMH -responsible for an area with at least 20,000 Medicaid beneficiaries

Insurance payment for NPs services

-Medicare: direct payment for NPs for services; pays 85% of physician rate for same service -Medicaid: FFS programs pay NPs directly, from 75-100% of physician rates; managed care programs - states vary whether NPs are PCPs in managed care -HMOs vary whether NPs are PCPs -oregon first state to mandate that private insurers pay NPs in independent practice same rates they pay physicians for same services

Growth in NP graduates

-NPs are growing in terms of graduates every year -growing pretty rapidly since 2004

Funding for CMHs and other mental health organizations in MIchigan

-Medicaid is major source of funding for Michigan's publicly funded mental health system, and care at CMHs is an entitled benefit under Medicaid -individuals with Medicaid coverage are more likely to reeve care through CMHs than uninsured and underinsured individuals -CMHs providing care for non-Medicaid individuals must use limited state general fund dollars to cover their care -state general fund dollars allocated to each CMH based on historical funding formulas that are modified at state's discretion -general fund dollars to CMHs reduced substantially when expanded Medicaid in Michigan under ACA -decreases have threatened ability of CMHs to deliver care to many of those in need -only non-Medicaid patients with the most severe mental illness of developmental disability receive care; many have waiting list -Medicaid funds allocated monthly to each CMH through PIHPs according to the number of beneficiaries in the PIHPs service area; no waiting list -emergency cases are an exception and are treated immediately regardless of persons ability to pay

Reimbursement status

-Medicaid reimbursement OK'd in 49 states, but could be less than physicians' fees (up to states to allow direct Medicaid reimbursement, many don't allow it) -complicated laws at state level that talk about which practitioners can practice under what circumstances; whether managed care plans have to bring on their panel anybody who is willing to practice under their circumstances = any willing provider act; can't only take certain providers in health plan - health plan has to be willing to hire others; health plans has to be willing to hire other person -other federal programs (e.g. FEHBP) allow direct reimbursement for NPs; many different health plans - federal employees get to make choices among many different plans - to be in this health plan, have to be willing to reimburse NPs; very important because many federal employees; not one insurer, but an option for federal employees can choose from many different plans - but all of them willing to reimburse NPs -in many states, any willing provider acts allow NPPs to participate in HMOs with direct reimbursement

Prime target for reducing national deficit

-Medicare -due to baby boomers, cost of care for elderly, etc.

Payment for long-term care

-Medicare and Medicaid are primary payers; each program pays for all or part of the services received by about 1/3 of community residents -1/4 pay out of pocket -private insurance rarely pays for such services -some 19.3% get their help paid for, in whole or in part, by some other source, generally a state or local program -people needing ADL help more likely to receive federally funded services, and much less likely to pay for the bulk of their services, than people needing only IADL help -much smaller # of non elderly than elderly receive paid help -services provided for people <65yo more likely to be paid for by Medicaid -nursing homes significantly more expensive than community resident care; differences in level of need could account for some, but not all differences in spending -out of pocket spending greater for institutional than non-institutional services -non-institutional services account for only 22.9% of total budget -80% of budget goes towards those 65+yo; elderly recipients account for majority of both community-based and nursing home-based expenditures, but most spent on institutional services; most comes from public spending, but substantial out-of-pocket

Expenditures on nursing home care

-Medicare and Medicaid payments account for >1/2 of these (skilled nursing facilities, nursing homes, or continuing care retirement communities)

Registered nurse safe staffing act introduced 2015

-Medicare participating hospitals must implement a hospital-wide staffing plan for nursing services furnished in the hospital -requires an appropriate number of registered nurses in each unit and each shift of the hospital to address the unique characteristics of the patients and hospital units and result in the delivery of safe, quality patient care -requires each participating hospital to establish a hospital nurse staffing committee to implement plan -penalties for violation of the requirements of the act -whistleblower protections -introduced US senate (S1132) and house (HR 2083) -if nurses are going to be professionals/expected to practice at a level that produces best care, need to be protected on the demands the hospital/field puts on them

NPs payment for primary care

-Medicare pays NPs practicing independently 85% of the physician rate for the same service; no analytic foundation for this difference; to change it, would have to change Medicare law, and would increase total Medicare spending if rates not offset by other savings -what Medicaid pays them compared to physicians varies state to state, most pay less; ACA calls for enhanced Medicaid payment for primary care and recommends same rates to NPs -health insurance plans have significant discretion to determine what services they cover and which providers the recognize; not all cover NP services; don't always recognize NP as primary care provider required -IOM recommended changes at state and federal levels to allows NPs to practice to the full extent of their education - requires FFS plans within state to cover NP services (including changes to Medicare coverage)

Medicare nursing home patients

-Medicare provides coverage for "skilled nursing facility services" for restorative rehabilitative care for up to 100 days immediately after an inpatient hospital stay for same condition or its sequelae -Medicare pays generously for these services -Medicare nursing home stays are frequent but brief, so Medicare beneficiaries account for large proportion of nursing home admissions but smaller proportion of average census

Medicare and ACO

-Medicare started ACO program, with many health plans following suit -1 in 4 Medicare beneficiaries chooses to be in private health plan through Medicare Advantage - they accept restrictions on choice of provider in return for better-coordinated care -ACOs different because beneficiaries don't join an ACO - providers do - patients can see any provider, but some of them may fall within a certain ACO -Medicare beneficiaries won't get any of the savings for being in an ACO, and don't have a choice whether to participate or not (paternalistic deciding what we think they need) -when trust fund saves through ACO savings, the security of Medicare grows, and premium growth can be better contained

Nurses are not doctors

-NY state passed bill granted NPs the right to provide primary care without physician oversight -support widespread; IOM called for dropping regulations that prevent nurses from practicing to the full extent of the education and training -physicians opinion: proposals underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of NPs -reason for primary care shortage is that they pay less than other specialties for physicians so interest is low along with baby boomers aging -while NP praised for being sensitive to patients' psychological and social concerns, appear to order more diagnostic tests than do their physician counterparts; also more specialty visits and hospital admissions; these cost differences are important and may offset or negate any cost savings achieved by hiring NPs in the place of physicians; plausible that they order more tests and expert consultations to compensate for a lack of training -medical school graduates are not considered fit to practice medicine independently; yet, NPs with perhaps less clinical education will be allowed to do so -have to know a lot to specialize in primary care; you are the first person a patient sees with a problem so have to know many different diseases rather than specializing in a single area -should be focusing on doctors for primary care and finding a way to increase their pay

Nursing home personnel

-RNs, LPNs/LVNs, and aides/orderlies account for 63% -within that, aides/orderlies are 41%, LPNs/LVNs 13%, RNs 8% -physician often oversees all of the care, but not on site

Detroit: community health and social services (CHASS) center, inc

-Ricardo Guzman - CEO of CHASS, chair of board NACHC -established in 1970s in response to community hospital closures in Detroit -1993: CHASS became an FQHC -partnership with henry ford health system -focus on three main barriers to health care: language; convenient access; and transportation -large % of Latino's who went to this center because they did not have anywhere to go when community hospitals closed in the 70s -this site experienced a lower decrease in number of uninsured patients who went to their site; partly due to eligibility of Medicaid and private coverage - may not cover because they are either immigrants or undocumented (either will never quality or have to wait a period of time) -in 2012 opened a new facility that allowed them to see many more patients (3x as big as original site); now has dental office, labs, walking track, etc. and many more services provided; responding to needs of the community and what they have been asking for; also developed nutrition program with demonstration kitchen

ACA's value-based purchasing program

-a way to exert additional pressure on hospitals to meet mandated quality benchmarks -Medicare payments will reduce payments to all hospitals for specific conditions -these funds will be reallocated to reward the hospitals that have done the best job of meeting the quality benchmarks that CMS will establish annually - they concern the process of care and patient satisfaction, and mortality statistics

Main reason for high hospital costs in the US

-fiscal, not medical -hospitals are the most powerful players in a health care system that has little or no price regulation in the private market

Fiduciary duty of the board

-a legal obligation of one part to act in the best interest of another -act in good faith - in best interest of the organization -operate according to the by-laws, mission -expectations and performance standards -a fiduciary duty is the highest standard of care at either equity or law; a fiduciary is expected to be extremely loyal to the person to whom he owes the duty: he must not put his personal interests before the duty, and must not profit from his position as a fiduciary, unless the principal consents -this term also connected with finance, but that is not the case - talking about acting in the best interest of another; board is a fiduciary for the community and health system in general

Horizontal integration

-a lot of hospitals together who are providing the same service; get together to recognize inefficiencies -they are all about the same in what they provide to the system

Medical divide definition

-a medical device is an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article -intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease -intended to affect the structure or any function of the body of man and which does not achieve any of its primary intended purposes through chemical action and which is not dependent upon being metabolized -physical thing that interacts with the body in a physical way, not a chemical way like prescription drugs

Vision statement

-a more emotionally or morally based statement of what the organization intends to do -organizational philosophy that guides the operation (has to do with operations and how operations are guided)

Vertically integrated system definitions

-a network of organizations that provides, or arranges to provide, a coordinated continuum of services to a defined population that is willing to be held fiscally and clinically accountable for the health status of the population served -a contractual or ownership relationship between hospitals and physician practices; such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals -ACA encourages ACOs; coming together of physician groups and hospitals to create and share in savings through promoting community health; one type of vertically integrated systems -provide continuum of care; some have hospitals, some outpatient, some long term care, etc. -they all provide different things to the system -vertical integration supposed to improve inefficiencies in system due to lack of coordinated care

Pillars of PCMH

-a patient-centered orientation: toward unique needs, culture, values and preferences; support of patient self-care efforts; involvement of the patient in care plans; have to make sure patients understand what you are telling them - longer appointments become necessary and are more expensive -comprehensive team-based care: meets majority of physical and mental health care needs (prevention and wellness, acute care, and chronic care); not only physician or primary care, but also behavioral health services; this is not well executed yet; behavioral health needs often poorly addressed -care is coordinated: across the health care system, connecting patients to medical and social resources -superb access to care: including care provided after hours, email, phone; do not get paid for answering email, so often not include to do this - in PCMH physicians more inclined because it is part of their required care they they get financial incentive/higher reimbursement overall for doing -system-based approach to quality and safety: assessment of patient experience data, quality improvement efforts, population health management

Problems health centers face

-access to specialist care is a problem system-wide, attributable to health care workforce shortages, geographic maldistribution of the workforce, and physician participation behavior (specifically with uninsured and Medicaid patients) -many patients face gaps in covered benefits and interruptions in their Medicaid coverage, which hinder efforts to deliver continuous and comprehensive care

Functions of the physician organization

-achieve excellent care (continuous quality improvement, case management, prevention) -credentialing and delineating privileges for physicians and related professions (recruiting and selecting new members, renewing privileges) -planning and implementing physician recruitment (physician needs planning) -providing clinical education for physicians and other professionals (case reviews, protocol development, scientific programs, GME = graduate medical education which is training of residents in a health system - organizations want to be involved in deciding how physicians are trained) -communicating and resolving unmet needs (bringing clinical viewpoint to governing board, strategic planning and budgeting) -negotiating and maintaining compensation arrangements (negotiating and implementing various financing opportunities) -governing board may not have clinical training, but bring outside perspective - need to inform the board of clinical practices -organizations want to be a part of developing the protocols that will be implemented in the health systems

Health center growth

-achieved steady growth -3 major expansionary cycles, coincided with successive expansions of Medicaid eligibility -first, Medicaid expansion in 1990's; then, inclusion of FQHC services as mandatory Medicaid benefits - lead to significant expansion of health centers -from ACA, expect that Medicaid and private insurance coverage will increase, and increase flow of third-party payments into health centers from higher rates of coverage; ACA increasing rates the plans on the exchange have to pay

Medicaid spending on long-term care

-acute care (62%) -long term care (33%) - of this, 57% institutional care, 43% home and community based services -disproportionate share hospital payments (5%)

Acute care vs. long-term care

-acute care: crisis oriented; sudden onset; responds to treatment or is self-limiting; high tech care; short-term disability -long term care: long term chronic illness or disability; gradual onset; limited opportunities for recovery, not self-limiting; low tech care; chronic disability; requires long term, broad range of services - NOT SIMPLY MEDICAL CARE OVER AN EXTENDED PERIOD -long term care more focused on activities of daily living such as feeding; many in these facilities have some aspect of dementia and this is why they are there in the first first place

Payments for mental health/substance use care

-adjusted capitation, bundled/episodic payments encourage continuity and efficiency -"carve outs" - specified services that are organized and administered separately from the service mix in which managed behavioral health care organizations and some community mental health centers function under various forms of capitation -CMS commitment to design of more coherent and stable organizational arrangements and payment incentives

Americans with long term care needs

-age 65+ (44%) -under age 65 (41%) (have some sort of disability ; mostly dual-eligibles) -nursing home residents: age 65+ (14%), under age 65 (2%) - most who are nursing home residents are the elderly -50.2% are under 65, 49.8% are over 65 -in institutions, majority are over 65 -among community residents, fairly even, but slightly more under 65

Increased demand for ambulatory services

-aging population important driver to increased demand and lack of access to ambulatory care -result is created hospital crowding and longer waits for services, including ED care and ancillary testing -demand for hospital outpatient services has grown steadily, contributing to increasing % of gross revenues for acute care hospitals

Levels of horizontal integration

-all long term care or acute hospital, etc., but across different locations -ex. including 3 hospitals that all only offer acute care

Medicaid long-term care benefits

-all states are federally required to cover nursing facility benefits -coverage of community-based services can be provided at state option -three pathways for Medicaid coverage of home and community-based care: mandatory home health services; optional personal care services; and home and community-based waiver services -states may provide home and community-based services to individuals "at risk" of needing institutional care if they get special permission from the federal government, call a "waiver" (waiver: state wants to do something a little different than the federal government sets out - do things differently that they think work better in their state) -states can develop programs that target specific populations such as people with development disabilities, elderly, or persons with HIV/AIDS

US hospitals and 19th century

-first voluntary hospitals (Pennsylvania hospital in 1951, NY hospital in 1773, Mass general in 1816) -social welfare institutions "harboring those shunned by society" -provider of indoor relief -hospitals served a broad, useless role -providing relief but not doing much

Community mental health authority

-alterative designation for CMHs to exist as a government entity, independent from the county/counties that founded them -authorities afforded powers that were not available to agencies such as owning and maintaining property, and constructing and operating facilities -operate independently from county government

ED/emergency services

-although designed to care for the acutely ill or injured patient, EDs also serve as a major source of walk-in services for less sick patients -emergency services bolstered by the emergence of emergency medicine as a formally recognized medical specialty -many hospitals have developed walk-in care centers to relieve EDs from having to assess and treat patients with conditions that do not demand immediate attention -nevertheless, EDs remain a common point of contact with the health care system for a large number of people with no regular source of care

Traditional model

-although each department retains relevant medical specialists, it does not provide the support services required by the physician to provide care, such as nursing, housekeeping, etc. staff -physicians not part of the hospital chain of command -referred to as dual authority structure -physicians not hospital employees

Substance abuse coordinating agencies

-amended public health code to create these in the state -do not deliver care directly but plan for and oversee public services for substance use disorders in the counties they serve

Nurse practitioners - cost effective

-american association of nurse practitioners evidence shows NPs deliver high quality care and are less costly than physicians -less costly to train (less years of education) -lower salaries -patient LOS (length of stay), ED use and hospitalization rates comparable to physicians -demonstrated lower costs in all settings - primary care, acute care, long-term care

Primary care practitioners perspectives on delivery system changes: physicians view increased reliance on NPs and PAs as more negative than positive for overall quality of care

-among all physicians: positive (29%), negative (41%) -among those with NP/PAs in their practice: positive (40%), negative (35%) -among those with no NP/PAs in their practice: positive (14%), negative (52%) -among all NP/PAs: positive (8%), negative <1%)

Beneficiaries living in the community

-among beneficiaries who use long-term services and supports, a larger share of non-elderly people with disabilities live in the community than seniors -seniors: about 50/50 on who lives in institutions vs. community -non-elderly people with disabilities: 80% live in community, 20% live in institution

Patient-centered medical home (PCMH)

-an approach to providing comprehensive primary care for children, youth, and adults -the PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient's family -concept introduced in pediatrics in 1960s

Post 1890 - great advances in scientific medicine

-anesthesia -aseptic techniques -x-rays -blood typing (learned benefit of getting people the same type of blood for them) -professional nursing and flexnerian reforms (Flexner report: how bad training was for physicians and improvements needed) -changed what hospitals did; had these techniques for the first time -allows hospitals to deliver services that originally they couldn't -learned about germ theory - learned how to perform good surgeries

Flow of physician credentialing

-applicant submits application and documentation of education and certification -executive staff review of application for completeness, check against national data base, and consistency with ned -review by specialty department -review by credentials committee -either negative or positive decision -negative decision can appeal hiring before credentials committee -positive decision: review by executive committee of physician organization; review by institutional governing board; privilege granted for specific activities for 1 or 2 years; renewal process; executive staff review for comp liane with outcomes standards, check against national database; then go back to review by specialty department, etc.

Late referral for hospice

-application of a curative model to end-stage incurable illnesses -Medicare's per diem hospice reimbursement, which precludes costly, aggressive therapies -the mistaken view that patients must have a do-not-resuscitate order -most important delay factor is physician attitudes - regard the death of a patient as a professional failure; also fear they will destroy their patients' hope; physicians view hospice care as something reserved for imminently dying instead of as a service designed to help people live as well as possible in advanced incurable disease

Role and scope of nurse practitioner

-application of advanced knowledge and skills: management of a wide range of health problems through physical examination, diagnosis, treatment, and patient/family education and counseling; primary care and health promotion -patient population served: individuals and families (women, infants and children, elderly, adults and others) -practice settings: primary care, long-term care, ambulatory and community care, tertiary care

Role and scope of clinical nurse specialists

-application of advanced knowledge and skills: management of complex patient health care problems in various clinical specialty areas through direct care, consultation, research, education and administrative roles -patient population served: individuals with physical or psychiatric illness and disability, maternal and child health problems, gerontologic problems -practice settings: tertiary care, ambulatory care, community care, home health care, rehabilitation

Role and scope of nurse anesthetist

-application of advanced knowledge and skills: pre-operative assessment, administration of anesthesia; and management of post-anesthsia recovery -patient population served: individuals in all age groups undergoing surgical procedures -practice settings: hospital operating rooms, ambulatory care, surgical settings

Role and scope of certified nurse midwives

-application of advanced knowledge and skills: well-women health care, management of pregnancy, childbirth, antepartum and postpartum care; health promotion -patient population served: childbearing women -practice setting: homes, hospitals, birthing centers, ambulatory care

Increase in total drug development time

-approval process staying the same or shrinking in terms of FDA work; pre-clinical and clinical time is taking longer now -in 1960s used to take around 8 years, with pre-clinical taking around 3, clinical taking about 2.5 and approval taking about 2.4 years -in 1990-96 increased time to about 15 years; preclinical now takes 6 years, clinical takes 6.7 years, approval take only 2.2 years now

What is private long-term care insurance?

-approximately 8 million private long-term care policies are currently in force -most private long term care insurance plans cover portion of nursing homes, assisted living facilities, home health care, hospice care, and respite care: other common benefits are case management services, homemaker or chore services, caregiver training, coverage of some medical equipment, and reimbursement of bed reservations in long-term care facilities; coverage is typically time-limited, requiring beneficiaries to estimate the amount of time that services will be needed -private long-term care insurance can be expensive, especially for the low-income population: in 2007, the average premium was $2,207/year; premium charges rise with age) -small proportion have private long-term care insurance -case management is a good aspect to this insurance - have all of their care coordinated; coordination important for those in nursing homes, who may need to frequently visit hospitals for acute care; care coordination rarely paid for outside of private insurance

ACA implications on tax-exempt hospitals

-as ACA mandate for individual health insurance is fully implemented, the need for hospital-based charity care should decline substantially -expansion of Medicaid coverage may add financial pressure on hospitals to cover the costs of patient care that exceed Medicaid payments -community-benefit expenditures have been largely directed to patient care services; do not contribute to prevent care and population health, which are key priorities of ACA -safety net for poor/uninsured

Resource allocation issues

-as a health officer running a local health department, or an official in state health department, you are a steward of public funds -criteria/questions to consider when deciding what public health services to invest in/provide: greatest net benefit? help greatest number of people? for which populations? which services?

Long-term care for seniors

-as a result of physical and cognitive impairment, 70% of seniors will need LTSS; average length of time needing assistance with ADLs is 3 years -Medicaid is the primary payer for long-term care (40%); Medicare post-acute care (21%); other (18%); out of pocket (15%); private insurance (7%); contrary to popular perception, Medicare does not provide extensive long-term care coverage, Medicaid is only available to individuals with limited incomes and assets -the number of americans aged 65+yo is growing dramatically (baby boomers) -the number of americans needing long-term care will more than double by 2050 -48% of americans 40+yo say that almost everyone will need long term care as they age; 35% say they have set aside money to pay for their long term care needs -Medicaid spending on long term care has been shifting toward community-based care -87% of the 12 million americans who need long term care receive it from unpaid family caregivers

Hospital mergers

-as result of ACA, many mergers with hospitals scrambling to shore up their market position, improve operational efficiency, and create organizations capable of managing population health -last hospital merger wave in 1990's led to substantial price increases with little or no benefit -most of deals today involve health care providers that cover separate geographic or service areas; non-horizontal combinations; currently not good evaluation on these mergers

NP process of care

-assess health status -diagnose -develop treatment plan -implement plan -follow-up and evaluate health status -practice emphasizes patient/family education, patient self-care, promotion of optimal health, continually competent care, facilitating access, safe environments -interdisciplinary collaboration (others in health care system often work independently, or with people mostly in their field; NPs work across professions) -accurate documentation of status and care -quality assurance and practice competence -patient advocate -uses research as basis of practice

Formal methods for setting priorities

-attempt to infuse rationality, professionalism into allocation processes -defined, consistent, written processes: criteria for whether organizational goals are being met; criteria can be applied to various program/service options for ranking -may include stakeholders, members of public as well as managers, staff, legislators

Ex. becoming a doctor, to become a doctor one must:

-attend a medical school accredited by a private body -take a national exam administered by a different non-gov't organization -obtain licensure from a state medical board -complete a hospital residency that is funded and governed by federal Medicare program -achieve certification from private specialty board -obtain clinical privileges at hospital that may be private or public -to get paid, probably need to qualify for participation in Medicare and/or a managed care organization

"Carve-out" for behavioral health services

-created under federally approved waivers -AKA prepaid inpatient health plans (PIHP) -must provide coverage to Medicaid recipients suffering from mental health issues, developmental disabilities, substance abuse, or serious emotional disturbances -must cover at least 20,000 Medicaid beneficiaries

Nursing stats general

-average age = 50 (very old field of people on average, aging profession) -percentage of working nurses over age 50 = 53% -percentage of nurses under age 40: 1980=54%, 1992=44.8%, 2000=31.7%, 2004=26.6%, 2008=29.5% -today, women have other options, so fewer people are going into this currently

Inpatient admissions to community hospitals, 1946-2012

-average length of stay has decreased; decreased largely around 1984 when Medicare put in prospective payment method - no longer pay for how many days patient is in hospital, but for what they are in hospital for - makes hospitals more efficient in their care -slight increase in admissions

State health inspections of nursing homes

-based on state health inspection reports that provide multiple types of information on nursing home deficiencies identified during annual inspections -includes number and severity of problems, revisits need to document that deficiencies were corrected, and actions taken by nursing homes to investigate complaints -weigh deficiencies that cause immediate jeopardy to resident health or safety more heavily, particularly when infractions are widespread and not isolated incidents -examples: failure to prevent/treat bedsores, failure to maintain food storage in areas free of pests, etc. -based on ranked performance of facilities within state to control for variation among states (lowest 20% get 1 star, highest 10% get 5 stars)

Primary care physicians and other specialties

-because of much stronger expected growth in the numbers of NPs and PAs relative to those of physicians, the share of primary care providers who are physicians is expected to shrink from 71 to 60%

Rational for regulatory reforms rests on 3 basic principles

-because the current system is unmanageable and duplicative, it is not service the objectives it was designed to achieve -the implementation of ACA will be disrupted without an adequate regulatory structure in place -the rapidly changing health care delivery system requires a dynamic regulatory capability, as opposed to the static regulatory approach now dominant

Creation of FDA

-before FDA, drug safety seen as best left to the discretion of physicians -FDA authority should compel companies to provide efficacy and safety data before a product could be sold; some thought it was unnecessarily trying to expand the power of government, threatening viability of pharmaceutical industry

How community health centers formed

-before health center movement access to care was difficult for some people (low income populations) - barriers like transportation and wait time and inefficient care -chronic health care model based on belief that poor get sicker and sicker get poor - believe community health centers can address roots of poverty and provide affordable/accessible care -economic opportunity act (1964): Johnson started health centers; economic opportunity act established funding for first community centers -community health center program (1975): congress authorized neighborhood health centers as community and migrate health centers - added primary care for residents of public housing and the homeless; guiding principles of community health centers were a focus on the need of service the underserved, functioning as a site of comprehensive primary care, providing high quality care delivered by professional staff, involving the community, and establishing partners in private/public sector and making a board -omnibus budget and reconciliation act (1989): established reimbursement methodology that set a minimum payment for FQHCs at 100% of the cost for an office visit; these payments reflect the actual costs of operation for FQHCs; costs of FQHC for the visit, not just the time and resources for the provider; related to Medicare and Medicaid patients; AKA enhanced reimbursement rate; purpose is to bring revenue -health center consolidation act (1996): combined different health centers into one health center program; today, health resource and services administration (HRSA)

Drug approval process: pre-clinical stages

-before it enters a human -first, drug sponsor develops a new drug compound and seeks to have it approved by FDA for sale in the US -first stage in pre-clinical: animal tested: sponsor must test new drug on animals for toxicity; multiple species are used to gather basic information on the safety and efficacy of the compound being investigated/researched -second stage: IND application: the sponsor submits an investigational new drug application to FDA based on the results from initial testing that include, the drug's composition and manufacturing, and develops a plan for testing the drug on humans -after this, linking to clinical trials, have IND review: FDA reviews the IND to assure that the proposed studies, generally referred to as clinical trials, do not place human subjects at unreasonable risk of harm; FDA also verifies that there are adequate informed consent and human subject protection

Hospice

-began more than 30 years ago, and added to Medicare entitlement program in 1983; now part of mainstream medicine; increased use, but still misunderstood largely by both physicians and patients -successfully addresses critical end of life concerns: dying with dignity, dying at home and without unnecessary pain, and reducing the burden placed on family caregivers -consistently high family satisfaction -primary goal: ensure that pain and such symptoms as insomnia, dyspnea, depression, constipation, agitation, nausea, and emotionally and spiritual distress are aggressively addressed

Examples of quality measures related to LTSS rebalancing and community integration

-beneficiary surveys: beneficiary's level of satisfaction with current living arrangement; ability to choose where she lives; degree of control over her daily activities; amount of community involvement in work and leisure activities; and whether beneficiary is receiving adequate services to support her needs -numeric reporting requirements: number or % of beneficiaries living in institutional or community-based settings; transitioning between institutional and community-based settings; and experiencing decreases in personal care hour authorizations

Parallel model

-creation of a separate organization to conduct certain activities that are not handled well by the formal hospital organization -certain physicians not selected to participate in a parallel organization for a certain % of their time, to work on important problems, and to report back to the formal structure

ACA changes to behavioral health services

-benefit people with mental illness who typically faced coverage denials in the past because of their existing behavioral disorders -delivery and payment innovations introduced by ACA could facilitate provision of behavioral health services that are not usually reimbursable including comprehensive care management, care coordination, social support, transition care, collaboration, social support, transition care, collaborative care, and other evidence based interventions

Benefits to NPs as primary care provider

-better results on patient follow up, consultation time, satisfaction, and then provision of screening, assessment and counseling -lower costs associated with NPs care; cost for a visit 20-35% lower than for physician visit -using NP's and PA's in delivery of primary care could result in substantial health care savings if implemented in other states

Overall need/goal for hospitals to make improvements in quality and efficiency of care

-boards need to focus less on individual providers' competence and more on how the entire system of inpatient and outpatient care functions -each hospitals quality oversight program is likely to be unique, reflecting the degree of board engagement in the process, the time and financial resources available, the changing legal and regulatory environment, and the hospitals individual culture

Functions of operational leadership

-boundary spanning - monitor external stakeholders, proper size/staffing by services line -knowledge management - through clinical/business information systems -accountability & corporate design - annual goal-setting, integration through corporate structures -continuous improvement -operational infrastructure - evaluate evidence about improvement processes

Glaxo says it will stop paying doctors to promote drugs

-british drug maker, glaxosmithkline will no longer pay doctors to promote its products and will stop tying compensation of sales representatives to the number of prescriptions doctors write (instead paid based on technical knowledge, quality of service they provide to clients to improve patient care, and the company's business performance) -ending 2 common industry practices that critics have long assailed as troublesome conflicts of interest -for decades, pharmaceutical companies have paid doctors to speak on their behalf at conferences (sometimes providing the financial support for them to attend the conference - not in US but in other countries) and other meetings of medical professionals, on the assumption that the doctors are most likely to value the advice of trusted peer - all of these payments will be made public under requirements of ACA -will continue to pay doctors consulting fees for market research because it is necessary for the company to gain insight from doctors about their products -will continue to provide "unsolicited, independent education grants" to continue educating doctors about their products; largely provided to for-profit companies that rely on these payments from drug companies

Nursing home industry today

-broadening services beyond residential care to continuum of services -sub-acute care (what Medicare pays for; rehabilitative services that follow some sort of acute care such as hip surgery) -adult day care -housing: assisted living, continuing care retirement communities (ex. glacier hills where affluent couples can move into these retirement communities, likely when one of them needs more care/attention than the other; they can move in to the area together and as they require more care, move into different part of the retirement community) -respite care: exhausting for family members to take care of their family members in the community - sometimes they need a break; nursing homes starting to offer respite care where it can be delivered in their home, or wherever they are in the continuum already -intermediate care for those with intellectual disabilities - optional medicaid benefit

Quality measures for nursing homes

-calculated using the minimum data set - an assessment instrument that nursing homes use to document the function and health status of their patients -have 11 selected measures, some applying to short-stay and others to long-stay patients

Options to restore credibility and trust in industry sponsored research

-can be involved in designing clinical studies, but the data analysis should be performed by academic investigators who are not employed by the company sponsoring the research; no financial interest in study outcome -preparation of manuscript reporting the study results should primarily be the responsibility of the academic investigators, especially with respect to the initial drafts of the paper, which establish frame and tone of article -data from clinical trials could be made publicly available to qualified investigators for analysis of important research questions; data sharing should be the norm; promote transparency -industry could agree to refrain from direct-to-consumer advertising for some specific period after a drug is approved or until post-marketing studies are completed; need post-marketing studies to know the trust risk and safety profile of drug in "real-world" patient population -physicians may have more confidence in prescribing product if integrity and trust in industry sponsored research is restored and studies show product improves health of patients

Primary care practitioners perspectives on delivery system changes: practice participation in an ACO arrangement with Medicare or private insurance

-currently participating = 29% -preparing to participate = 9% -not participating = 32% -not sure = 28%

Primary care services

-can be provided by a range of practitioners, all of whom have advanced degrees and can examine, diagnose and treat patients: physicians, PAs (oriented in medical way; different from medical assistant who takes vital signs in doctors office), NPs (oriented in nursing way - nurses about being patient advocate and considering the whole person) -PAs must practice with a physician, NPs may or may not work independent of a physician depending on state scope of practice laws (legal framework that providers in the state can practice on their own)

Long-term care services

-can be provided in institutions or the community, and are essential to the well-being of many elderly and non elderly people with limitations in performing daily activities -most long-term care spending goes to the relatively small minority of long-term care recipients living in nursing homes, that the vast majority of community residents needing long-term care get only unpaid help -although about 1/2 of all long-term care recipients are under 65, 4/5 of long-term care spending is for elderly recipients

Implications of LTSS financing

-care gap of those who can't afford LTSS can not only harm those who need assistance, but also increase cost of Medicare which pays for hospitalization and other medical treatment that often result from acute episodes cause by inadequate assistance -1/5 family caregivers report high levels of emotional and financial stress; >3/5 say that caregiving limits their ability to do paid work

Resource allocation decisions

-central to public health systems operations, yet we know little about the allocation decisions confronted by local public health officials -study aimed at gaining understand of the types of allocation decisions LHOs make and what influences those decisions

Nursing home certification/quality

-certified by either Medicaid or Medicare or both; meet minimum standards as a condition of their payment -serious concerns about the quality of nursing home care and adequacy of oversight and enforcement -created nursing home provisions in OBRA act, but problems persist -CMS launched 5-star quality rating system to provide summary information to help consumers choose a nursing home in their area, working on continually improving them

Continuous changing landscape: payment models drive integration of care delivery

-changes in ACA that changes how health systems are organized and how care is delivered -FFS is most loose way in providing service; little effort in the system to capture savings and efficiencies - as become more integrated, more incentive to squeeze efficiencies out of the system -from least to most integrated: FFS, pay for performance, patient centered medical homes, bundled payments, ACOs, capitation

Clinical trials

-clinical phase in humans -take steps to make sure it does what it should do with larger and larger numbers of people - don't immediately give it to thousands of people -phase 1: 20-80 is the typical number of healthy volunteers used in phase 1; this phase emphasizes safety; the goal in this phase is to determine what the drug's most frequent side effects are and, often, how the drug is metabolized and excreted -phase 2: 100's of patients used in phase 2; this phase emphasizes effectiveness; this goal is to obtain preliminary data on whether the drug works in people who have a certain disease or condition; for controlled trials, patients receiving the drug are compared with similar patients receiving a different treatment - usually a placebo, or a different drug; safety continues to be evaluated and short term side effects are studied; at the end of phase 2, FDA and sponsors discuss how large-scale studies in phase 3 will be done -phase 3: 1000s of patients used in phase 3; these studies gather more information about safety and effectiveness, study different populations and different dosages, and uses the drug in combination with other drugs -approval phase: new drug application; phase 4 trials

Withdrawal of pioneer ACO programs

-commonly included un-sustainability of the financial model for already-efficient organizations and concerns that savings that are determined by CMS in comparison with benchmarks may underestimate actual savings achiever by ACOs -reduction in spending may be more difficult for efficient organizations, which have fewer opportunities to cut wasteful care

Rural hospitals: a community's anchor

-community hospital important to community beyond the inpatient care that they provide -educate future health care providers -it is a central business point; many are employed by the hospital -important emergency center in the community (since 9/11 have put lots of resources into emergency preparedness because realized not adequately prepared) -also place to educate community, have members gather under certain situations in emergencies, etc. -partnerships around keeping the community healthy; in rural area, rural hospital runs community wellness programming while in urban areas often have separate organizations doing this -many have closed over the years (hard for not for profit hospitals with low occupancy rates to stay open - lose jobs in community, have to travel for care, lose other benefits of the hospital) -get donations from community members and other businesses in the area; large interest in keeping these open -have a board; those on board in rural communities considered very important -access to primary care -safe haven in times of emergency -jobs for community members -24/7 care -community partnerships to ensure wellness and total health -rural america includes about 18% of population, and 84% of geographic area of US -there are 1,855 rural hospitals that support nearly 2 million jobs -every dollar spent by a rural hospital produces another $2.29 of economic activity -a typical critical access hospital employs 213 community members -rural hospitals handle more than 21.5 million emergency visits

Services provided by NPs

-comprehensive health histories and physical exams -diagnosis and treatment of acute problems such as infections and injuries -diagnosis, treatment and management of chronic problems such as asthma or diabetes -routine care such as prenatal, well child care, preventive adult care -order and interpret lab tests, x-rays and other diagnostic studies -preventive health guidance and counseling -referral to specialists for additional services as needed

Consequences of vertical integration

-consequences of looser forms of vertical integration (not fully integrated) were more benign and potentially socially beneficial; did not affect price or spending significantly and even decrease hospital admission rates; consistent with theory of improving coordination of care -has potential to increase the market power of providers, and to encourage physicians to supply inappropriate treatments by facilitating hospitals' payments of kickbacks that would be illegal if they were made formally -concern that it might have unintended harmful consequences for consumers -greater coordination of care, especially between physicians and hospitals, would be in the patients best interest

Primary care practitioners perspectives on delivery system changes: nearly half of all physicians say they are considering early retirement because of health care trends

-considering early retirement = 47% -retirement plans unaffected = 34% -considering delayed retirement = 18%

Changes in pharmaceutical industry

-consolidation among companies -revenues and profit margins have increased -many "blockbuster" drugs had entered the marketplace -innovation leading to new product development has declined -in 2013, industry will face substantial drug patent expiration, losing patent protection with an estimated value of $35 billion in annual sales; to maintain market share, some companies proposed new uses for or minor modifications to existing products

Retail clinics general

-convenient, low-cost, accessible way to deliver basic screening, diagnosis and treatment; mostly owned by pharmacies and big box stores -more than 10m visits at more than 1800 sites -typically employ NPs and PAs -more prevalent in higher-income areas (unfortunately not locating in areas where access is a problem) -most take commercial and gov't insurance -some indication that quality is comparable to other settings, but impact on clinical outcomes unclear; need more research -unclear whether can reduce total cost of care (add on or replacement for other primary care?); may be at target, etc. and consider that maybe you should get a strep test, when you don't necessarily need them and wouldn't go to the doctors office to get one (not sure if it is making care more convenient, or adding on to what is necessary) -most common to least common: CVS MinuteClinic, walgreens healthcare clinic, kroger little clinic, walmart retail clinics, target clinic, RiteAid RediClinic

Incentives for staffing at health centers

-coordination of new national health service corps investments with health center resources can help optimize efforts to ramp up health centers clinical capacity -residency and training programs partnering -ensure adequate health care workforce, particularly in medically underserved communities

For-profit hospitals

-corporation owned by investors -purpose: management has legal obligation to promote wealth of shareholders within the boundaries of law; does so by providing services -can distribute some proportion of profits to owners -management ultimately accountable to owners (stockholders) -sources of capital include: equity capital from investors, debt, retained earnings (plus depreciation and deferred taxes), return on equity payments form third part payers (Medicare) -revenues derived from sale of services -pay property, sales and income taxes

Non-profit hospitals

-corporations without owners or owned by "members" -purpose: has legal obligation to fulfill a stated mission (provide services, education, research, etc.); must maintain economic viability to do so -cannot distribute surplus to those who control the organization -management accountable to voluntary, self-perpetuating boards -sources of capital include: charitable contributions, debt (generally tax-exempt), retained earnings (plus depreciation), government grants -revenues derived from sale of services and from charitable contributions -generally eligible for exemptions for most taxes

Cost of care

-cost of inpatient and ambulatory care has risen significantly -cost containment central issue in acute care today -patients in higher spending areas receive more care, have more frequent visits, have more tests/minor procedures, and use more specialty and hospital services than patients in lower spending areas, with no effect on health outcomes or patient satisfaction

Mental health insurance coverage: Michigan state law required insured group plans to

-cover intermediate and outpatient care and provide minimum dollar amount for coverage for substance use disorder treatment -cover a minimum of 20 outpatient visits for mental health services

Impacts of ACA

-coverage expansion: prescription drugs included among "essential health benefits" -closing Medicare Part D "donut hole" -annual fees imposed on manufacturers of $5 million-plus drugs -new process for FDA licensure of biosimilar (i.e. interchangeable), including 12 years of exclusive use for most -new authority for the HHS secretary to oversee labeling and advertising requirements -trying to figure out who can take on burden of all this extra spending

Pioneer program for ACOs

-created by CMS -created for high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk

Chargemaster price list

-created by each hospital and almost nothing is free -these are not connected to underlying costs or market prices -move up and down and are extremely variable -after each hospital stay or visit, computer programs and human coders and billers use this price list to translate the services rendered into a price -ER visits typically include separate charges for doctors services and for supplies, as well as "facility fee" for walking in the door -in other countries, conversely, price of a day in the hospital often includes many basic services

ACA improvements in nursing homes

-created federal coordinated health care office within CMS with explicit mandate of addressing the inconsistencies between Medicare and Medicaid policies -developing ACOs to integrate care across the boundary between acute and long-term services -reimbursement experiments with "bundled payments" that cross the acute/long-term care divide, thereby reducing the incentive to shuffle patients back and forth

Partial summary of LTSS

-currently, there is no national system of long-term care insurance - individuals must first rely on their own resources and then primarily on Medicaid -Medicaid is the primary payer for long-term care services -gradual shift from nursing home to home and community-based services -Medicare plays a limited role, and families play a critical role in providing and paying for care -private sector options are still limited and often costly -few policy options currently available to address long-term care needs and costs

Mandatory overtime

-dangerous - negative impact on patient care, increased errors in care -unprofessional treatment -driving nurses away from bedside -lower patient satisfaction -most nurses work 12 hour shifts already; practice today is that nurses are mandated to stay the next shift if someone does not show up -difficult for many nurses - many are parents and have kids at home, have transportation issues, etc. -this type of issue drives many people out of the field when they consider their quality of life

Informal methods for setting priorities

-decisions based on: gut feelings, political concerns, traditions, leaders' preferences, stakeholders' preferences -virtually always present in some form in government allocation processes -we don't have great formal tools for making decisions

Number of nursing school graduates by type of degree offered

-decline in diploma degree beginning around 1985, very low starting in 2000's -as diploma degree went down, bachelor's and associate's degree both went up -associate's degree always higher than bachelors, through 2005 (no data beyond this)

Community hospital trends, % change 1995-2012

-decrease in beds -increase in admissions -decrease in average length of stay -increase in outpatient visits

ACO

-definition: network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending; at heart is the patient's primary care physician -ACA encourages doctors, hospitals, and other health care providers to form these networks that coordinate patient care and become eligible for bonuses whenever they deliver that care more efficiently (specifically in Medicare - providers make more if they keep their patients healthy) -ACA says to be considered ACO, have to manage minimum of 5,000 Medicare beneficiaries for at least 3 years -providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money -doctors and hospitals will likely refer patients to hospitals and specialists within the ACO network, but patients still free to see doctor of their choice outside the network without paying more -can include hospitals, specialists, post-acute providers, and even private companies like Walgreens -must have primary care physicians -because hospitals generally have access to capital, they may have an easier time than doctors in financing the initial investment, such as creating the electronic health system necessary -insurers track and collect data on patients that allow systems to evaluate patient care and report on the results -want to eliminate duplication of services and coordinate patients' care, and to boost preventive efforts that may ultimately reduce the need for high-cost services such as hospital stays -ultimate goal not ACOs, but for providers to take on full financial responsibility for caring for a population of patients for a fixed payment, but that will require a transition beyond ACOs

Advanced practice registered nurses (APRN)

-definition: nurses who have a least a master's degree in nursing, are certified by professional or specialty nursing organizations, and are licensed to deliver care consistent with their areas of expertise and the laws that govern nursing scope of practice within each state -growth in RN workforce has led to increase in # and capacity of APRNs -most work in primary care -often take lead clinical, management, and accountability roles in innovative primary care models such as nurse managed health centers and retail clinics

2 major categories of ambulatory care

-delivered in physician offices by individual physicians (in solo practice or who have organized themselves into partnerships or private group practices) -care organized and delivered under the auspices of institutions; includes ambulatory care provided in hospital-based outpatient clinics, walk-in centers, and EDs; hospital sponsored group practices and health promotion centers; freestanding "surgicenters"; health department clinics; neighborhood and community health centers; organized home care; community mental health centers; school and workplace health services; and prison health services

Projection of RN supply vs. demand

-demand is increasing greatly while supply is actually slightly decreasing -one of the things we could do to increase supply is encourage people to not retire early (delay retirement 4 years)

Departments vs. hospital diagnosis and therapeutic services vs. nonclinical services

-departments: medicine, surgery, OB/GYN, etc. -hospital diagnostic and therapeutic services: laboratory services, radiology, etc. -nonclinical services: finance, human resources, etc.

Problems with informal methods

-dependent on judgment and intuition of a few key individuals: often little opportunity to incorporate the views of broad range of stakeholders, or to access good information about options; "squeaky wheel" or dominant personalities can get more sources than are warranted -lack of transparency -lack of consistency: criteria/measures/reasons used to evaluate programs/services change over time or place

Disabled and employment

-encourage most severely disabled clients to pursue employment (minimum jobs open to anyone) -provide them with support for unlimited period of time -practice with self-presentation, forming relationships, and identifying and resolving problems at work

"Never events"

-describe hospital-acquired conditions that CMS has deemed to be avoidable in most cases through the exercise of reasonable care -CMS defines never events for which they will not pay providers, and has been adopted by commercial payers and state governments, increasing financial pressure on providers to improve patient safety and to change clinical practices and procedures to follow recommended quality guidelines more closely -ACA will extend this by new financial penalties for hospitals that fall short of quality expectations -1% annual penalty of quartile of hospitals reporting highest % of never events -Medicare payments reduced for hospitals with higher-than-expected readmission rates -requires all states to implement "never events" policies or lose their eligibility to receive federal Medicaid $

Employment by hospitals: the hospital's perspective

-desire to compete with other hospitals or large multi specialty groups -get specialists to lead profitable service lines -harder to get specialists to be on call in the ED -fill shortage of specialists in certain fields -preempt competition from specialists (e.g. ASC, specialty hospitals) -increase leverage with health plans -more regular work hours -less frequent call responsibility -shelter from complex, unstable market "we have a lot of financial pressures, from rent to labor to malpractice, and our revenues are well controlled [by health plans and Medicare]-there's no way to increase them a lot; given that lousy business model, the handwriting is on the wall; physicians don't always want to align, but from a business point of view we have to do it

Health center funding

-despite the larger role for health centers envisioned by ACA, in 2011 they experienced their first federal funding setback - reduction in federal appropriation; this diverted millions of $ from the new HCTF to support existing capacity, reducing resources available for expansion -health centers represent the nation's single largest investment in comprehensive primary care for medically underserved -produce an 8:1 return on investment -grants from regular federal appropriates, state and local grants, private philanthropy, and private investment (such as community development financing) -third party payments from public and private health insurers are critical to their survival -funding sources: Medicaid (38%), state/local/private grants/contracts (15%), federal grants (23%), Medicare (6%), private third party payments (7%), self-pay (6%), etc. -shift in funding: in 1985, federal grants accounted for health centers' total operating revenues; now federal grants have dropped and Medicaid increased due to expansion of Medicaid (3 expansion periods), federal legislation making FQHC services a mandatory Medicaid benefit and same legislation requiring state Medicaid programs to pay health centers for FQHC services and other Medicaid-covered ambulatory services in accordance with a prospective established rate that reflects the reasonable cost of care -as revenues from Medicaid have increased, federal grant funding can instead be used to increase the number of uninsured patients health centers serve, services Medicaid does not cover, and expansion into new communities -importance of different sources of revenue depends on location and patients (ex. states that expanded Medicaid vs. did not) -17% patients have private insurance but private third-party payments only 7% of revenues (high deductibles and copays, more limited benefits, and lesser pay for NPs) -even with ACA coverage expansion, federal grants will still be necessary, because those newly insured likely to utilize services more

Class II devices

-devices for which general controls are insufficient to provide assurance of safety and effectiveness and there are existing methods to assure patient safety -this class requires special controls, including special labeling, performance standards, and post-market surveillance -examples of class II devices include power wheelchairs, infusion pumps, and surgical drapes

Class III devices

-devices for which insufficient information exists to determine whether general or special controls by themselves are sufficient assurance of safety and effectiveness -these devices follow controls but also require premarket approval and scientific review of safety and effectiveness -examples of class III devices include replacement heart valves, silicone gel-filled breast implants, and cerebellar stimulators -often things that are implanted into body

Acute care definition

-diagnosis and treatment of active or acute medical conditions in a hospital or ambulatory setting (ambulatory care covers health care services provided on an outpatient basis, requiring no overnight hospital stay) -increasing proportion of acute care has moved to outpatient settings driven by financial incentives, advances in medical technology, and physician and patient preferences -patients more likely to be care for by NP and PAs in addition to primary care physicians for acute care -locations: clinic, doctor's office, outpatient facility, hospital, telephone, internet

Differences in resource allocation

-differ by the size of the population served and governance structure -differences in expenditures associated with variation in need for public health services, the extent to which environmental and clinical services are offered, as well as simply the variation in wealth and capacity of communities to generate local revenues and provide a range of services -median per capita expenditures greater for larger departments and those with centralized governance structure (largely likely have capacity to deliver a wider range of services and activities than smaller departments) -centralized public health systems do not have the same infrastructure at the city or county level that locally governed LHDs have to influence local leaders (smaller/locally governed do not have authority over state resources)

State findings

-differences between states in the overall ratings primarily reflect differences in the 2 domains that rely on self-reported data; as a result, drawing comparisons between states, based on star ratings, is problematic -among the 5 states with the largest number of people age 65+, the share of nursing homes with the best possible rating ranges from 32% in California to just 12% in Texas -2/3 of all counties in the US have at least one Medicare or Medicaid certified nursing home with a 4 or 5 star rating

Educational training of a RN

-diploma (generally trained in hospital program - spend less time in classroom; less professional approach to nursing training; very few of these programs exist anymore) -associate degree (AA) (3 year program; offered at community colleges/smaller colleges) -bachelor's degree (BSN) (essentially the same thing, but at a larger school/4 year college) -diploma, AA, and BSN all sit for the same state board exam and are paid the same thing, have same responsibilities on the floor; although have the same job, they have significantly different training, but this is invisible to the patient -about 40% have BSN, and 40% have AA; current growth in BSN -advance practice nurse: could be midwife, etc.; have master's decree or doctoral degree -master's degree (MSN) -doctoral degree (PhD) -LPNs (LVNs) = non-RNs (virtually the same thing as RN, only a few states don't call them RN; 12 month program and take licensure exam; can do many but not all of the things an RN does; minimum amount of education to be a nurse) -licensed in state by board of nursing -regulations of what RNs can do are different in every state, regulated at state level, even though all take the same exam in every state

Doctorate level degrees

-doctorate improves professional image, promotes more autonomous practice, and serves as an appropriate response to advancing technologies and the increasing complexity of health care -others think doctoral degrees are sought largely for professional status rather than issues related to clinical competence and market demand -added cost has the potential to adversely affect recruitment of low-income and minority students -have not been proven to enhance students' clinical abilities -many do not believe the perceived benefits justify the additional expense, time, and delay in getting clinicians into the workforce

Evaluating clinical privileges/key questions for evaluating clinical privileges

-does the physician comply with the general requirements for continuing education, maintaining certification, and meeting minimum levels of activity? -does the physician correctly perform the procedures that are his or her direct responsibility, including appropriate selection of, compliance with, and departure from protocols -does the physician achieve outcomes consistent with the expectations of the community, with due consideration of differences in the population being treated? -has the physician avoided all activity that directly threatens the rights or safety of patients or colleagues? -does the physician have appropriate interpersonal communication skills, and does he or she abstain from disruptive behavior?

Percentage share of inpatient vs. outpatient surgeries, 1981-2012

-doing more surgeries overall -most used to be inpatient surgeries, now most are outpatient surgeries

Health insurers pressing down on drug prices

-drug companies now have to bargain or be banned -to slow rapid rise in drug prices, more health plans refusing to cover certain drugs unless companies charge less for them; making pharmaceutical makers compete on price -most of increased spending comes not from new drugs or new patients, but from price increases on older drugs that can often exceed 10% year after year -many other countries control drug prices in some manner, so drug companies have become dependent on increasing prices in the US -formularies are lists of drugs that a health plan will cover; they are being tightened; try to wring discounts from drug companies by offering better placement in the formulary; a less expensive drug will have a lower co-payment to encourage patients to use it; becomes a winner-take-all contest - winning companies gain more market share because rivals are excluded, so willing to give greater discounts -drug companies now help patients with their copays through coupons, removing incentive for patients to use lower-priced drugs and lessens incentives for drug companies to bargain -some executives said exclusions could disrupt patients who must switch drugs; exclusions can only be used when there are several equivalent drugs available; can't just go for least expensive, have to think about what is best for patient -patient groups have expressed concern that health plans offered through new exchanges tend to have more exclusions and other restrictions on drugs than employer-funded plans

Brief history of Rx drugs

-drug supply in 19th century US depended largely on imports from Europe -US became a dumping ground for unsafe and unadultered drugs -drug marketplace was so corrupt that many states hired their own chemists to certify the quality of drugs sold -need for comprehensive federal law to protect consumers was recognized by researchers, physicians and pharmacists

Growth in the number of undergraduates by degree and type of education program

-field getting a little more diverse, and more men (from 10 to 13% men; from 7 to 10% hispanic) -more people getting bachelor's rather than associate's -most attend a public institution, although private not-for-profit and private for-profit are increasing

Currently health care regulatory system

-dysfunctional, fragmented, ad hoc arrangement with little structural or thematic coherence -incoherence is in part a function of the accretion of regulatory approaches responding to different eras of health care delivery (FFS, managed care, etc.) -regulations written in bad language, and are susceptible to myriad interpretations; regulatory agencies cannot provide consistent interpretations - leads to muddle of confusion and inconsistent regulation that provide minimal useful guidance to health care administrators and physicians -difficult and costly to implement -regulatory barriers can impede innovative arrangements between physicians and health systems, serving neither patients nor providers -as long as US relies on the private market to improve quality and control costs, we need to create a flexible regulatory system that can appropriately adjust to allow new market innovations (like managed care) the possibility to success -often, failure of new market innovations is due to them not being able to be carried out in the intended way due to regulatory barriers (e.g. ACOs violate antitrust and self-referral constraints because physicians work within a network to provide care) -simply suspending certain current federal regulations would only postpone the need for fundamental and comprehensive regulatory reform -poor regulatory design freezes in time legitimate market arrangements that have the potential to improve quality of care and reduce costs (physician - health system network arrangements) -attorneys and health care administrators are struggling to interpret and comply with their regulatory obligations; compliance with the law is exceedingly difficult for even the best-intentioned providers

Where to start regulation reform

-ease of implementation would be a useful starting point for translating the criteria into practice -then, eliminating duplicative or inconsistent regulations and clearly expressing regulatory goals and rationales are achievable first steps in regulatory reform -other actions, such as finding the balance between costs and benefits, are also crucially important but are more difficult and therefore should be undertaken after regulations gain public legitimacy through clearly specific goals and rationales

Potential downfalls of ACOs

-economists warn that they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they're the only game in town -if ACO unable to save money, it could be stuck with the costs of investments made to improve care; may also have to pay a penalty if it doesn't meet performance and saving benchmarks -hospital mergers and provider consolidation, leaving fewer independent hospitals and doctors -greater market share gives these systems more leverage in negotiations with insurers, which can drive up health costs and limit patient choice -ACOs driving more power to hospitals, not doctors - hospitals buying up physician practices to become ACOs -ACOs unlikely to save the federal government any money - instead ulterior motives like creating market leverage with private health plans may be the real reason providers are interested in ACOs; many hospitals already lose money on Medicare -patients may see doctors outside of ACO, eroding or erasing the cost savings the agreement achieves -patients could insist on unnecessary tests and procedures or ignore advice - patient accountability important

Physician assistants

-education: most have a master's degree - 2 year program beyond bachelor's degree, often requiring some experience in the field before applying (e.g. medical assistant, EMT, nursing assistant) -some bachelor's and some certificate programs -most clinically practicing pas in primary care, then surgical subspecialties, then other specialties, etc. -national median salary is $100,000; primary care and internal medicine slightly lower while surgery, pediatrics and other specialties higher -many practice in single specialty physician group practice (18.7%), then inpatient unit of hospital and solo physician practice office, hospital emergency room, etc. -often not able to tell when being treated in hospital or ER if you are being seen by a physician or a PA; important to ask

Ambulatory care

-efforts to decrease hospital length of stay and to shift many surgical procedures to ambulatory setting mean that some ambulatory settings are caring for very sick patients -82% of ambulatory care visits to physicians offices -high rates among women, and increasing with age -whites visited physicians' offices more often than blacks, but blacks used ED services at nearly double the rate of whites -59% poor and 74% of non-poor families reported physician visit within last year -utilization of ambulatory care appears to be more strongly determined by insurance status than by income bracket

ACA offer benefits specifically intended for people with mental illness and substance abuse disorders and make care accessible to more

-eliminates requirement that clients meet eligibility for institutional care, thus authorizing earlier interventions for eligible clients -states allowed to use home and community-based services to care for specific populations - services can no longer place limits on the # of people covered, have waiting lists, or restrict coverage to specific areas -in addition to usual coverage, eligible for day treatment, partial hospitalization services, psychosocial rehabilitation, and clinical services -states can provide home and community-based services to people whose incomes are no more than 150% FPL and who, in absence of such services, would require placement in a nursing facility

Federal regulation example: EMTALA

-emergency medical treatment and labor act - 1986 "anti-dumping law" -this law is to prevent affluent hospitals from bouncing poor patients (uninsured, Medicaid, etc.) to a county hospital - ER now has to screen them and identify if there is an emergency, and treat them sufficiently to stabilize them (required for hospitals receiving money from Medicare), but only a safety net level - does not ensure quality care -medicare-participating hospitals that offer emergency services must provide medical screening to stabilize and treat, regardless of ability to pay -"unfunded mandate": law requiring an institution/organization to do something, but does not give money for doing so

Hospitals flourish from the 1960s through the 1980s

-enactment of Medicare and Medicaid -growth of third-party funding (i.e. private health insurance) -advancements in technology

Medicaid and MH services

-encourage state Medicaid programs to offer a health home option where states reimburse a patient-designated health home provider who provides care management, makes necessary referrals, provides individual and family support as needed, and uses health information technology to monitor and coordinate the various service providers involved -Medicaid enrollees eligible for participation in health homes must have 2 chronic conditions, one such condition and a risk for a second, or a serious and persistent mental condition -states are considering health homes focused on a variety of chronic disease populations, but almost all states include among their target conditions mental illness and substance abuse

Exmple: H5N1 "avian flu"

-endemic in domestic poultry and wild birds in many parts of the world -some bird to human transmission with very high case fatality rates -worries about human to human transmission and reassortment with another virus, like H1N1 -where is the virus now? -need to educate on how some can transfer from animal population to human population

Health center trust fund (HCTF)

-established in ACA -supporting significant expansion of health center capacity to meet expected greater demands for care -had to be diverted to offset the funding cut in 2011, taking away funds for new centers and expansion (funding from many states has declined as well)

Credentialing process for physicians

-evaluate the qualifications and practice history of a doctor; review of a doctor's completed education, training, residency and licenses; it also includes any certifications issued by a board in the doctor's area of specialty -applies to hospitals, payers, HMOs -conducted by medical staff review bodies that make a recommendation to the governing board -first look through credentials, then interviewed (may contact previous employer to see why they left and if there were any problems), before being included in organization

Hospital board and care delivered at the hospital

-even though board members may not be health care providers, they must set up the conditions (people, equipment, process) under which high quality care can be delivered -ACA promotes clinically integrated, systems-based approach to care; hospital board need oversight processes to achieve objectives/changes (big focus of board changes from individual providers to the entire system)

CMHSP organization

-expanded definition of CMH organization -formed between 1+ counties and an institute of higher education with a medical school -organization would still be a governmental entity separate from the bodies that formed it

Key issue of pharmaceutical regulation: safety vs. efficacy

-expansion of drug armamentarium over the 20th century has unquestionable enhanced public health -however, newer synthetic drugs are powerful - and potentially toxic -goal: relative safety - a drug should be less dangerous than the disease against which it is used -key point: history of drug regulation in US has largely been born out of events that have killed and injured thousands; steps implemented often took place after the problem happened - reactive regulation is the pattern in history

Tax-exempt hospitals services and variation

-expend on average 7.5% on their operating expenses for community services and activities -consider variation among the hospitals in terms of the level of benefits provided -of expenditures for community benefits, >85% went to services directly related to patient care; almost 1/2 went to subsidizing cost of care for patients covered by government insurance -for activities not directly related to patient care, most expenditures devoted to community health improvement activities and health professions education -not likely that if hospital provided a relatively high level of one benefit that it would also provide relatively high level of another benefit -less than 30% of the study hospitals were in top quartile for 3+ of the 7 community benefit measures -hospital expenditures positively associated with the state-level requirements for reporting community benefits in patient care model, 2 institutional level characteristics (teaching status and sole community provider designation) and state level reporting requirements for community benefits in the community service model -hospitals in the west had relatively higher expenditures -lack of correspondence between community need and the provision of benefits by hospitals, raising questions regarding how hospitals decide which community benefits to provide; provision of community benefits not associated with % of uninsured residents or per capita income

NPs and primary care

-federal and state laws and other policies limit how these professionals can help meet the growing need for primary care (expansion of scope of practice could be solution to shortage) -most done at state level, but also consider federal level for their ability to be reimbursed for care -NPs could fill gap more rapidly due to shorter education

Addressing care problems in nursing homes

-federal government contracts with states to inspect nursing homes, but states may place additional conditions on nursing homes to meet state licensing requirements (carrying out OBRA) -in some areas, quality of care in nursing homes has improved since OBRA: lower use of physical restraints; but deficiencies and citations continue to be prevalent

What are FQHCs

-federally funded community health centers -primary care and some specialty care services to underserved (low income, Medicaid, or populations who otherwise would not be able to access health care as easily) -provide services to all people, regardless of ability to pay -most patients are Medicaid, uninsured, or other vulnerable populations -grantee programs that receive federal funding - each FQHC has several sites -receive federal funding -many have several sites attached to the FQHCs -free clinics and rural health community clinics are not FQHCs - get money from grants, charitable donations, reimbursement from patients, etc., but not government like FQHCs do

Areas of local health department regulation

-food service establishments -public swimming pools/beaches -septic tanks -schools/daycare centers -private drinking water -lead inspection -hotels/motels -campgrounds -smoke-free ordinances

Mental health in Michigan- where we are now:

-formation of mental health and wellness commission and mental health diversion council (try to solve the problems relating MH and criminal/judicial system by getting them to work together) -structural reorganization of publicly funded mental health system (PIHP and CAs) -integrated care a goal, but not a reality (demo: integrated for dual-eligibles: the care bridge model working to integrate the care for these dual-eligibles that have MH service needs)

Possible LTSS policies to implement

-front-end benefit: begins after 90 day waiting period and covers max of 2 years -back-end/catastrophic only: begins after waiting period of 2 years but provides a lifetime benefit thereafter -comprehensive program: begins after 90 day waiting period and provides lifetime benefit -all can either be mandatory or voluntary

Nurse practitioner scope of practice

-full practice: state law provides for nurse practitioners to evaluate, diagnose, treat, and prescribe under the exclusive licensure authority of the state board of nursing; this is the model recommended by the IOM (many western states) -reduced practice: state requires NPs to have a regulated collaborative agreement with a physician in order to provide patient care, and limits NPs engagement in at least one element of NP practice (manx mid-west, eastern and some southern states) -restricted practice: state requires supervision, delegation, or team-management by a physician in order for NPs to provide patient care, and limits NP engagement in at least one element of NP practice (many southern states)

ACA grant funding, 2010-2015

-funding from FQHC went from being very small to one of largest sections recently -of the total ACA funding between FY 2010-2015 ($28.5 billion), $11 billion was awarded to health centers

Patents and generic drugs

-generic drugs effectively = existing patented drugs; chemically identical to branded drug/reference drug; don't have to do clinical trials because industries did this, so they can step in and sell it at a lower cost than those who invested in figuring out how to make the drug (costs less to make) -FDA review can start prior to patent expiration with launch upon patent expiration -generics reduce drug expenditures: for many drugs with many generics available, generic prices are >20% lower (in 2008, generics accounted for 72% of prescription volume - up from less than 20% in the early 1980s; 22% of total sales) -generics for biologics are different ("biosimilars"); harder to make; new and emerging area -took time for physicians to become adjusted to them, but now they are widely accepted

Cost containment efforts

-given the high prices of Rx drugs, employers, health plans, and public payers have engaged in a variety of cost containment strategies: utilization management, purchasing pools, Medicaid reforms -in addition, consumers have taken action: consumer action, drug re(importation)

Proportion of value-based payments is increasing rapidly

-goal 1: 30% of Medicare FFS payments are tied to value through alternative payment models by the end of 2016, and 50% by the end of 2018 -goal 2: 85% of all Medicare FFS payments are tied to quality metrics by the end of 2016, and 90% by the end of 2018 -by 2018, want most of our patients to have alternative payment models so we can get efficiencies out of the system -Medicare as an organization is really changing the way it pays - will have a system wide effect

Misc. health system organization

-have a CEO on top, and then other chief officers (nursing, operation, etc.), so that not every reporting to CEO, but only a select few who are leaders of their department -health systems often physically huge organizations; main campuses and have outside branches in different cities -most health systems now have population health management systems to coordinate care for populations and to provide efficient care -health systems go through major re-organizations often -most health systems report to a board, whereas UM the ultimate people that they report to are the regents (this is unusual); regents are elected whereas hospital boards are not elected - they have expertise in the area and are asked to be a part of the board

Criteria for regulatory reform

-goals and rationale for the regulatory approach must be clearly articulated so that executives and physicians have an overall understanding of the reasoning and intent behind the government's regulatory strategy; transparent and easy to comprehend (within reason, physicians and other stakeholders should be able to anticipate generally how regulators might respond to planned initiatives) -the regulatory approach must strive for consistency within and across regulations -the goal of regulation should be to facilitate market arrangements rather than to replace them; regulatory approach must be dynamic and flexible; regulators must be able to respond to innovative market arrangements within a realistic length of time; regulatory framework must better reflect changes in how health care is organized and how physicians deliver care; retain flexibility to adapt to new ways of providing health care -regulatory focus should be on broad guidance rather than specific, detailed regulations with hard to define safe harbors; necessary to provide physicians and administrators with sufficient flexibility to facilitate innovation -the regulations should meet reasonable cost-benefit/effectiveness criteria

Health systems organization - distinctions

-governance: provides framework (includes organization of health system, rather than organization of the work which is what management does), leadership, strategy for the big picture, and ensures that work gets done -management: organizes the work -operations: doing the work -blurring the lines can be problematic, but is easy because they are interrelated

Justification for public health regulation

-government should justify interventions because they intrude on individual rights and interests, and they incur costs -3 general justifications: risk tooters (the harm principle - have freedom as an individual but can't go as far as to harm someone else); protection of incompetent persons; risk to self (harder to justify - controversial)

Characteristics of privileges today

-granted within a medical/surgical department and matches physician's training, specialty certification, and demonstrated capability -must be very specific (re: what the physician can do; types of procedures, tests, operations, etc.; independently or with supervision) -must be time limited - usually 1 or 2 years - before credentialing process begins anew

Network

-group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community -network participation does not preclude system affiliation -working together, but does not necessarily have central organizing piece

Percentage of hospitals by affiliation category, 2012

-group purchasing organization (43%) -network (19%) -system (38%)

FQHC patients, by coverage type, in Michigan, 2008-2014

-growth in various coverage by FQHC patients in Michigan -between 2013-2014, dramatic increase in coverage in Medicaid and decline in uninsured population -many more FQHC patients qualified for Medicaid rather than subsidized private insurance -increase of 70% in Medicaid patients from 2013-2014 -from top to lowest for number of patients covered by each insurance: Medicaid, uninsured, private, Medicare, other public -Medicaid increased a lot, specifically recently -uninsured decreased a lot, specifically recently -private and Medicare increase, but not a lot; have largely remained stable

Primary care shortage

-growth of chronically ill and elderly populations, gaps in health care quality and increase in health care spending will intensify the demand for high-quality primary care services at the same time it is shrinking; NPs could be the answer -additional funds needed to expand the pipeline of primary care practitioners, including advanced-practice nurses; encourage faculty at nursing schools; loan forgiveness and redirecting medical education program to education of NPs for primary care

Physician assistant pipeline growth

-growth over time -health systems much more comfortable now in using PAs, as a result of higher demand, more schools are popping up around the country

State roles in making health policy, states as:

-guardians of public health: protect environment, ensure safe workplaces and food service, promote healthy behaviors, control communicable diseases, protection from terrorist attacks -purchasers of healthcare services: largest purchaser of health care services in a state, funds Medicaid and CHIP, pays benefits for state employees (state involved as purchaser and regulator for health care) -regulators: license health professionals and organizations; regulate insurance industry (1945 McCarran-Ferguson Act left most insurance regulation to states; Ex. of exception is ERISA pre-empts states' regulation of self-insured employer plans) -safety net providers: support for community provers, hospitals that provide charity care, local health departments -supporters of health education: graduate medical education payments through Medicaid to teaching hospitals, student loan repayment programs, public service campaigns, school health programming -laboratories: various approaches to reform delivery or payment or both (state innovation models)

Macro-level priority setting

-guiding principles vs. defined practices -criteria for evaluating different priority setting approaches: adequate public input - goals of transparency; problems with representation; appropriate principles, including cost considerations - how to balance principles?; impact on policy - concrete or direct link? or simply "advisory" -think about which principles making decisions on and how they would affect certain policies

Teaching hospitals

-had an affiliation agreement with a medical school and demonstrate a commitment to graduate medical education by participating in at least 4 residency training programs -private or government supported -provide disproportionate share of uncompensated care

Why is mental health treated differently than physical health?

-hard to diagnose -don't know how to help them/address these problems (so often don't diagnose) -stigma -acute and chronic mental health problems -hard to validate compared to, for example, a broken leg

Number of community hospitals, 1981-2012

-haven't seen large change in how many community hospitals we have -there are more urban hospitals than rural hospitals -urban have largely stayed the same, while number of rural hospitals has decreased slightly

Opinions on ACA

-partly good, but also lost opportunity because failed to enact meaningful cost controls -congress needs to reconsider and reform the way health care delivery is regulated -reevaluation and overhaul of health care regulatory policy is overdue and essential for successfully implementing health insurance reform

Growth in FQHC funding

-health center initiative (bush administration): added many more access points in US (sites for existing grantees and creation of new ones); give grants to expand services, particularly in mental health/substance use -american recovery and reinvestment act (2009): dedicated to capital development, expanded services, etc. to offset problems from recession -ACA (2010): improve services particularly in mental health services

Common culture to reach goals

-health system must create a common culture (among everyone in department - physicians, food service, janitor, etc. - everyone trying to accomplish the same thing) to accomplish their goals -must establish mission, vision and values -empowers people to focus and improve their work

The problem

-healthcare allocation decisions are politically, emotionally, intellectually and morally difficult -how do we get to a right answer about how to allocate resources? guiding principle? fair process? -all can disagree about which principle should be in place; if can't decide on guiding principle, should put fair process into place (how our judicial system works) - even if answer at the end isn't what we expect, we will feel like it was a fair process

Med devices comparison to pharma: similarities

-heavily regulated -risk of litigation -high margins -large R&D spend: high barriers to entry (money and experience) -large sales force -high budget deficits could impact spending: significant exposure to government trends -global applicability -need to demonstrate clinical efficacy -customers -reimbursement: bundling an increasing trend

Patient self-care

-helps balance primary care demand and capacity by reducing demand -can use home tests, monitor disease status, self treat, etc. -patients can be peer coaches to patients with same condition

Those with long-term care needs vs. those without

-high proportion of whites and blacks, lower proportion of latinos, asians and pacific islanders -tend to be less educated and lower personal incomes -majority experience mobility impairments; cognitive impairments only effect 55.3% of household residents, 75.8% of institutional residents, and 84.8% of those in non-institutional group quarters

Particularly challenging population at risk made up of people with severe mental illnesses and comorbid substance use and abuse and may have other chronic conditions as well

-high risk for treatment nonadherance, hospitalization, homelessness, and incarceration -require integrated long-term treatment program and assertive case management -challenging and expensive clients -assertive community treatment and case management successfully reduce hospitalization and retain patients in care, often improving their general function and employment and preventing them from becoming homeless

Health health care

-home care also encompasses the use of medical equipment, telemedicine, monitoring, and portable diagnostic tools -technologically intensive services range from simple intravenous therapy to multi-drug preloaded infusion pumps, hemodialysis, and ventilators -over age 85: 17% -36.2% male, 63.8% female -26.3% married; 29.6% widowed; 5.2% divorced or separated; 11.3% single or never married

Hospice cost

-hospice care at home is free -Medicare is primary payer in approximately 80% of cases, with care most often provided in the patient's home -almost all expenses patients ill have paid for by Medicare -commercial insurers also provide hospice benefits, but specifics of coverage vary

Drug (re)importation

-idea: allow individuals to purchase drugs abroad to avoid high US drug prices -generally illegal; however, government does not always stop individuals from purchasing drugs abroad (importation from Canada: $700 million, 0.3% of US drug sales, in 2003) -will not solve long-term problems as pharmaceutical companies may reduce shipments to countries who re-export to US

Mission statement

-identifies what business the organization is in (and what businesses it is not in) -statement of preferred good or benefit to be achieved by the organization -a statement of formal goals -what would be the last things to give up if we had to downsize? -often includes: community served, services provided, financing of patients -written by board or regent generally

High cost of hospital charges

-hospital charges represent about 1/3 of the annual US health care bill; biggest single segment and largest driver of medical inflation -many hospitals use ER as profit centers - why some of simplest procedures (stitches), cost so much more than they should -rising costs of drugs, medical equipment, and other services and fees from middlemen play a significant role in escalating hospital bills -mergers and consolidation have resulted in a couple of hospital chains dominating many parts of the country -must have highly trained professional available 24 hours a day, 7 days a week -must constantly upgrade to latest equipment and building standards to meet patients' expectations and state mandates -charge paying/well-insured patients more to compensate for others they treat at a loss -even though most hospitals are nonprofit, they are often flush with revenue and guilty of unnecessary spending; infinite amount of stuff to buy, but what do you need to deliver good health are? -ERs can bill with relative impunity, since injured patients generally rush to the nearest treatment facility -try to do fewer services that are not paid well -no correlation between prices and patient outcomes; hospitals with highest complication rates tended to have higher prices -insurers generally pay 40-50% of charges; but with powerful chains, prices are high and the discounts are often not so generous -high prices by big companies have ripple effect, allowing smaller hospitals to charge more as well

Closed physician hospital organization

-hospital contracts with selected physicians on the basis of cost, quality or both

Fully integrated organizations

-hospital owns physician practice -originally had smallest market shire, but this relationship flipped -35% of market use fully integrated hospitals (23% use other forms of integration and 40% use hospitals that used none of these forms of integration) -associated with increase in hospital prices, increase in market share = increase in price -changes in spending with increase in share of fully integrated orgs smaller than changes in price -tightest form -appears to lead to economically significant increases in hospital prices and spending - consistent with theory of increasing hospitals' market power -growing with ACA, may be a negative thing

Benefits of working in a hospital

-hospital system negotiates with insurers on providers behalf -hospital pays overhead and malpractice insurance -hospital handles much for eh ever-expanding paperwork -stability -hospital provides expensive equipment, takes care of bureaucratic chores and doctors have buffer from turmoil of rapidly changing business -have more time outside of work, but work hard when at the hospital (have to rush through many patient visits) -generally provide baseline salary and potential bonuses tied to productivity (likely to change as ACA calls for basing payments on results instead of volume)

Employment settings of registered nurses

-hospitals 66% -nursing care facilities 8% -physician offices 5% -many other areas: home health care services, outpatient care centers, elem/sec schools, employment services, insurance and related, colleges, other, etc. take up the remaining % of employment settings -nurses don't identify themselves very well, hard to identify who is a nurse and not -sometimes this blend is nice, other times is not - patients may want to know who they are being cared for by (need to improve professionalism in this way)

More physicians are choosing between employment by hospitals or competition with them

-hospitals are increasingly employing physicians, particularly specialists -non-employed physicians are separating from hospitals passively by refusing to serve on medical staff committees or take emergency department call, and actively by creating specialized facilities, such as ambulatory surgery centers (ASCs) to compete for hospitals' most profitable services

Selected measures in community hospitals, 1985, 1995, and 2012

-hospitals decreasing (-9.4%) -beds decreasing (-12.8%) -average number of beds/hosp decreasing (-3.8%) -admissions decreasing (-7.5%) -average daily census decreasing (-15.6%) -average length of stay decreasing (-8.5%) -impatient days decreasing (-15.5%) -surgical operations increasing (15.2%) -bassinets decreasing (-13.6%) -births increase (6.9%) -outpatient visits increasing the most (89.4%)

Major reason for choosing a retail clinic (most common reason to least common)

-hours were more convenient (58.6%) -no need to make appointment (55.9%) -location was more convenient (48.1%) -cost was lower than another source of care (38.7%) (76.2% among uninsured; 30.7% among insured) -no usual source of care (24.6%) (52.4% among uninsured; 18.8% among insured)

Community residents

-households and non institutional group quarters such as group homes, dormitories, and homeless shelters -broadly defined long-term care population needs help with 1+ ADLs or IADLs; get assistance from family members, friends, or paid helpers; might rely on meal delivery, transportation, or homemaker services; concern about the continued availability of family members, the impact of such help on families, and the ability of people with disabilities to fully participate in society -intermediate long-term care population composed of people needing ADL help; assistance they receive essential for their health, functioning, personal dignity, and survival; most often paid help, especially for people without live-in family helpers; minimum eligibility for publicly funded community-based long-term care services -narrowly defined long-term care population includes people needing help with 2+ ADLs; have an "institutional level of need"; eligible for many federal and state programs entailing institutional services and long-term care insurance benefits -1/2 of long-term care population living in community is non elderly -higher proportion of AI/AN compared to institutional long-term care recipients -although more likely to be married than those in institution, less likely to be married than adults without long-term care needs; those unmarried in community setting are of particular policy interest, because they often lack a ready supply of unpaid helpers -family members principal providers (only 13% use paid helpers in primary or secondary role) -help from parents dominates for people under 30, but then falls sharply at higher ages -between 30-74, spouse is dominant source of help, following by offspring (more likely daughter); when 75+, children principal helpers -often get additional services, generally delivered by professionals such as nurses of PT/OT; charges for these are substantial so most only get personally assistance -those only with personal assistance mostly paid through Medicaid and self-pay -most live with a spouse, family or other relatives, who typically serve as unpaid help -9/10 community-dwelling long-term care population relies on a family member, relative, friend, or volunteer as primary source of help with daily activities -usage of secondary paid help is small across all groups, indicating that paid help is rarely used to supplement unpaid help -those living along are particularly vulnerable; low income to pay for services; Medicaid varies from state to state, and one disability group to another; as a result, undoubtedly access disparities in some places and some population groups

Primary care practitioners perspectives on delivery system changes: physicians rate private insurers more highly than public insurers on payment and ease of reimbursement (% rating each type of insurer excellent/good)

-how much you are paid: private (46%), Medicare (21%), Medicaid (11%) -ease of administration related to reimbursements: private (32%), Medicare (25%), Medicaid (16%)

How ACOs work

-if Dr. Jones joins an ACO, the people who use Dr. Jones are "attributed" to that ACO, but Dr. Jones's patients can still go to any Medicare provider -if ACO meets stringent conditions of governance, transparency, and quality performance, may share in savings with Medicare if overall costs of care for beneficiaries attributed to it are lower than predicted -ACO looks like a terrible business deal for providers - have to spend millions on consulting, systems, care managers and IT staff to only potentially get any shared savings (initial large investment with no guarantee in savings); because so expensive, likely to be dominated by hospitals (private physicians cannot come up with money to create ACOs); if hospitals take control, concept of ACO will have failed -patients didn't understand they were getting poorly coordinated care before - only reason to tolerate managed care now is to save money in lower premiums and cost sharing -changing to capitated payments instead of FFS would be better incentive for doctors to change behaviors than ACOs -ACOs need to somehow focus and assure they have people who disproportionately cost the most for health care in their "attributed" population -ACOs in high cost areas especially will have greater opportunities for cost savings

Rural hospitals

-if located in a city of less than 50,000 or a total metropolitan population of less than 100,000 -41% of hospitals classified as rural -admissions rising -74% have fewer than 100 beds -under clinical, financial and regulatory pressures to meet current standards of medical practice -many leaving rural areas, and those staying tend to be older and poorer and Hispanic immigrants -hard to attract physicians -telemedicine (audio and video communication) gives local providers new kind of access to specialist consultations -receive more generous payment from Medicare -require federal subsidies to make technology investments and to cover operating costs in order to maintain financial viability

Nurse practitioners

-in 18 states and DC, allowed to diagnose illnesses and treat patients, and prescribe medications without doctor's involvement -as capable of providing primary care as doctors; more sensitive to patient wants and needs -IOM calls for removal of legal barriers to providing care for which they have been trained; also, higher level of education for nurses

ACA effects on FQHCs: Detroit's experience

-in 2014, over 85,000 patients received care at an FQHC in Detroit -between 2012 and 2014, Detroit FQHCs were awarded $33.4 million in federal grant funding -in Detroit, between 2013 and 2014: patient volume increased by 6.4%; number of uninsured dropped by 31% and Medicaid/CHIP increased by 33%; number of healthcare providers increased by 21.5% -they saw the same trend as overall in MI -patient volume increased, but the increase was lower than expected from 2013-2014 -speculate that these may be due to patients seeking care at other locations as they gain coverage -ACA grant funding critical to outreach and enrollment, expanding services, and quality improvement -modest increase in patient volume between 2013-2014 -expanded services such as behavioral health, dental, vision -also allowed for administrative help as more people qualified for Medicaid and private insurance (understanding billing for different plans) -expect to see a bigger increase from 2014-2015

PCMH - BCBS of Michigan

-in 2015, over 4,300 physicians in over 1,500 practices designed as PCMH (high proportion of all the practices in the state) -practices received enhanced reimbursement to compensate for extra time/effort -estimated savings $512, in first 6 years -reduced ED use and hospitalizations (where a lot of the cost savings comes from) -based on savings, some evidence that this is a good model -patients often don't know if they are in PCMH because physicians/providers not reimbursed for these conversations; where problem with health literacy comes from - no opportunity that is reimbursed for people to learn about their health; important for patients to know, allows them to know their benefits of PCMH, such as after hour care

Percent change in national expenditures for health services and supplies by category, 2012-2013

-in general, we are spending more on everything we do, but not spending the same amount more in each category; some areas spending increased even more than others -increased spending the most in administrative & net cost of private health insurance -also increased greatly in hospital care and other medical durables and non-durables -increased the least in nursing home care and prescription drugs, although still a significant increase

Hill-burton outcomes: immediate impacts

-in total, hill burton funds were given to 4,602 hospitals (1,588 in rural areas where the high proportion of those living in rural areas had no resources before this; 600 hospitals in areas with none previously) -ensured adequate supply of beds (really caused oversupply - 194,000 excess beds in 1990) -provided new sources of capital for hospitals in the forms of grants and guaranteed loans (combined with private health insurance, hospitals were financially stable) (opportunity to stabilize the hospitals; provided existing hospitals an opportunity to add on wings, etc.)

Safe staffing levels

-inappropriate staff levels: threaten patient health and safety - longed LOS, increased infections, medical errors, falls, injuries; lead to greater complexity of care; increase pressure, fatigue, nursing injury rates -may be assigned many more patients than you are able to handle -better staffing associated with lower hospital mortality when working environment is good -licensed professionals assigned a number of patients that are not reasonable to handle causing stress, and causing many people to leave the field; assigned work beyond what they are capable of doing -solutions: ratios (many have suggested that we set up ratios of how many patients 1 nurse is responsible for; some like this idea that is very black and white and easy to regulate; some disagree because depending on the floor you are on/type of patients you see, ratios may not be consistent across disciplines); staffing committees (nurses that sit on a committee that say the ratio allowable on each floor/discipline) -nearly 20 years of legislation, but very few states have done anything about these ratios

Self-regulatory entities

-includes the joint commission and the national committee on quality assurance -complement governmental regulations with voluntary standards that have become industry practice -mixed form of public and private regulation rather than top-down governmental model

ACA expands in 3 distinct ways

-including mental health and substance use disorder benefits in the essential health benefits (available in all non-grandfathered plans in individual and small group markets) -applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets -providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder

Staffing ratios for nursing homes

-incorporate information reported by nursing homes on the ratio of nurses to residents, as measured by nurses/resident days -adjusts for patient care needs -includes both RNs and total nurses -home with <3 hours of total nursing staff per resident days and fewer than 16 minutes of RN time per resident day assigned 1 star

Internationally educated nurses passing the NCLEX-RN, 2001 to 2011

-increased from 2001 to about 2007, but has been decreasing since then -during recession, number of nurses who came in from other countries decreased significantly -also creating more nurses of our own during this time, leaving less room for international nurses to come in

Primary care practitioners perspectives on delivery system changes: physicians see effect of health IT as positive, quality metrics and financial penalties are negative, for overall quality of care

-increased use of health information technology (IT): positive (50%), negative (28%) -increased use of quality metrics to assess provider performance: positive (22%), negative (50%) -programs that include financial penalties for unnecessary hospital admissions or readmissions: positive (12%), negative (52%)

National expenditures for health services and supplies by category, 1980 and 2013

-increased what we spend on prescription drugs; proportion of what we spend has largely decrease in hospital care -have always spent most on hospital care, but decreased from 42% to 34% -physician services increased from 20% to 21% home health care increased from 1% to 3% -prescription drugs increased from 5% to about 10%

Changes in the number of master's and doctoral graduates in nursing, 1984-2012

-increasing greatly beginning in 2004 -states making more room for advance practice nurses

Reasons for increases in expenditures

-increasing utilization: from 1999 to 2009, the number of prescriptions purchased increased 39%; average number of prescriptions per person per year increased from 10.1 in 1999 to 12.6 in 2009 -changes in types of drugs used: newer, higher-priced drugs replacing older, cheaper drugs; number of new drugs approved up and down over last decade -price increases for existing drugs: increase of 3.6% per year from 2000-2009, much more than the average annual rate of inflation of 2.6%; cost more because there are newer/higher cost drugs now on the market (ex. biologics), also prices that companies can charge for them is increasing -spend more because prescribing more drugs and cost more; cost increasing because of volume and price

Average cost to develop one new medicine

-increasingly over the years -currently costs around $1.28 billion for one drug

Med devices comparison to pharma: differences

-incremental technologies mean a faster development cycle: 1-3 years vs. 7-10 years -many segments are volatile - technology "leapfrogging" -engineering not chemistry/biology (changing) -sales model: more partner, less sales (CRM exception); device reps more often have healthcare background, higher compensated/more power -reimbursement: many cases by procedure and not by item -lower market penetration -marketing: less DTC (ortho, CRM, IC); device companies have looser restrictions in US, but likely to change -margins: devices (generally) less

Expanded coverage and parity for mental health and substance abuse services will benefit

-individuals in individual plans -individuals currently in small group plans -individuals currently uninsured -will now both have access to these services, and parity guaranteeing their coverage be comparable to medical and surgical coverage -benefit from new coverage, federal parity protection, etc.

% of certified nursing facilities with top 10 deficiencies

-infection control (43% - 55% in MI) -accident environment (41% - 73% in MI) -food sanitation (36% - 47% in MI) -quality of care (33% - 49% in MI) -professional standards (21% - 31% in MI) -comprehensive care plans (25% - 30% in MI) -unnecessary drugs (22% - 40% in MI) -clinical records (20% - 9% in MI) -dignity (19% - 30% in MI) -housekeeping (20% - 40% in MI) -not doing very well, and Michigan doing even worse! -some of these hard to measure, but also not things we want to ignore

Direct to consumer ad benefits

-information and education of consumers; education on if they have the condition; commercial may list conditions and you will think that you have it and go to your doctor about it -alleviation of under-diagnosis and under-treatment of certain diseases -improvement in patient compliance; serves a reminder function (reminder to take drug)

New access point

-initial investment needed for a new site to deliver comprehensive primary and preventive care; depends on many factors -once operational, health centers expected to become financially viable

Mental health insurance coverage: VA

-inpatient/outpatient treatment, residential psychiatric rehabilitation, emergency care, prescription drugs -has fairly generous mental health benefits - many patients need inpatient and outpatient mental health services

Least influential factors in decision making

-input from public (public expectations alternatively moderately or very influential, but direct public input had nearly lowest impact - few opportunities for direct public input and instead gain understanding of public expectations from elected BOH, county commission or media sources; should create opportunity for direct public input because important component of stewardship), colleagues in other departments, county councils, and state health departments were least influential -devision tools or economic analysis (despite highly prizing effectiveness); may be that LHOs are skeptical of the benefits of formalizing decision processes; may judge that their professional experiences and knowledge of their communities are adequate guides in allocation

State regulation of health insurance

-insured people pay insurance company for coverage, and if losses occur the insurance company pays -insurers pool risk and collect premiums from many insured people but only a few recover their full premium; insurer at risk of paying out large sums -this is problematic! claims could exceed premiums; insured person depends on insurer to pay promptly and fairly; its in insurers best interest to delay/dispute payment; contract is very complex; problems of adverse selection and moral hazard -insurer solvency requirements (have enough in the bank to pay out what they need to) -coverage mandates (required to cover certain diseases) -underwriting limits (fixed under ACA, no pre-existing conditions rules, etc.; insurers have to put these aside because ACA gave them a huge pool of customers through mandate) -rate approvals (state approves rate changes annually) -protect consumers from fraud

Hospice services

-intensive emotional and spiritual counseling -24-hour crisis management -bereavement support for 1 year after patient's death -most do not see a physician; care provided by hospice nurse -can also help with personal hygiene and dressing, etc. -social worked has volunteer get groceries and provide companionship -emphasizes an interdisciplinary approach to care: nurses, social workers, pastoral counselor, bereavement coordinator, and medical director; often meet to discuss needs of the patient and family -physicians have little to no training in use of medications for pain and symptom management; rely on hospice nurse, but problem with current nursing shortage

Decision making

-issues of equity and fairness in apportioning limited resources often cannot be resolved through science and laws along but require normative judgments -local health officials trusted to make these judgments and be efficient and fair in their decision making -overall, adding more activities than eliminating; small departments significantly less likely to eliminate activities than medium departments (generally harder to eliminate services than to add them; difficulty more pronounced for small departments because often sole provider of some services) -LHOs challenged to allocate limited funds, staff time, and other resources to meet the public health needs in their communities

Lay understanding of social issues and the affect on health policy

-it is important to know what the community thinks - the importance of lay understanding and action - when designing policies -there will be a variety of levels of understand and perceptions of any public health issue -may uncover an array of public fears, expectations, folk beliefs, etc. that can be used to inform policies

Lack of insurance coverage for Rx drugs

-lack of insurance coverage for prescription drugs can have adverse effects on patients (prescription drug coverage not included in all plans; not everything will be on formulary) -uninsured adults are more than twice as likely as insured adults to say that they or a family member did not fill a prescription (45% vs 22%) or cut pills or skipped doses of medicine (38% vs 18%) -early evidence that enrollees in high-deductible health plans are more likely to discontinue certain drugs, such as cholesterol-lowering drugs -not much protection for cost of drugs even though we are using more and spending more on them

Restoring confidence in the pharmaceutical industry

-lack of trust threatens future of biomedical research -credibility of pharmaceutical company research has declined; serious concerns about manipulation and misrepresentation of data from industry-sponsored research; comparing FDA documents for approved new drug applications with information published in journal - slow to public and often different results -clinicians devalue the credibility of industry funded trials, as compared with the same trials characterized as having NIH funding or no source of support listed; less likely to prescribe a drug evaluated in a clinical trial supported by industry, even if study was high quality -society increasingly risk adverse and patients less tolerant of even rare adverse outcomes (virtually no drug is entirely safe) -2 competing ideas for pharmaceutical companies: health care important to everyone and unique, but also publicly traded companies trying to generate a profit

Mental health insurance coverage: employer-based plans

-large employer plans determine which diagnoses are covered unless state law specifies coverage -small employer plans typically offer some inpatient and outpatient coverage, but some had annual visit limitations

Physician organizations

-leaders in healthcare organizations with substantial autonomy -networks of communication among physicians and the organization and the board -multiple functions

Nurse-managed clinics

-led by APNs = advance practice nurses (mostly NPs) -provide primary care, health promotion, chronic disease management and disease prevention services -usually serve underserved populations - "safety net" services - 65% of nurse-led clinics in 2013 (people who don't have a regular source of care; those who are not insured - today, this may be immigrants) -prone to closing and opening because they are expensive, training sites, and oftener squire help of health system to stay up and running (don't generate enough resources to keep up and running on their own) -usually affiliated with schools of nursing and partnerships with medical, pharmacy, social work, public health and other students

Regulation

-legal restriction promulgated by government administrative agencies through rule making, supported by threat of sanction or fine -rule created by an administration or administrative agency or body that is charged with interpreting statuses -form of "secondary legislation" used to implement a primary piece of legislation appropriately, or take into account circumstances or factors emerging during implementation of primary legislation

Accountable care results

-less hospital admissions, less days spent int he hospital, and declining average length of stay, doctors providing less but not worse care -health care spending has grown at slowest rate in more than 50 years (bulk is related to poor economy, changes among insurers and healthcare providers have contributed as well)

Physician assistants legal status

-licensed by states under the Medical Practice Act and certified (PA-C) -PAs must be supervised by a physician, but this need not be on-site and can be intermittent (varies by state) -PAs are generally not seeking practice autonomy (different from NPs who are seeking practice autonomy) -LARA: department of licensing and regulatory affairs is who does licensing; can get information about licensure here

Nurse practitioners general

-licensed practitioners who provide primary and/or specialty nursing and medical care in ambulatory, acute and long-term care settings (independence of authority varies by state - Michigan restrictive/requires more physician supervision) -registered nurses with specialized, advanced education and clinical competency to provide health and medical care for diverse populations in a variety of primary care, acute and long-term care settings -master's, post-master's or doctoral preparation is required for entry-level practice

Role of local public health department in enforcement

-local health department staff must educate regulated individuals and organizations about meaning, purpose, and benefit of public health laws and regulations, and how to comply -monitor compliance and conduct enforcement -creative strategies to increase compliance (seattle-king county game "don't gamble on food safety")

Revenue and expenditures of health departments

-local revenues were the largest source of funds -greater per capita expenditures were associated with larger department size -departments governed locally had lower per capita expenditures than state level

Personal assistance services

-long term care provided outside of institutions -personal assistance services, personal care services, or home and community-based services enables many people with disabilities to maintain their independence, avoid institutionalization, and participate in family, community and economic activities

What is long-term care?

-long term services and supports (LTSS) -care in a nursing facility, adult daycare, home health aide services, personal care services, transportation, supported employment, care by family caregiver, care planning and care coordination -delivered in institutions, group homes and homes -many people using LTSS also have substantial acute care needs -example is PACE in Ann Arbor: dual-eligibles who would otherwise qualify for nursing home facilities but they would rather stay at home; determined that people could get high quality care in these settings (adult day care)

Levels of vertical integration

-long-term care -acute hospital -community health center -community prevention -not all systems will have all of the same levels included, but overall different levels included to be considered vertical -integrated together in terms of business and the care that they provide

Problems found with drugs - learning about the safety of drugs

-looking at sleeping aid called Kevadon; questionable studies for approval -meanwhile, in same population, babies being born with severe limb-reduction defects, their hands or feet emerging directly from their torsos; many theories about the cause -high numbers in children whose mothers had been prescribed Contergan during pregnancy - drug marketed as safe sleeping pill that also treated morning sickness, influenza, depression, stress headaches, alcoholism, anxiety and emotional instability -women with deformed babies had taken this drug -physicians asked for drug to be taken off the market; company refused saying risk was unproven -same year, another physician found same deformities in newborns from mothers taking drug called Distaval -both taken off market, but because the drug marketed under many different names, the compound continued to be sold elsewhere -because of FDA, never sold in US -foundational example for the development of drug safety policy, legitimizing the idea that governments have the right to require manufacturers to provide adequate data about risk and benefit before they can market a prescription drug

Perspectives of the governing body or board of trustees

-managerial or corporate perspective: to create and maintain a foundation for relationships among the stakeholders that identifies and implements their wishes as effectively as possible -resource distribution perspective: governing board is a body to distribute resources -resource contribution perspective: emphasizes funds or services that board members may donate to the organizations -most organizations balance all three perspectives; excellent organizations emphasize the first/make sure framework is consistent with what the stakeholders want and need

Medicaid coverage for LTC

-low income, disabled -varies by state; states required to cover nursing facility benefits but most HCBS (home and community based services) is optional for Medicaid in each state to pay for this; most decide to cover this because it is less expensive and beneficial to patients -quality changes under ACA: requires CMS and nursing homes to improve transparency and accountability, enforcement, and resident abuse prevention; development of quality measures across HCBS -rebalancing programs to focus more on HCBS -people often spend down their assets when they start needing long term care services so they get to a point when they qualify for Medicaid coverage for long term care services; however, lots of facilities will kick people out once they are covered by Medicaid; Medicaid won't immediately pay whole bill for people, but will pay the difference between what they can pay out of pocket to what they owe and cannot pay -scorecard data: general public can look at data so family can make decisions on where to put their family members at/what facility

Hill-burton outcomes: longer-term impacts

-made the hospital the central focus of the health care system (wanted to make hospitals central point where everything else related to - different from today where now it is just one piece of health care system, not the center of it) -got government into direct support of health care -left a legacy of small, inefficient hospitals -led to unplanned, uncoordinated growth -hill-burton obligation (exists today for 170 facilities)

Hospital boards - functions

-maintain management capacity (ensure that the people at the top are good and qualified) -establish the mission, vision, and values (often done in strategic planning session) -approve corporate stately and annual implementation -ensure quality of clinical care -monitor performance against plans and budgets -improve board performance -the board's measures of success are a balanced scorecard of the organizations financial, market, operations, and human resources management and a checklist of process control

Functions of the governing body/board of trustees

-maintains management capability (selects CEO, evaluates executive performance) -establishes the mission, vision and values -approves the corporate strategy and annual implementation (establishes scope & organization of services; approves budget; establishes plans for expansion) -ensures clinical quality of care (approves strategic goals for quality improvement, approves privileges of attending physicians) -monitors performance against plans and budgets -improves board performance

Demographics of nursing home population

-majority (73%) women - mostly because they live longer, men can be taken care of by their spouse -majority (83%) white; 11% black, 4% hispanic, 2% asian

Number of US hospitals by ownership type

-majority (88% are community/non-federal acute care) -7% non-federal psychiatric (these are largely disappearing, only about 4 left in Michigan) -4% federal government -the rest non-federal long term care or hospital units of institutions (college infirmaries, hospitals in prisons, etc.)

Internationally educated nurses passing the NCLEX-RN, by country, 2010

-majority from Philippines -after them, next is south korea, indian, canada, and nigera; but all of these have MUCH FEWER than Philippines

The 1990s were a period of stagnation or decline in the hospital world

-managed care extracted discounts (worries about growth in health care costs resulted in growth in managed care; created situation where hospitals were feeling the effects of managed care constrictions on payment and growth) -movement toward outpatient care -balanced budget act of 1997 made drastic cuts (drastic cuts to things like capital cuts; combination of this legislation and managed care was very difficult for hospitals)

Mental health insurance coverage: Medicaid

-managed care: 20 outpatient visit limit -FFS: 10 outpatient visit limit (provided by MD or DO)

Rx drug ads: costs and benefits

-manufacturers spend $10.9 billion for advertising in 2009 ($6.6 billion directed to physicians; $4.3 billion directed to consumers through DTC ads) -advertising costs increased between 1996 ($6.6 billion) and 2006 ($12.4 billion) but has fallen steadily since -at least one study has indicated sales increases due to DTC advertising are small - almost negligible direct impact on overall health spending -spending a lot of money and not necessarily seeing much return

Michigan community mental health service program (CMHSP) boards

-many in southern michigan are CMHs responsible for public health system in 1 county; one CMH responsible for all of the mental health services in the county -in northern michigan, CMHs often contract with those in the county that have the specialized services; a few counties have the same CMH serving all of them

Types of acute care hospitals

-many now part of multi hospital and integrated health care systems -teaching hospitals -public hospitals -rural hospitals -multihospital and integrated health care systems

Problems with nursing homes

-many people prefer to live in their own homes than nursing homes; many fear nursing homes -many physicians/nurses choose not to work at nursing home -hospital administrators rely on them as a place to send patients who cannot be discharged home; get many from nursing home as source of admission; most don't understand them very well -state and federal budget-makers understand the need but don't fund them well -no one likes them, but they are necessary and misunderstood -nursing homes sit atop 2 of most problematic seams: the disjunction between Medicaid and Medicare, and the disjunction between episodic acute care and long-term care - as a result, have 2 different missions in the same nursing home, and serving 2 very different kinds of patients -average nursing home loses money on the average Medicaid patient; need to make up difference with profits from Medicare and private-pay patients -typical level of communication between clinicians in nursing homes and those in hospitals or the community is limited, and sharing responsibility for planning/modifying patient care is even less

PA doctorate

-many want to keep it a masters degree, but significant pressure to transition to a doctoral degree, especially as other clinicians work to expand their prestige and scope of practice -have a didactic year of instruction in the sciences and clinical year spent on rotations -accreditation of PA school requires at least 1 physician serve as faculty -advocacy by physicians has played essential role in success and expansion of PA profession -PAs work in a team approach to health care that recognizes physicians as the team leaders -PA scope of practice and level of autonomy flexible but primarily determined by supervising physician -physicians support PA professions current education; have a large influence on health care policy and keeping education for PAs the way it is now, best way to benefit the interest of physicians and the public

Legal and accreditation hurdles for hospitals in moving toward a systems-based approach to quality oversight

-many, such as Medicare and state licensing laws, focus on competence or professionalism of each provider as an individual rather than as part of a system of care -big burden: historic division of management and medical oversight functions in the hospital setting; many place the responsibility for peer review in the hands of self governing and organized medical staff rather than management -many high-quality hospitals now employ physicians as a means of integrating the providers more completely into the operations of the organization and better aligning the goals and objectives of hospitals and physicians; need to be sure their physician leads are proponents of systems-based care -in current legal environment, hospitals are legally liable for actions taken to limit or restrict a provider's practice if the ground for the action is a systems-based issue, as opposed to a matter of individual quality or competence -another hurdle is the requirement to comply with the confidentiality and immunity protections in state peer review laws; supposed to make it less likely that peer reviewers will be sued by the practitioners the review determine should be disciplined

Regulatory policies

-market-entry restrictions (ex. becoming an RN have to go to school, pass boards, get certification, etc. have regulations on who can become a nurse - have to do these things) -rate or price setting controls on providers (Medicare payment regulation having fee-scale/structure for how much they will pay physicians) -quality controls on services delivered -market-preserving controls (antitrust and the role of antitrust regulation in healthcare) -social regulation (things that don't fall into other 4 regulatory policies; things like regulating the environment)

Goals of a rational health services system

-maximize: quality (quality of care provided- can learn from each other in an integrated system - learn who provides high quality of care and can communicate how that is done to other partners in the system), access to appropriate services, efficiency (specifically economic and operational), comprehensiveness and continuity, ability to train and educate providers, consumer inputs -minimize: costs, duplication (not only costly, but has a risk for patients), fragmentation, underserved populations, inconvenience and dissatisfaction (among patients and among providers)

Things that need to be considered in decision making

-may be valuable for LHOs to assess the potential usefulness of more structured methods for allocation decisions, such as evaluation frameworks, economic analyses, or other decision tools if appropriate funding and training are available -expansion of opportunities for public engagement in priority setting may strengthen ties between LHDs and their communities -important to develop and disseminate resources and tools including decision tools, needs assessment tools, and tools to engage the public, which can be readily, easily, and affordable used by LHOs

Nursing stats (2014)

-median pay for RNs = $66,640 (for LPNs/LVNs $42,490, for NPS $97,990) -workplaces: hospitals, physicians' offices, home healthcare settings, nursing facilities, correctional facilities, military, schools; 58% of RNs work in general medical and surgical hospitals -nurses are largest single component of hospital staff, are primary providers of hospital patient care, and deliver most of the nation's long-term care -starting pay is good, but it does not increase much over years and experience -when health systems get tight with their budget, go to where the money is: nurses because they are the largest component of staff

Benefits for FQHCs

-medical malpractice coverage -federally backed loan guarantees for capital improvement projects -ability to recruit through national health services corps (go to health provider shortage area and get loan forgiveness for working there; FQHCs are designated in health provider shortage areas) -drug pricing discounts (340B drug program) (requires drug manufacturers to provide outpatient drugs to covered entities at a discounted prices at request/agreements of HHS; intent is to allow providers to stretch their federal funding as far as possible; these only apply to qualified individuals

Independent-corporate model

-medical staff becomes a separate legal entity support services -independent group of physicians provides medical services to the hospital under contract

Different committees and leadership in hospital

-medical staff bylaws specify procedures for election of medical staff offices by their membership; officers given authority to enforce rules and regulations -executive committee coordinates all activity, sets general policies for the medical staff, and accepts and acts upon recommendations from the other medical staff committees -joint conference committee acts as a liaison between the medical staff and the governing board in deliberations over matters involving medical and non medical considerations

Focus group session - pandemic

-members of the public: some employed, some unemployed; some parenting young/school-age children -short education sessions (ex. how long to take a flu vaccine) -discussion questions (ex. some say they would comply and others that they can't and why not) -ethical challenges in 2 main areas: allocation of scarce resources; social distancing measures -bring together a number of focus groups and talk about some of the issues a health officer may deal with if they have to allocate scarce resources during a pandemic; this is one way of engaging people - using a focus group

Mental health: state efforts

-mental health and wellness commission report released 1/21/2014 -focused on: reducing stigma, increasing information sharing, and standardizing processes across state -report does not: request funding, address capacity issues, and improve continuity of care for individuals in community mental health system -we do not have enough practicing psychiatrists that are willing to see those with mild or severe mental health illnesses -many people need injections (those with severe/chronic mental illness) - can often function at a higher level if they receive proper drugs but need to be injected by a doctor -provider may not want to do this because these may be very difficult patients and have bad reimbursement rates because covered by Medicaid and Medicare; may also not always show up to appointments (unreliable)

Horizontal mergers

-merger of providers that supply similar services in geographic proximity (acquire nearby rivals) -specifically concerned about these -agencies responsible for enforcing antitrust laws investigate and challenge these consolidations

Average annual % change in selected national health expenditures

-money spent on prescription drugs are higher than the others spent (physician and clinical services, hospital care) each year -dip in 2007-2008 growth, but it has shot back up recently so overall trend is increasing

Utilization of prescription drugs

-more americans are using prescription drugs than ever before (66% of americans take at least one prescription) -number of prescriptions per user has increased -number of days of therapy per prescription has increased -the elderly account for 13% of US population but 34% of Rx medicines dispensed and 42% of Rx drug expenditures

Michigan pre-paid inpatient health plans (PIHPs)

-more counties clumped together - much larger groupings than CMHs -PIHP then allocates the money to the counties based on how many people eligible in the counties for these services -think that we can deliver better care to people with mental illnesses if we can integrate that care with their physical health illnesses; the care for these should not be separate; should have integrated care -some think that we should get rid of PIHPs and instead give Medicaid $ to Medicaid managed care organizations - allocate these funds to many different people -many people disagree: people who receive these services have very strong connections with their providers; don't want the state to reorganize this so that they have to see a different provider through a new Medicaid managed care plan; they have strong lobby/advocates

Other decision tools used during decision process

-more than 1/2 usually or always reviewed government guidelines for allocation -less than 1/2 usually or always used economic analysis or conducted needs assessments -only 1/3 use decision tools usually or always in allocation

Necessity of nursing homes

-more than 1/3 of US residents who reach age 65 will spend some time in a nursing home before they die

Key findings of 5-star ratings

-more than 1/3 of nursing homes certified by Medicare or Medicaid have relatively low overall star ratings (1 or 2), accounting for 39% of all nursing home residents; 45% of nursing homes have 4 or 5 star ratings, accounting for 41% of all nursing home residents -for-profit nursing homes, which are more prevalent, tend to have lower star ratings than non-profit nursing homes; smaller nursing homes (with fewer beds) tend to have higher star ratings than larger nursing homes -ratings tend to be higher for measures that are self-reported (quality measures and staffing levels) than for measures derived from state health inspections -in 11 states, at least 40% of nursing homes in the state have relatively low ratings (1 or 2 stars); in 22 states and DC, at least 50% have relatively high ratings (4 or 5 starts) -states that have higher proportions of low-income seniors tend to have lower-rated nursing homes

Nursing stats (2015)

-more than 3.1 million registered nurses nationwide (of all licensed RNs, 2.6 million (84.8%) are employed in nursing; jobs projected to grow 16% by 2024, faster than most other occupations) -12% african american, 9% asian, 7% hispanic/latino -89% women (RNs) -had prediction of nursing shortage on and off for many decades; it changes based on how we calculate demand and how we calculate supply

FQHC sources of revenue

-most from patient revenues (62%) -next, federal grants (21%) -state and local grants (10%) -foundation/private grants (4%) -other revenue (4%) -patient revenues primarily come from: Medicaid (40%), Medicare (6%), self-pay (6%), private insurance (8%), other public insurance (2%); many people have/qualify for and use Medicaid at these centers

Populations served at FQHCs, US, 2014

-most have income below 200% of FPL (92.4%); 71.2% have income below 100% of FPL -number of uninsured has declined significantly since ACA (27.9%); Medicaid/CHIP 46.7%; Medicare (8.6%); other third party (16.3%) -majority are adults of working age (61%); children 31.3%; adults 65+ are 7.6% -most are racial or ethnic minority (62.2%) - hispanic/latino ethnicity (34.9%), black (23.4%); non-hispanic white (41.9%)

Potential of ACOs

-most health economists agree ACOs are one of the most promising recent developments -many providers also work outside of ACO - what is occurring is that even when they are practicing at hospitals that are not under value-based contracts, they've changed how they practice, and we are seeing declines in utilization there, too

Multihospital and integrated health care systems

-most hospitals integrated into their communities through ties with area physicians and other health care providers, clinics and outpatient facilities, and other practitioners -almost 1/2 of nations hospitals tied to larger organizational entities -network is a group of hospitals, physicians, other providers, insurers or community agencies that work together to deliver health services -multihospital systems include 2 or more hospitals owned, leased, sponsored, or contract managed by central organizations -alliance is a formal organization, usually owned by shareholders or members, that works on behalf of its individual members in the provision of services and products and in the promotion of activities and ventures

Community hospitals by ownership type

-most non-government not-for-profit (58%) -22% investor-owned for profit -20% non government not for profit -for profit = investors own the hospital, so profits from hospital go to them, rather than going back into the hospital and patient care/making the hospital better as in non-profit -all hospitals in MI were non-profit until a few years ago

Review and consultation during decision process

-most officials usually or always consult staff during allocation decision making, especially in smaller departments; less common at state level -just over 1/2 usually or always consulted their board of health (BOH) or city councils when making allocation decisions -allocation decisions made collaboratively in most LHDs, even reaching out to colleagues in other LHDs and state level, especially in smaller departments (also consult BOH) -input from BOH reported as one of the most highly influential factors

Changes in the number of baccalaureate and associate degree graduates

-most people went into nursing because it was a guaranteed ob, and more schools had more graduates as a result of the predicted shortage -associates degree is now beginning to level off while bachelor's degree is taking over (only recently, maybe around 2009) -before this, associates degree numbers always higher than bachelor's degree in terms of graduates, but both fluctuated up and down together, just with associates degree always slightly higher

Community hospitals by bed size categories, 2009

-most rural community hospitals have 25 or fewer beds -most urban hospitals have 200 or more beds -see switch about half way in between, but in general, urban hospitals typically much larger (more beds) than rural hospitals

Nursing home concerns

-most serious quality concerns inclose those relating to inadequate staffing, high rates of preventable conditions (bedsores), and fire safety hazards -almost 1/5 nursing homes had deficiencies that caused harm or immediate jeopardy to residents -1/2 of nursing homes certified by Medicare or Medicaid have 4 or 5 star ratings; but more than 1/3 have 1 or 2 stars (accounting for 40% of residents)

Retail clinics

-mostly staffed by NPs -open in drugstores and big retail stores around the country (e.g. CVS and walgreens) -treat common conditions like ear infections, administer vaccines, and perform simple lab tests -deliver better and cheaper care than doctor's offices, urgent care centers and ER's (says CVS) -savings in retail clinics which are generally staffed by NPs

Prescription drug summary

-policy follows tragedy -3 phases of the drug testing and approval process -patents and generic drug competition an important motivator -DTC advertising growing -use and expenditures growing, despite "blip" associated with recession -various cost-containment efforts underway -FDA is reactive - create policies reacting to problems

Number of US hospitals

-movement from inpatient care to outpatient services -in 1965, a lot of care was delivered in a hospital, it is now provided on an outpatient basis -used to be many fewer investor-owned hospitals than today -federal hospitals decreasing -number of investor-owned beds have increased as well -growth in hospital admissions in general -not only growth in population, but people living longer with chronic diseases; gives wrong idea about where we are giving most of the care (outpatient rather than inpatient is more common today) -again, large growth in investor-ownder hospital admissions -overall lower occupancy rates because moving towards outpatient services and don't get rid of beds at the same rate; surprising it is as low as it is -to some extent, need to have enough beds to be able to respond to emergencies; never want to have 100% occupancy so that they have room for emergency -those with high occupancy rates struggle to meet this demand - more common in academic institutions than local community hospitals

Health center requirements

-must operate in or serve medically underserved communities and populations -must prospectively adjust feed according to a schedule adjusted for family income -must be governed by a board, a majority of whose members are patients of the health centers -include federally funded health centers and "look-alike" health centers that meet all federal health care requirements, but receive their core support from state/local sources of funding - both considered FQHCs for Medicare, Medicaid and CHIP coverage purposes

Mental health: looking ahead

-national legislation - excellence in mental health act demo to create certified community behavioral health centers (michigan planning grant of nearly $1m; fall 2016 CMS will fund demos) -demonstration in some states - demonstration will allow us to see best way to integrate physical and mental health care (national legislation) -HHS awarding ACA funding to expand mental health and substance use disorder services in community health centers

Privilege agreement

-nationally standardized be accrediting organizations (NCQA and JCAHO = joint commission) -binds privileged physicians to bylaws, privileges, independent physician-patient relationship, continuous quality improvement and peer review

Emergency allocation

-nearly 1/3 answered they had to manage at least 1 of the following: actual emergency, decide how to allocate funds, deal with staff shortages, shortage of biological/non-biological resources, etc. during emergency -less of a problem for small departments -emphasis on emergency planning and response led to officials being well versed in their departments' plans for managing staff shortages and scarcity of vaccine -40% of LHOs must manage acute staff shortages even when not under pressure of public health emergency; inadequate funding -few guidelines of how to handle staff shortages compared to other emergency responses; development of guidelines in this area could help to meet the needs of LHDs

Financing long-term services and supports

-nearly 1/6 population 65+yo have severe LTSS needs -Medicaid will pay for about 1/3 of lifetime costs ($138,000) associated with severe LTSS -market penetration of private long-term care insurance has been limited because of high premiums, the potential for Medicaid to crow out demand for private coverage, and adverse selection (pays <1/10 of LTSS expenses) -older adults will pay about 1/2 of expenses out of pocket

Problems with pricing

-need captitated rather than FFS -Medicare and Medicaid prices are fixed - all paid the same regardless of quality; need competitive, not fixed prices

Most sometimes or never conduct needs assessments when making allocation devision

-needs assessments can be time-consuming and expensive -LHOs may not have formal training in assessments -assessment is one of 3 core functions in public health and is foundational for planning and priority-setting activities

Utilization management strategies

-negotiation of discounts -use of formularies -generic substitution -tiered patient co-payments -prior authorization of expensive drugs -quantity dispensing limits -therapeutic exchange -step therapy

Program of All-Inclusive Care for the Elderly (PACE)

-new adult day-care centers -provide almost all the services a nursing home might, including periodic exams by doctors and nurses, daytime social activities, PT/OT and 2 or 3 daily meals -all PACE participants considered eligible for nursing homes because they cannot perform 2+ essential activities like bathing, dressing, or going to the toilet, but they get to sleep in their own beds at night, often with a home health aide or relative nearby -nonprofit groups that operate these centers receive a fixed monthly fee for each participant and manage their entire care, including visits to specialists, hospitalizations, home care, and even placement in a nursing home; motivated to provide preventive care and avoid costly care (hospitalization or nursing home) -some don't like PACE because would have to leave their current physician; but most elderly want to live at home -for-profit companies have not yet moved into managed care market, in part because of uncertainties about reimbursement formulas and the risk of taking on a nursing home population -PACE population tends to be younger than at nursing homes, which raises question of if the clients would really need nursing homes without PACE

Advanced practice nurses

-nurse practitioners (more often in outpatient care; practice less "medical care") -clinical nurse specialists (often in acute care setting such as hospital; practice more medical care) -nurse midwives (different from lay midwife - lay midwife do not have any education and licensure in the states; nurse midwives work in hospitals, homes, etc.; often deliver second and third children, but rarely first children - may use them once more comfortable with the birth process) -nurse anesthetists: less than half of states now allow CRNAs (nurse anesthetist) to practice without physician supervision

ACA expanding mental health and substance use disorder benefits

-new small group and individual market plans will be required to cover 10 essential benefit categories, including mental health and substance use disorder services -required to cover them at parity with medical and surgical benefits -while almost all large group plans and most small group plans include some coverage for mental health/substance use disorder services, there are gaps; many don't receive benefit of federal parity protection -1/3 in individual market currently have no coverage for substance use disorder services and 20% have no coverage for mental health services -even when individual market plans provide these benefits, the federal parity law does not apply to these plans to ensure that coverage for these services is generally comparable to coverage for medical and surgical care -coverage in small group market for these services more common than in individual market (estimated 95% coverage); previous federal parity law still does not apply to small group plans -25% of uninsured adults have a mental health or substance use disorder or both -HHS finalized regulations that apply federal parity rules to mental health and substance use disorder benefits included in essential health benefits; can count on coverage comparable to general medical and surgical coverage

Study looking at different potentials for LTSS policies in the future

-no ideal solution, but differences between studies important -voluntary programs must overcome several challenges, including price, perceived value, adverse selection, and moral hazard -people in fair/poor health, have functional limitations, or are experiencing cognitive decline much more likely to purchase voluntary insurance; problem exacerbated in absence of medical underwriting - at risk of not being financially sustainable in the long term without controlling for adverse selection -enrollment lower for comprehensive programs, but higher and similar for front and back end programs -participation higher in subsidized programs -consumers want a balance between price and benefit, but top priority is low cost -mandatory program especially beneficial to middle-income consumers -per beneficiary expenses tended to be lower in mandatory programs, reflecting affordability; contributions lower in mandatory programs because avoid adverse selection and require contributions that lasted throughout a person's career -total program costs of mandatory insurance would be substantial and require payroll tax increases of 0.6-1.35% -instead, we could focus on reforming the private long-term care insurance market which would require little to no government spending; need to reduce premiums to increase coverage rates, but this could be difficult; could divert some 401k account contributions to insurance premium payments, but employees might opt out of this due to high premiums and reduced financial security at older ages -policy makers will have to choose between imperfect options that achieve different goals -if primary goal is to significantly increase insurance coverage, mandatory programs would be best -if primary goal is to reduce Medicaid cost, comprehensive and back-end mandatory programs best

Independent practice associations

-nonexclusive arrangements in which the hospital generally provides physicians with few services other than assistance in contracting with health plans

Tax-exempt US hospitals

-nonprofit hospitals have tax exemptions; exempt from income, property and sales taxes on the basis that they qualify as charitable organizations -questions regarding whether they provide appropriate levels of community benefits (some property tax exemptions challenged or revoked on this basis) -ACA requires tax-exempt hospitals to conduct an assessment of community needs every 3 years and develop an implementation strategy to address identified needs (these have limitations of lack of uniform, national data and a lack of standard approaches to defining and measuring community benefits) -more than 90% of tax-exempt hospitals are private, tax-exempt hospitals that provide general, acute care services

What makes a problem an "ethical" one?

-not every challenge is an ethical issue -some require normative judgment and moral consideration -what should be done in a particular circumstance? -do many alternatives seem right? is one alternative more right than another? do none seem right? -would individual practitioners vary in the way they would respond? -if you can think that there is a right answer, then it is an ethical problem

Characteristics of pioneer ACOs

-not well described, study wanted to look at this -adjusted Medicare spending and spending trends similar in the ACO group and control group during pre-contract period (none ACO yet) -after contract, 1.2% savings for those in ACO group compared with control group; savings for ACO with baseline spending above local average were significantly greater -savings similar in ACOs with financial integration between hospitals and physician groups, and those without, as well as in ACOs that withdrew from the program and those that did not -year 1 associated with modest reductions in Medicare spending -savings greater for ACOs with higher baseline spending than those with lower baseline spending -contributing to these estimated savings were reductions in spending on acute and post-acute care as well as an apparent substitution of care in lower-proved office settings for care in higher-priced hospital outpatient departments -first year not significantly associated with changes in the rates of readmissions, hospitalizations for ACSCs, or screening mammography; associated with slight increases in the rates of use of preventive services in diabetes care

4 distinct roles of APRN

-nurse anesthetist -nurse midwives -clinical nurse specialists (advanced knowledge and skills in the care of special patient populations based primarily in acute care settings) -nurse practitioners

Types of long-term care facilities

-nursing homes (usually statistics include intermediate care facilities where don't need the deep care that they would get at skilled nursing facility - more considered assisted living): certified by CMS for Medicaid, Medicare for reimbursement; non-certified usually don't want Medicaid or Medicare; licensed by states -custodial care homes/bed: also called "personal care," "domiciliary care" or "care and board" homes (assisted living is also included here); patients need some assistance, but not nursing care; not reimbursed by health insurance programs; personal care as opposed to medical care

Institutional residents

-nursing homes, facilities for people with intellectual and developmental disabilities, other residential health care facilities, and prisons and jails -many need help with multiple ADLs -nursing home population is predominantly elderly unlike community-dwelling long-term care population -far older and much more likely to be female -lower proportion of AI/AN -less than 1/2 as likely to be married as those living in households -Medicaid and consumer 2 major payers for nursing home stays; out of pocket generally secondary to Medicaid -Medicare pays for first 3 months of nursing home stay -a lot paid of out pocket from 4-12 months into the stay; no longer qualify for Medicare, but have to spend down their assets to qualify for Medicaid -higher rate of cognitive impairment among those living in nursing homes -greater likelihood of nursing home residents being widowed or otherwise unmarried compared to community-dwelling counterparts

Enforces against hospital mergers

-object to hospitals' accumulating market power in physician services by acquiring competing practices in the same specialty and geographic area -must devote substantial time and resources to evaluate these individual transactions and to satisfying the legal standards for challenging them; assess the extent to which the merging hospitals compete and to predict the magnitude of likely price increases -must also weight potential benefits of cost reductions, improvements in quality or access to care, or all the above -very difficult to determine if it should be blocked; less likely that they will investigate or attempt to halt mergers for which potential effects are unclear -unwinding deals is very difficult in practice; should give enforcers more tools for doing their jobs and to develop other avenues for slowing the mergers -investors and venture capitalists could be in charge of the organizations rather than local health care systems to hopefully integrate care without reducing competition -Medicare could experiment with reimbursement schemes that provide incentives to newly formed ACOs to pursue organizational structures that do not involve joint ownership of all assets; joint ventures/contractual relationships easier to unwind than mergers -urge private and public insurers to make detailed claims data readily available to public agencies and private researchers; enable researchers and enforcers to assess how the latest types of consolidations affect both costs and quality

Public health regulation

-objective of regulation is to diminish risk -but gov't should demonstrate with data that intervention is likely to achieve objective before regulating -economic costs to regulation (should we spend large sums for trivial gains? need to prioritize, consider if the return we are getting is worth the cost) -least restrictive alternative - how invasive? how frequent and how long will it last?

Long-term services and supports are expensive

-often exceed what beneficiaries and their families can afford -nursing facilities are most expensive; most people do not have money to pay for this and rely on Medicaid to cover these services; annually about $91,250 -home health aids also fairly expensive ($45,760/year) -adult day health care is the only one that is under the 100% FPL for a family/household of three, but even then would require all of the families income -it is really hard to afford these long term services at 100% FPL (or in general)

Long-term care settings

-often provided in home and community by family members and friends -paid home and community-based care: family and friends; para-professionals; home health; personal care -residential care facilities (assisted living) -care in institutions: nursing homes; skilled nursing facility; intermediate care facility for the intellectually disabled -intellectually disabled may be younger people who can still live in the community, but may need to be in an institution -most nursing homes are also certified as skilled nursing facility (to get Medicaid payment need to be certified as a skilled nursing facility)

Mental health parity

-often would have a copay or only be covered up to a certain number - have a history of very skinny mental health benefits; parity laws passed to address this -mental health parity act (1996): large group health plans can't impose annual or lifetime dollar limits less favorable than medical benefits -medical health parity and addiction equity act -MHPAEA (2008): required plans offering MH or SU coverage to offer coverage no more restrictive than medical benefits (copays, coinsurance, out of pocket maximums; limits on # inpatient days or outpatient visits, out of network providers, medical necessity) -interim rules (2010) and final rules (2013) for MHPAEA -network adequacy/provider shortage big worries

Health systems components (triangle)

-on bottom/support of it all is strategic support teams: provide marketing, governance, internal consulting, finance, stakeholder relations management, and strategic positioning; they protect the HCOs culture and tangible resources -next is logistic support teams: provide trained personnel, information, facilities, accounting, cash management and supplies -next is clinical support teams: provide specific clinical services to caregiving teams; important examples are clinical laboratory, pharmacy, imaging, cardiopulmonary laboratory, surgery/anethesia/recovery intensive care, physical therapy, social services -next, on top is caregiving teams: provide care to patients with similar needs; major caregiving groups are primary care (family medicine, general internal medicine, pediatrics, obstetrics, psychiatry, advanced care practitioners), acute care (by specialty), rehabilitation, home care, hospice, continuing care -caregivers supported by many other people in the system/those lower in the triangle

Stewardship

-one of the core functions of managers in the health system -the careful and responsible management of the well-being of the population under the guise of good government -when public officials act as good stewards, citizens see their actions as legitimate and trust the officials will act in ways that are beneficial to their communities and will allocate resources effectively -also emphasize collectivism and community trust in officials to efficiently and ethically serve in public interest; priority setting

Role of operational leadership

-operational leadership/senior management keeps the healthcare organization and its mission consistent with stakeholder needs (maintain contact with the stakeholders and make it happen; board is more removed than this whereas operational leadership are those who actually make the connection) -maintains contact with all stakeholder groups -sizes the organization and its components (makes sure the health system if appropriate for the community - if it meets the demand) -measures and reports performance -supports a learning organization (wants to learn quickly in order to make improvements and bring evidence-base into clinical care) -resolves issues in a timely manner, adheres to an annual calendar

Acute care history

-originally, women family members responsible for treating illnesses using medicinal herbs, traditions, etc prior to late 1870's; physicians and lay healers treated paying patients in their homes; hospitals used for care, but not for curing purposes - the more seriously ill and poor -early 1900s: hospitals evolved into medical facilities we are familiar with today; doctors treating patients for specific illness; improvements in hygiene and techniques moved surgery from home to hospital -1920-30s: doctors generally solo practitioners -WWII era brought significant change; new developments such as antibiotic use; health insurance became more widespread -Hill-Burton act (1946): provided federal funds for hospital construction and brought hospitals to undeserved areas -1960s: Medicare and Medicaid intro; concerns about whether enough doctors to meet populations needs led to increased funding for medical training and establishing new healthcare occupations (NP and PAs) -1970s: had more access to health care and insurance; FFS reimbursement; escalation of medical costs -1980s: prospective payment system for hospitalizations under Medicare instead of FFS, depending on diagnosis; cost containment strategies -financial pressures (care cheaper in outpatient than inpatient setting) and safer anesthesia, less invasive surgical techniques, and other technologies led to acute care more often on outpatient basis

Primary care shortage and surplus, depending on specialty

-our status quo scenario projected a shortage of 45,000 primary care physicians in 2025, a surplus of 34,000 NPs, and a surplus of 4,000 PAs -all data on what medical home/nurse-managed health center could contribute to shortage suggest that physician shortage prediction may be overstated

Michigan long-term services and supports scorecard results

-overall, MI ranked 31 -4 of their indicators showed substantial improvement = most related to access for disabled or elderly or low-income through Medicaid -1 indicator showed substantial decline = nursing home staffing turnover: ratio of employee terminations to the average number of active employees -ranking for the following dimensions: affordability & access (32), choice of setting & provider (13), quality of care & quality of life (26), support for family caregivers (44), effective transitions (18)

Typology of hospital beds over time

-overall, reduction in number of beds in these non-profit, general hospitals -some of the others have not changed a whole lot -federal hospitals are second type that have changed a bit (reduction) -overall, decrease in number of beds

What goes in to public health law

-partners: the public health system, comprising health care, business, the community, media and academia -state's police power and limits: coercive measures to protect the public's health, balanced with respect for individual rights -government: power and duty to protect the public's health and safety -social justice: fair and equitable treatment of groups and individuals, with particular attention to the disadvantaged -prevention: interventions to reduce risk or avert harm from injury/disease -communities: healthy social interactions, mutual support and civic participation -populations: shared-risk, large-scale interventions to protect the community's health and well-being -all of these are areas where regulation can come into play in public health from a legal structure

Nursing shortage

-past decades predicted large shortages in nursing -shortage of faculty restricting enrollment in educational programs (to be on faculty at a nursing school you have to have a PhD, but very few nurses today have a PhD, so not enough faculty to teach new nurses, leading to shortage - less accepted into schools, less graduating, due to lack of faculty forcing smaller class sizes) -significant segment nearing retirement -increased demand for nursing services due to aging population, increasing chronic diseases, insurance expansions -high stress leading to poor job satisfaction and high turnover (makes shortage difficult to predict) -other professional options for women in workplace -difficult to assess and predict actual magnitude and timing of shortage

Direct to consumer ad concerns

-patient anxiety through incomplete information; may wrongly think that you have symptoms, and wouldn't have throughout to bring them up to physicians -encouragement of patients to seek unnecessary treatment and medicalization of everyday experiences (for example, erectile dysfunction - part of aging but we are making it a medical problem) -excessive and even dangerous prescribing -excessive costs

Addressing expected primary care provider shortages

-patient-centered medical homes: level of performance by a patient-centered medical home; generally a health care practice that providers a variety of physicians, NPs and other providers; this is largely invisible to patients, but is more clean for payment purposes - get enhanced reimbursement for doing this medical home practice; not sure how important it is for patient to know that they are a part of an organization that does this -nurse-led clinics: nurses practicing; sometimes physician oversight and sometimes without -retail clinics: don't have very much research about how they are doing; they are very new; not even sure what we want them to do -the patient-centered nature of NP training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes NPs particularly well prepared for and interested in providing primary care

Principles of PCMH

-patients have a personal physician -physician directed team of providers -whole person orientation (influence of nursing) -care is coordinated/integrated (poor quality of care and expense is largely a result of poor care coordination; repeat tests, see many specialists who don't have access to info from other specialists, etc.) -quality and safety are emphasized -evidence and clinical decisions-support tools guide decision making -enhanced access (need to have after hours availability - difficult/expensive to do this, but important to give good care) -payment reform -principles of what you have to embed in your practice in order to qualify as a PCMH; if you are designated as one, amount of money insurer pays is higher; there is some cost associated with becoming PCMH if you were not one in the past - to meet these principles to become one can be expensive -employ a care/case manager - often a nurse who is embedded in the physicians practice; they get to know the patients and how the providers work; help the patient go out into health system and manage their appointments with other providers/specialists; look at prescriptions to make sure no problems with care coordination; need to think about everything that is happening to patient and coordinate/integrate care; this adds expense to practice, because likely hiring an additional person to do this

Health center demographics

-patients nearly 5x as likely to be poor ->2x as likely to be uninsured -2.5x as likely to be covered by Medicaid -75% uninsured or covered by Medicaid -minority populations over-represented: blacks (21%), latinos (1/3) -children <15 and women of child bearing age over 1/4 -adults 45-64 are 1/5 -elderly account for only 7%, but their number have doubled as elderly population grows -chronic conditions prevalent; also, mental illness, diabetes, asthma, and hypertension higher

Self-care at home

-patients with hypertension, diabetes, and congestive heart failure decide whether they want a care coordinator to visit them at home or measure their own blood pressure, pulse or glucose and enter the results online, viewed by doctor -can consult with nurse by phone or email, avoiding costly visit -only happens in certain health systems, may be different diseases, etc.

Ethical issues in public health practice

-people see allocating resources as an ethical problem: how do you decide what/who to fund -determining appropriate use of public health authority -making decisions related to resource allocation -negotiating political interference in public health practice -ensuring standards of quality of care -questioning the role of scope of public health

Stigmatization and results for behavioral health services

-people suffering from mental and behavioral health problems receive less and lower-quality medical care -federal government, states and localities have struggled to devise programs that integrate needed services for people with severe mental illness -implementation of effective services has been limited by inadequacies of the behavioral health policy framework, poorly designed payment approaches, and dysfunctional and counterproductive regulations -lack of coordination of Medicare and Medicaid's coverage and payment policies results in both major service gaps and wasteful duplication - mix of issues requires integrated care -Medicaid covers about 1/4 of all mental health expenditures in US

Nursing facility special care beds

-people with certain conditions have different level of care need that those without the conditions; all required different services -not every nursing facility will have all of these specialty beds, depends on the facility and the providers they have available -from most common special care beds to least common: alzheimer's, rehabilitation, ventilator, hospice, AIDS

Health center performance

-performance on measures of prevention and primary care equal to or exceeding the performance of office-based physicians; improvement in prenatal care -patients more likely to report a generalist physician visit and have a regular source of care, and have fewer uninsured ED visits -more likely to receive preventive services such as pap smear, breast exam, mammography, etc. -25% lower ambulatory care expenditures and 24% lower total annual medical expenditures because broad range of services under a single roof and health care teams practicing in clinically integrated way -high levels of satisfaction reported from patients; often stay with them even after gaining health insurance

More drugs emerge, but few blockbusters

-pharmaceutical companies are launching new drugs at the fastest pace since 1990s -drug makers are finding it hard to convince doctors, patients, and insurers that the new advances are worth their typically premium prices -skepticism particularly high for drugs aimed at conditions that already have effective treatments -new drugs have less revenue from sales than in previous years -it likely will be more difficult for drug makes than expected to overcome the big hit they are suffered from generic competition from previous blockbusters -when multiple treatments are available, insurers can be aggressive in trying to steer prescriptions to less-expensive options, especially generic drugs -many doctors also prefer to stick with tried-and-true treatments

Patent protection

-pharmaceutical companies customarily apply for patent protection on new chemical entities -patents usually grant 20 years of exclusive use, but some of this time is spent on drug testing and approval -average effective life of a drug patent: 11-13 years -goal is to prevent sale of generic counterpart of brand name drug, and establish monopolistic pricing (there will be no competitors so they can basically charge whatever they want) -health reform: biologic drugs get 12 years of exclusive use before generics -biologics are a class of drugs that are a little different from typical pharmaceuticals (put chemicals together to get the drug); biological products like genetically engineered proteins that you derive from human genes; they are harder to make/expensive; cut down patent period for this drug because government does not want to spend as much time on them -companies research and develop because when it pays off, it pays off really well -patent protects manufacturers revenue for a specified people of time (clinical trial piece is counted in the time of the patent) -why companies invest in clinical trials - they get a huge pay off during patent period

Terminology

-physician extenders, allied health professional, non-physician providers, and mid-level providers terms opposed by AANP; want full partnership -instead, use nurse practitioner or advance practice nurse

Integrated mental health care for dual-eligible individuals

-pilot program will create a delivery and payment model that will integrate clinical, long-term care, behavioral and support services into a managed care model -dual-eligible can opt out of pilot -PIHPs will continue their work with behavioral health needs -clinical and long term care will be managed by integrated care organizations (ICOs) that contract with PIHPs; work together via a "care bridge" -each multi-disciplinary team that makes up a care bridge will be led by a services or support coordinator who will coordinate all care according to each individuals' particular need; coordinator will be associated with either the PIHP or ICO depending on the individual's needs -create a 3 way contract between: (1) ICOs (responsible for long term care and primary care for dual-eligibles) and PIHPs, (2) the state, and (3) the federal government to manage, coordinate and pay for all services for dual-eligibles

Divisional model

-placement of functional support services within medical divisions, which are organized along departmental lines -each division includes many of the support services it needs -each medical division leader is responsible for management, including financial management, of medical and support services

Team-based care

-plays a central role in the inpatient settings as well, where management of a patient with an acute medical condition associated with a chronic condition is enhanced by involving an interdisciplinary provider team -allows primary care physicians to partner with hospitals to care for their patients across settings -integrating provider teams and information systems that span ambulatory and inpatient settings will begin to make improvements in acute care delivery a realizable goal

3 core functions of public health and regulatory elements in them

-policy development (develop policies, mobilize community partnerships, inform, educate, empower) -assessment (monitor health, diagnose & investigate -assurance (ensure competent workforce, evaluate, link to/provide care, enforce laws) -at center of it all is research

Patient-centered medical home and nurse-managed health center

-potential innovations seeking to fundamentally change how primary care is delivered - could change the number of providers needed -both appear to use higher proportions of NPs and PAs than do other models of care today -current models assume that the number of full-time equivalent primary care physicians available today is, on average, the optimal amount needed for a given population and that, with slight adjustments for factors such as population aging, this amount will not change appreciably in the future - these assumptions could render shortage projections biased or even irrelevant if the production function for primary care can be changed -assuming both of these changes occurred, only half of primary care delivered outside of nurse-managed health center and medical homes, cut the physician shortage nearly in half and reduced the NPs surplus by 2/3, and supply of PAs was very close to demand

NP demographics: practice characteristics

-practice setting: 66% practice in at least one primary care setting; 31% in non-primary care setting; 62% practice in areas >50,000 residents (of these, 52% suburban, 39% inner city, 9% other) -compensation: mean full-time NP base salary (2008) is $84,250; average full-time total income is $92,100

Drug testing and approval process

-pre-clinical phase inc. animal testing: drug discovery (includes 5,000-10,000 compounds), preclinical (includes about 250 compounds); takes about 3-6 years -IND submitted -clinical phase inc. human testing: clinical trials phase I (20-100 volunteers), II (100-500 volunteers) and III (1000-5000 volunteers); takes about 6-7 years; may have about 5 or less different compounds -NDA submitted -approval phase: FDA review and phase IV, down to one FDA approved drug

Three different types of organizations manage and administer Michigan's publicly funded mental health system

-prepaid inpatient health plans (PIHPs) -community mental health services programs (CMHs) -substance abuse coordinating agencies (CAs)

Drugs are important

-prevent and treat illness and control chronic disease -increase life expectancy & improve quality of life -help avoid more costly medical problems and treatments, such as surgeries and hospitalizations -we spend a lot on them! spending is increasing

Safety on the job

-preventing back injuries (health systems have purchased equipment to help nurses lift patients avoiding back injuries) -needle safety -hazardous products -workplace violence -reciprocal safety - influenza vaccine requirements for nurses

Parity in mental health before the ACA - things exempt from federal parity law

-previously, while trying to equate this coverage, some insurance policies did not even have mental health benefits/coverage -previously, did not really matter until ACA required that insurers cover mental health services - now parity acts really matter since insurers are required to include them in the first place -small employer-sponsored plans (<=50 employees) -individual health plans -Medicaid (fee-for-service) -Medicare -TriCare (active duty service members) and veterans affairs -church-sponsored plan -retiree-only plans

Primary care - ambulatory care

-primary care signifies relationship between patient and clinician that is longitudinal and that both patient and clinician view as the patient's principal source of general outpatient medical care; integrated, accessible care services; longitudinal care and comprehensive approach to patients' multiple medical needs; provider as coordinator of patients care -primary care thus one type of ambulatory care a patient pay receive -provided by physicians, NPs, PAs, and nurse mid-wives; other specialist and sub specialist physicians can also provide primary care -a person seeking medical care directly from various sub specialists as the need may arise, but who has no principal ongoing relationship with any of them, would be using ambulatory care but not primary care -over last 2 decades, the 5 of primary care visits provided by generalists has declined relative to that provided by specialists -most common for site: private physician offices; community-based and hospital-based primary care clinics expanding in response to increased # of people insured under ACA

Priority setting

-process by which an organization identifies functions/programs/services most important to attain its goals -which services will be delivered to which persons at what cost? -translates broad organizational objectives to practical guidelines -budgeting -managing the inherent structural imbalance between gov't supply of resources and public demand for them -health officer at LHD and state health departments have to set priorities based on what their goals are -think about who and what programs to prioritize -a lot of this has to do with budgeting -usually base budget off of what they did last year, and tweak it -balance between budget provided and what health departments want to do

PACE - alternative to nursing home care

-program of all-inclusive care for the elderly -managed care - the sole source of services: day care (nursing, Rx, social work, PT, OT, RT, meals, personal care); in home services; hospital and nursing home care as needed -for dual eligibles who qualify for nursing home care but want to live at home -only in certain areas of the state

Future for long-term care

-projections of doubling in next 40 years; spending on publicly paid services is already increasing, but is especially a concern now -want to improve long-term care system and reduce spending; limited by lack of information on how much is spent, for what services and in what setting, and the extent and nature of unpaid help that people receive

Medical device regulation

-regulated by the FDA -approximately 1,700 different types of medical devices -all medical devices are classified into 1 of 3 different regulatory classes: class I, class II, class III -classification is risk based, the lower the class indicates lower risk to the patient -class I: gloves vs. class III: stent

ACA's shared savings program

-promotes the development of ACOs (groups of providers that jointly take responsibility for providing coordinated care to a minimum of 5,000 Medicare FFS patients) -if it meets certain benchmarks, can share in the savings generated as a result of its enhanced quality and efficiency -65 potential benchmarks across 5 quality domains: patient and caregiver experience, care coordination, patient safety, preventive health, and at-risk populations -benchmarks range from ensuring timely appointments and courteous treatment of patients by office staff to documenting certain conditions -to achieve success, hospitals will have to provide and promote high-quality care for their patients in both the inpatient and outpatient settings

Substance abuse coordinating agencies (CAs)

-provide comprehensive planning for substance abuse treatment, rehabilitation and prevention services, but are prohibited from directly providing serves -contract with community providers for service delivery -soon will merge with PIHPs; PIHPs will be responsible for coordination of substance us disorder services

Community mental health services programs (CMHs)

-provide direct mental health care or contract with community providers to do so -structure of each CMH varies throughout the state -can be designated as authorities, agencies, of county government or organizations

Nurse managed health centers

-provide full range of primary care and some specialty services -managed and operated by nurses with NPs functioning as primary providers -could greatly reduce the need for primary care physicians -assuming nurse-managed health center would provide 5% of the US primary care, had almost the same effect on the projected shortage of primary care physicians as medical homes did; also reduced the surplus of NPs by nearly half, but increased the surplus of PAs not used in this model -changes in panel size had relatively small impact on shortage and surplus projections because it accounted for a relatively small proportion of total primary care -these have historical mission to treat underserved populations; thus, their panel sizes are already essentially at their max; patients/payers sometimes reluctant to accept this model of care - unsure if it can expand -ACA supports these; many provide care in underserved areas

Strengths of formal methods

-provide more/better informal for decision making (want public to understand, because they are ultimately where you get funding from); foster trust and increase accountability -supply defensible justifications for decisions: agreed upon set of rules; documented procedures; regularly reviewed, revised -increase/improve public understanding: increased accountability fosters trust; may encourage compliance with unpalatable or difficult requests (e.g. rationing)

Federal community mental health act (CMHA)

-provided federal funding for the establishment of community mental health centers -appropriated funds for the construction of CMHs on the basis of population health need and the financial need of states -started trend towards deinstitutionalizing mental health patients

Pioneer ACO program

-providers can share savings with Medicare if spending falls below a financial benchmark; incur loss if spending exceeds benchmark -benchmark is based on spending for the attributed population at baseline, trended forward by national spending growth -financial integration of outpatient practices with hospitals could enhance care coordination and savings, or, conversely, could limit savings owing to weaker incentives to constrain inpatient care

Health reform law

-provides money to increase number of medical residents, NPs, and PAs trained in primary care -bonuses for up to 5 hospitals to train advanced practice nurses and has demonstrated projects to promote primary care coordination of complex illnesses -financial incentives for doctors to practice primary care

Mental health care

-public and private system resources (different from most other diseases); in private system, primarily those with mild conditions with private insurance - this could be people with depression or anxiety treated in primary care setting; in public system, moderate and severe/persistent conditions - use public $ - people qualify for this based on severity of their symptoms - mostly funded by Medicaid in MI and most other states (before Medicaid expansion, most covered by state general funds; now think CMHs don't need as much funding because more people covered by Medicaid leading t crisis in CMHs) -limitations to coverage - may only get certain numbers of visit per year -deinstitutionalization starting in 60s: aggressive closure of hospitals in Michigan; start to put people back in the communities and think that people can be better treated in the community than in institutes -community-based care, codified in '74 in Michigan's Mental Health Code; creation of CMHs -in 90's, growth of managed care in Medicaid and a Medicaid waiver allowed a "carve out" of behavioral health services (PIHPs and CAs); insurer offers product but it isn't complete (mental health is absent, other insurer offers carved out serviced) -prepaid inpatient health plan = PIHP; state passes money through them to CMHs; monitor CMHs to make sure they are doing what they are supposed to be doing -coordinating agencies = CAs; distribute substance abuse treatment $ that come from federal government and states out to the agencies -today, most care in CMHs for Medicaid covered and very limited services for others using general funds

Democratic deliberation

-public engagement approach -approach to decision-making using participant deliberation to make decisions -equal distribution of power among decision makers -make sure that they have information to base their decision/opinions off of; need to have an educational process up front so that everyone is educated about the issue and everyone has the same ability to contribute to the conversation -may add legitimacy and form public will or trust: arguments should be informed by facts, balanced by contrary arguments, considered on merits, not on who makes them, and all points of view should be considered; participants should talk and listen with civility and respect -example: distributing scarce resources during a flu pandemic

Hospital ownership is varied

-public: federal (VA), state (UM), local (Cook Count Health and Hospital System) -private: investor-owned (HCA), non-profit (St. joes) -the vast majority of hospitals are private, non-profit, especially in Michigan

Long-term services and supports scorecards

-purpose of scorecard is to measure system performance from the viewpoint of the service users and their families (specifically older adults, people with physical disabilities and family caregivers) -designed to help states improve the performance of their LTSS systems so that users in all states can exercise choice and control over their lives, maximizing their independence and well-being -state policymakers often control key indicators measured, and they can influence others through oversight activities and incentives -scorecard examines state performance both overall and among 5 key dimensions, with each dimension comprising 3-6 data indicators -also measure changes in performance since the first scorecard, wherever possible

Nursing school capacity/faculty shortages

-qualified applicants turned away from nursing baccalaureate and graduate programs in 2012: 79,659 (turn away students because not enough faculty for them) -national nurse faculty vacancy rate in 2013: 8.3% -percentage of full-time nursing faculty age 50 and over: 72% -average age of doctorally-prepared nurse faculty holding title of "professor" in 2013: 61.3 -average age of master's degree-prepared nurse faculty holding title of "professor" (2013): 57.2 -PhD is not attractive in nursing right now, leading to faculty shortage

Primary care practitioners perspectives on delivery system changes: physician or practice is currently receiving incentives or payments based on the following

-quality of care or patient experiences = 50% -utilization or efficiency in care = 43% -qualifying as a patient-centered medical home (PCMH) or advanced primary care practice (APCP) = 30%

Quality of care provided by NPPs

-randomized clinical trial compared primary care outcomes of independent NPs vs. primary care physicians (Mundinger et al) -no significant differences found in: satisfaction at initial assessment; health status or physiologic tests (patients with diabetes, asthma) at 6 months; health services utilization at 6 months and 1 year -significant differences found in: diastolic blood pressure (lower for hypertensive patients of NPs) and one dimension of satisfaction (provider attributes; physicians rated 0.1 point higher on a 5 point scale) at 6 months -conclusion: patient outcomes comparable (some even tend to be better with NPs) -patient population tends to be different between who NPs are seeing and who physicians are seeing - try to adjust for this in research but difficult to do it perfectly

Public hospitals

-receive financial support from local, state, or federal government beyond patient care reimbursement received from Medicaid and Medicare -categorized into 3 models (direct operation by local or state governments; operation by a separate public entity; ownership and operation by a not for profit corporation usually with a contractual relationship with the local government) -larger -considered "safety net" hospitals -constitute only 2% of the nation's hospital, but provide 1/4 of uncompensated care -often deal with emergencies -training programs provided/residents

Hospital magnet status standard of nursing excellence

-recognizes strength and quality of nursing culture -less than 10% of all hospitals designated as magnet -helps attract and retain high-quality nurses -magnet hospitals have better patient outcomes, engaged employees -appraisal process for magnet status has 14 points "forces" (criteria hospitals are assessed on when they want to become magnet hospitals) -very rigorous process to go through to get magnet status -nurses treated with high level of professionalism, protected from problems in the field, patient satisfaction higher; great place for nurses to work

ACA effects on FQHCs: detriots experience (challenges)

-recruiting and maintaining a workforce -administrative complexities (result of expanded coverage - use of electronic health records to transfer information between delivery sites about their patients; also more complex billing) -transportation (especially important for urgent patients - those need to be seen that day; as a result, patients may turn to ER instead of FQHC) -patients maintaining coverage (FQHCs help them maintain their enrollment)

Justification for regulation

-redress market failures -healthcare regulation not effective: developed in response to many system changes over time; regs not written clearly enough so susceptible to multiple interpretations so difficult and costly to implement

Physicians and primary care

-reduced interest in primary care among new medical graduates; due to decreased pay compared to specialty care and being overqualified for those tasks -policies intended to encourage future doctors to specialize in primary care (loan forgiveness, increasing payment) will probably require a long time before having a significant impact on capacity -instead of these policies, should focus on restructuring the delivery of primary care

Nurse practitioners legal status

-regulated through nurse practice act, medical practice act; often separate board for NPs -have independent practice authority in many states (not in Michigan - need supervision for prescribing, etc.) -in other states, NPs are dependent on physician supervision and oversight to varying degrees; interval of contact with physician can be up to 2 weeks -often times, even when have oversight, physician does not have to be present at all times, but check in a few times a week; it is supervision, but not constant onsite supervision

Regulation definition

-regulation is more than a set of laws and rules; it is a network of heterogeneous bureaucratic structures that fulfill distinct missions, sometimes complementary and sometimes conflicting, in response to public policy challenges that have emerged over many years and that continue to arise -expect that drugs being put into me, and healthcare providers giving care to me are all regulated -regulation tries to protect people: ensure quality of care, increases accountability, protect personal information, etc

Regulation in health care

-regulatory policies influence actions by directives -public regulation: federal - DHHS (CMS, CDC, FDA), EPA, OSHA; state - MDCH, LARA (insurance regulators) -private regulation: joint commission (health system going through accreditation - voluntary and have to pay joint commission to come in and accredit it - need this accreditation to be paid by Medicare), NCQA, professional boards and societies

Pharmacists

-remarkably underutilized given their education, training, and closeness to the community -exceptions are pharmacists in federal agencies (VA, IHS, etc.); diagnosis made by doctor and then federal pharmacists manage the care when medications are primary treatment -tasks they can do: stop/adjust medications, order and interpret lab tests, and coordinate follow up care -law make it hard for them to do these things without doctors supervision

Mental health parity and addiction equity act (2008)

-requires group health plans and insurers that offer mental health and substance use disorder benefits to provide coverage that is comparable to coverage for general medical and surgical care -ACA new laws build on this

Current needs for HCTF and health centers programs

-restoration of the cuts in federal appropriations in 2011; ensure HCTF $ not used to replace basic funding for existing operations but remain available for expanded capacity -HCTF $ provide support for additional dental and medical care, as well as general capacity -build capacity to provide care for increasing # of Medicare patients and serve as health homes for patients with chronic conditions -private insurance often has bad rates to these health centers; ACA requires these plans pay health centers their Medicaid rates for covered services; exchange plans must also pay at this rate -health center efforts to partner with specialized providers and institutions should be fostered -new payment models may be needed (currently have prospective payment) -full funding of the program consistent with expected larger role in the coming years would help ensure that health centers continue to bring essential primary care to millions of medically underserved people, regardless of their insurance coverage or ability to pay

Barriers to expansion of NPP clinical role

-restrictive state laws (this is the hardest one - whenever expansion of scope of practice is put forward, physicians try to fight this siting concern for their patients as the main reason to be against expansion) -limited prescriptive authority -reimbursement problems -physician resistance

Shift from nursing homes to managed care at home

-results of soaring health care costs and shrinking Medicare and Medicaid financing; nursing home operators closing some facilities and embracing an emerging model of care that allows many elderly patients to remain in their homes and still receive the medical and social services available in institutions -nursing home model no longer financially viable or medically justified -newer model: team of doctors, social workers, PT/OT, and other specialists provide managed care for individual patients at home, at adult day-care centers, and in visits to specialists; less expensive and better medical outcomes -seniors and others who have chronic health needs should not have to give up their home and independence just to get medical care and other attention they need to live safely and comfortable

Important aspects to be addressed in MH care

-risk of homelessness and victimization and providing stable housing critical to long-term management -substance abuse evaluation and treatment must be incorporated into the central tasks of monitoring and managing medications and educating clients about medication and illness; lack of integration between mental health and substance abuse treatment has been a persistent deterrent to appropriate care -patients must be involved in meaningful daily activities for them to overcome their prevalent restlessness, isolation, boredom, and lack of self-regard; supported employment programs very effective and valuable -dual-eligibles should be an important focus of reinvented care for the mentally ill; 2/5 of dual-eligibles have severe mental disabilities; very expensive -new Medicare-Medicaid coordination office should ensure full access to seamless, high quality care and to make the system as cost-effective as possible for dual-eligible population -behavioral health workforce will have to make many adjustments as they shoulder new responsibilities, work more collaboratively with others, increasingly depend on information technology, and re-conceptualize their tasks and professional responsibilities -if fail to seize opportunity now, will have missed a HUGE chance to address some of the largest disparities and deficiencies in our health care system

Major concerns for nurses

-safe staffing levels -mandatory overtime -safety on the job -scope of practice

The drug approval process: clinical phases

-safety and efficacy tests performed on humans -want to gain information, while hurting the fewest amount of people as possible -phase I: tests of drug safety, tolerability, and pharmacology in 20 to 100 healthy volunteers; only with health volunteers to see if its safe - if it has any side effects -phase II: tests of drug in larger group of 100 to 500 patients who have the disease the drug is intended to treat; start to look at if it is doing what we want to do - they have participants with the disease to see if it works, no longer recruiting health patients -phase III: tests of drug in randomized controlled trials with several thousand patients (e.g. 1,000-5,000); looking at if it is really working and if they want to put it out on the market -Phase IV (post marketing surveillance trials): comparative effectiveness/cost-effectiveness studies versus other drugs, long-term effectiveness -since 1980, average number of clinical trials has more than doubled and number of patients involved has almost tripled, from 1,500 to about 4,200

Summary of readings on FQHCs

-services delivered at FQHCs in Michigan and growth in these services and changes in coverage over that time period -significant growth in behavioral health services during that time - also growth in volume and number of covered patients in these health centers -change in number of free clinics in Michigan (free clinic definition has evolved; traditionally run by volunteers and are free, some may not be open more than 1 or 2 days a month, often housed in church, health department, etc.) free clinics have had to respond to coverage in their patients and how FQHCs there are and how they deliver care -as more patients gained coverage and could go to FQHCs, fewer went to free clinics -as a result, free clinics have started accepting some covered patients - may also do information centers (not only direct patient care), education events, group visits, etc -their purpose has shifted as coverage and health care as developed -as FQHCs have increased, free clinics have declined in Michigan -those who gain coverage then have to consider if they want to leave their provider at the free clinic, and make the decision about who to see if they change providers now that they have insurance - these people often have lower health literacy and may not understand how the health system works and have to deal with many new things they didn't have to before (choosing providers, copays, etc.)

FQHC/health center services

-services of physicians, PAs, nurse, social worker, and ancillary services and supplies, when furnished by a federally qualified health center -medical care accounts for majority of visit (73%), but patients visit for dental care (12%), behavioral health (7%), "enabling services" (6%) such as case management and health education -# of visits for mental and dental health has grown due to high level of need and absence of other sources of such care

Services and providers at FQHCs

-services: medical, dental, behavioral health, substance abuse, vision, enabling services and other services based on community needs -providers: physicians, nurse practitioners, physician assistants, dentists, behavioral health and substance abuse specialists, pharmacists -about 80% provide medical services -20% provide dental services -10% provide enabling services (transportation, etc.) -5% mental services -2% vision services -<1% provide substance abuse services (availability of mental health services has increased significantly) -can also provide family planning, nutrition, and services related to domestic abuse, etc. -more than 40% of patients come in for chronic conditions (hypertension, diabetes, etc.) -equal number located in urban and rural areas in the US

Hospital boards accountable for quality of care, and should ensure new ACA mandates are met

-should re-evaluate the design and effectiveness of their quality oversight processes - need to have clinically integrated, systems-based care -evaluate practitioners in credentialing (have education, training, experience, etc.) and peer review (oversight process once they are granted privileges to practice on hospital staff) -ACA shifts focus from individual practitioners abilities to whether that practitioner functions effectively within the system of integrated care -hospitals could coordinate peer review, quality oversight, and organizational planning to implement a systems-based approach to quality oversight -systems based approach to quality oversight requires proactive board leadership; should involve all key stakeholder groups (physicians, quality management personnel, etc.); measure not only individual competence but the quality and effectiveness of the entire system of care -it is very important for the board to act on the information it receives; must meet 3 criteria to be of value: information must be accurate and accessible, must be relevant to quality interventions, and it should be specific to the individual practitioner and the provider organization, to target quality initiatives effectively -evaluate providers on the following practices: compliance with the hospitals approved quality benchmarks and evidence-based guidelines, effective coordination with other providers and staff members, and appropriate use of the hospitals electronic health record system -hospitals will need to extend their quality oversight process as they pursue increasing numbers of collaborative relationships with physicians and other external entities

Addressing short supply of primary doctors

-should rely much more on NPs, PAs, pharmacists, community members and even the patients themselves to do many routine tasks traditionally reserved for doctors -also paid less than doctors, so they can save the patient and health care system money

FQHC versus FQHC look-alike

-similarities: enhanced Medicare/Medicaid reimbursement and must meet same 4 statutory requirements -differences: look-alikes do not receive federal grant funds -look-alikes are non-competitive and centers can apply for this at any time (unlike FQHCs)

Example: CHAT - choosing health plans all together

-simulation exercise: design a hypothetical health plan constrained by limited resources; group product -> group deliberation -research and policy goals: what health insurance features/benefits do citizens/consumers prefer?; what reasons or values do citizens/consumers use to justify their choices or preferences? -simulation: created this game to create a health benefit plan to represent what the people really want -spin a wheel where each color is a different level of care (hospital, primary, etc.) -allows people to say, if I was creating a health insurance plan, this is where I would allocate my money -people first do it for themselves, then think about the community - some think certain aspects are more important than others

Federally qualified health centers (FQHC)

-sliding fee scale -present without any insurance and still will have to pay something for your services, not easy for people who are low income without insurance

Hospice patients characteristics

-slightly <1/2 have terminal cancer -nearly 40% are for end-stage cardiac disease, end-stage dementia, debility, pulmonary disease, and stroke -median hospice service is only 26 days, with 1/3 of patients referred to hospice care during last week of life (can last more than 6 months) because of late referral

Mental health insurance coverage: individual health plans

-some comprehensive plans, many with visit limitations or limits on coverage for pre-existing conditions -some exclude coverage entirely

Alternatives to current regulation

-some have argued the regulatory pluralism (a mix of state, federal, and private sector activity) is an effective strategy -others propose a federal government commission to review delivery system experimentation -others favor a market-based libertarianism (market orientation)

Star rating for nursing homes

-some have criticized the heavy reliance on self-reported data -CMS planning to modify/address concerns -based on performance in 3 types of measures: state health inspections, staffing ratios, and quality measures -CMS made changes to star rating, making it harder to get high star rating when most used to get 4 or 5 stars -does not include facilities that do not receive payment from Medicare or Medicaid (many independent and assisted living facilities) -state health inspections are the only measures that do not rely on self-reported data

NP state regulations

-some more restrictive: limit drug quartiles NPs may prescribe; not allowed to prescribe controlled substances; have to have provider present at practice site a certain amount of time of the NP's scheduled hours; have charts and prescriptions reviewed; etc. -different categories of medication; those with largest side effects are most restricted; depending on category for if NP can prescribe them -some less restrictive: allowed to admit patients to hospitals and hold hospital privileges; full prescriptive authority; etc. -can either have: no physician oversight, collaborative agreement with physicians to prescribe, or collaborate agreement with physician required to diagnose, treat and prescribe

Concerns over expanded scope of practice for NPs

-some physicians cite concerns over patient safety when opposing expansion of NPs scope of practice -in actuality, clinical outcomes similar between NPs and physicians (consistent health status, treatment practices, and prescribing behavior) -patients perceive that receiving primary care and having a usual source of care is more important than who it was that provided these services -NPs give better satisfaction of care; do better on patient follow up, time spent in consultations, and provision of screening, assessment and counseling services; more patient-centered, consider impact of social and cultural factors, and coordinate care -American Medical Association asserts that encouraging patients to see NPs rather than primary care physicians may put patients' health at risk; evidence does not support this -patients seeing NPs instead of physicians had equivalent mortality, satisfaction, and physical, emotional and social functioning; equivalent quality care; sometimes found to have better satisfaction and more effective care

Specialty care

-specialty care is given by physicians who have received additional training in a specific area of expertise -managed care financially penalizes self-referral, so less people are bypassing generalist physicians and going directly to a specialist -surgical ambulatory care consists of surgical procedures performed on non hospital patients; market change and growth in these outpatient surgeries

Percent change in national expenditures for hospital care, 2003-2011

-spending more in outpatient care -spending in hospitals has decreased from about 8% to about 4%

Key nursing home problems with care

-staffing capacity -training -supervision

Drug industry consolidation

-started with 22 drug companies, ended up with 7 -a lot of consolidation recently in pharmaceutical companies -it pools the risk a little bit, rather than hope that the 1 drug in development pans out -can share cost of drugs - can share expertise of getting drugs developed, etc. -consolidation is important to maintain power, such as when it comes to insurance companies

Alternatives to nursing homes

-state governments devoted enormous energy with variable success to developing and financing systems of community-based care for Medicaid beneficiaries who otherwise would be eligible for nursing home care -is cheaper to care at home, and most people prefer it anyways -more than 1/2 of individuals receiving Medicaid long-term care receiving it in the community as a result -as a result, patients in nursing homes are sicker and more difficult to care for than in the past; more likely to have cognitive impairments

Barriers to potential of NP workforce

-state laws: scope of practice laws define nurses' roles, articulate oversight requirements, and govern practice and prescriptive authorities; often unnecessarily restrictive; state to state variation -payment policies: reimburse NPs only a portion of what is paid to physician rate if they bill under physician's provider # and are supervised by physician, otherwise, paid at rate of 75-85% like Medicaid and private insurers -professional tensions: often due to feat of increased competition

ACA's new Medicaid waiver program

-states can develop health homes for the treatment of patients with chronic conditions - a designated provider operating in coordination with a team of other health care professionals

Other organization issues

-strategy and marketing -organization of other providers - nurses; clinical support services -human resources -financial management

Focus groups research questions

-which allocation criteria would the public see as legitimate? would one ethical principle guide decision making? -will the public be willing to accept and abide by social distancing measures likely to be implemented during a severe pandemic? -will deliberative processes elicit this information from members of the public?

Apprehensive, many doctors shift to jobs with salaries

-streaming into salaried jobs with hospitals because of worries about changes in health care market -shift from private practice most pronounced in primary care, but specialists are following -64% of job offers filled involved hospital employment compared with only 11% in 2004 -experts caution that the change from private practice to salaried jobs may not yield better or cheaper care for patients; in many places, will almost certainly lead to more expensive care in the short run -when hospitals gather the right mix of salaried front-line doctors and specialists, it can yield cost-efficient and coordinated patient care -however, many doctors on salary are offered bonuses tied to how much billing they generate -hospitals have been offering physicians attractive employment deals, with incomes often greater than in private practice, since they need to form networks to take advantage of incentives under ACA -many also switch to hospitals because they see that they are losing ground in their practice - private insurers are paying less to private practice doctors -no longer have to worry about paying malpractice premiums themselves of finding health insurance for their staff -can become employees by practicing in a hospital building or by selling their practice to a hospital, so their office becomes part of a network (attracting specialists) -some hospitals changing: providing bonuses that reward doctors for delivering high quality and cost effective care, such as high marks from patients or low numbers of patients with asthma admitted to the hospital

Factors lessening the impact of nursing shortage

-substantial growth in nursing school graduates since 2000 (where possible, nursing schools have allowed more students of popped up in addition to already existing schools - growth in graduates) -economic recession and slow growth after has kept people in workforce, including nurses -additional general shift toward later retirement in past few decades, before recession -internationally trained nurses (most come from the Philippines)

Allocation of flu vaccine during pandemic

-take a long time to produce vaccines (duck eggs) and in process lots of people die -tiers of who should get vaccine first (from 1 to 5) -tier 1: deployed forces, critical healthcare, EMS, fire, police, pregnant women, infants, toddlers -tier 2: military support, border protection, national guard, intelligence services, other national security, pharmacists, mortuary services, community services, utilities, communications, critical government, infant contacts, high risk children -tier 3: other active duty, other healthcare, other CI sectors, other government, healthy children -tier 4: high risk adults, elderly -tier 5: rest of population

Patient-centered medical home

-team based care (non-physician providers) and the adoption of technology -team can provide quality, comprehensive care for a larger number of patients with the use of practice innovations such as electronic health record systems and care coordination -assuming medical home provide 45% of the nation's primary care, shortage of primary care physicians reduced by about 1/4, demand for non-physician providers increased in this scenario, making a dent in the projected surplus of NPs and changed a small projected surplus of PAs to a small deficit -when panel size of medical home grew by 20% (from 45 to 65%), the physician shortage was nearly eliminated; when panel size shrank by 20% shortage returned to near the figure of our current scenario -staffing of medical home does not appear to differ as radically from standard models as that of the nurse managed health center -if change away from FFS, may be easier to expand their panel size for medical homes

Approaches to nursing practice

-team nursing (there is a team, 1 person is in charge, but all f them provide fairly equal care in tasks) -primary nursing (1 nurse is responsible for designing the whole care plan of the patient and managing the care that all other nurses delivery on that patient; this is very popular among nurses - gives them autonomy/authority; often better relationship with patient - patient can interact with the person they know is in charge of their care; when primary nurse is there, all care delivered by that nurse - managed by this nurse when they are no working) -care management (not always done by nurses; helping patients manage care when they have a complicated care situation - such as helping them understand who to see and when); not great reimbursement; see reduction in cost of care with care management, and better outcomes) -case management (not always done by nurses; refers to social needs; people who have multiple health needs and often have behavioral health needs; may need lots of help; may also be very resource poor) -care management and case management is recognizing importance of social determinants of health; show change based on all the years of research in social determinants of health; it has taken a long time to see any inclusion of this research

Nursing home residents

-tend to have significant limitations, including functional and/or cognitive limitations and multiple chronic conditions -majority are Medicare beneficiaries (short stay; skilled nursing care), even though Medicaid is primary payer for >60% of residents (those people stay longer) -long-stay residents often have dementia, and reside in nursing homes because they or their family are unable to care for them in their own home -women and people 85+ account for disproportionate share of nursing home residents

Projection of growth of elderly

-the 65+ population will more than double and the 85+ population will more than triple by 2050 -understand the increasing demand of long term care services over time as a result of this growth -baby boomers will have a dramatic impact on use and costs of services -people who need more long term care services generally older, and more people are living longer and population is aging

Very influential factors in decision making

-the effectiveness of the activity -previous allocation -being the sole provider of an activity in the community -reluctance to lay off employees -influence from a BOH -those in small health departments reported greater influence from BOHs and colleagues than those in medium/large departments -those in state-governed departments reported decision tools and input from state health department more influential than those locally governed -evidence based public health practice widely accepted by LHOs, but unclear if they have access to relevant data fro studies that evaluate the services and activities they provide or have the capacity to collect/analyze their own data on effectiveness -heavily rely on previous years budget for decisions and knowledge (can mean a perpetuation of weaknesses and strengths)

Hospitals in the 2000s

-the hospital is no longer the "center of the health care universe" -it is now one of the pieces of a larger delivery system -back to core business-acute care hospitals -financial status is mixed; some are doing well, others are in trouble; hospitals did ok through 2007, but the recession lowered their financial position -due to provisions in the ACA, mergers and system formation are increasing -new facilities -a lot of vertical integration today

Hospital boards

-the purpose of the governing board of a well-managed HCO (health care organization) is to create and maintain a foundation for relationships among the stakeholders (patients, physicians, payers such as BCBS, broader community - big health systems have MANY stakeholders) that identifies and implements their wishes as effectively as possible -prudence and trust; make prudent, thoughtful, well-researched decisions (may not always be correct); all have to be trustworthy -members should be familiar with community, with business decisions -CEO usually ex officio of the board (there by virtue of the role that they fill in the health system; often don't vote; they are there because of the seat they occupy in the health system)

Public health law

-the state's legal powers and duties, in collaboration with its partners, to ensure the conditions for people to be healthy, and limits on the state's power to constrain individual rights -public health pursues high levels of health, consistent with social justice

Class I devices

-these devices are not intended to extend or support life -as such, these devices are subject only to general control -general controls are related to adulteration of a device, misbranding, device registration, pre-market notification, and good manufacturing practices -examples of class I devices include elastic bandages and examination gloves

The drug approval process: approval phase

-this is manufacturer asking FDA if they can sell the drug now that they have completed clinical phases; have to submit results from all clinical phases -just because a drug has made it through the phases does not mean that it will necessarily make it through the approval process -manufacturers are the ones who pay for clinical trials - conflict of interest is a concern -new drug application (NDA): manufacturer submits results of clinical phases I-III; focus on safety, including extensive reporting of adverse events, and efficacy; draft labeling is submitted, and final labeling is negotiated; 20% of INDs are ultimately approved for marketing; occasionally, phase IV studies required by FDA -phase IV (post marketing surveillance trials): on-going trials after NDA approval; mandatory since 1962; types of trials include comparative effectiveness/cost-effectiveness studies versus other drugs, long-term effectiveness; can result in drugs being pulled from the market (example: vioxx); can look at side effects that may develop over time that are not caught during the time of the phase III trial - these studies can result in the drugs being pulled from the market

Truman's surgeon general proposed "coordinated (regionalized) hospital system"

-thomas parran, jr. suggested a regionally-organized, federally-supported health services infrastructure -instead, the hill-burton act (AKA hospital survey and construction act) passed in 1946; major features include: states appoint single agency to coordinate; inventory state facilities; identify most needy areas (fewest beds, lowest per-capita income); feds provide matching funds for construction -the hill-burton act was the most important of proposals around how to make improvements in hospital care because it decided to invest in hospitals -hill-burton act: state level coordination of the development of hospital (what do we have vs. what do we need); identify areas that really needed a hospital, and provided money to create hospitals in these areas -had federal support for increasing hospitals -increased so much that there was an oversupply; excess beds

Vertical integration trend and implications

-trend toward this between hospitals and physicians = share of US physician practices owned by hospitals has doubled -means that more producers of complementary services that were once independent are now either commonly owned or related by contract -potential to improve quality and efficiency of care by reducing "transaction costs" -could also hurt consumers by allowing hospitals and physicians to raise prices and hospitals increase their market power by amassing control over a larger bundle of services by employing or contracting with physicians (increase bargaining power with insurance) -may also increase physicians' incentives to supply unnecessary treatments if such treatments are used as a vehicle to pay what are effectively kickbacks for inappropriate referrals -ACA incentives intensify this trend because these are eligible for cash bonuses from Medicare -hospitals can use vertically integrated relationships with physicians to gain a competitive advantage over other hospitals -can be a way for physicians and hospitals to bundle their services together and charge insurers higher prices

New law's demands on doctors have many seeking a network

-those in hospital system feel more secure than those in small practice, specifically in primary care; the law is bringing new regulations and payment rates the squeeze self-employed doctors -private practice physician cherishes autonomy (and flexibility in their time, not having to rush through patients) and speaks badly of rush of independent physicians into hospital networks - see it as growing monopolies -some try to keep practice afloat amid rising overheat, flat or dropping reimbursement rates, and new federal rules, many of them related to the health care law -Medicaid pays too poorly for those in private practice to treat any of the new enrollees; even have to reject some of the independent plans that pay too low (although some will recommend it for their patients if they think it is best for them, even if they wouldn't be able to see them anymore -only 40% of family doctors and pediatricians remain independent -many private practices have not yet made investment in electronic records system -as a survival tactic, practice can join an ACO of independent physicians; reaps financial rewards if they improve patients' health and spend less doing it -many of their patients will follow from private practice to hospital

Idealistic policies for NPs

-those that regulate practice should reflect knowledge, skills, and experience instead of being constrained by parochial command and control relationships -should facilitate inter-professional collaboration, foster innovative practice, and enhance the accessibility of high quality primary care -should achieve pay parity for the same services -medical home models, ACOs, and bundle payments should be structured to recognize NPs as eligible providers -require the development and reinforcement of inter-professional teams

Shared savings program in CMS

-those that save money while also meeting quality targets keep a portion of the savings

Hospice eligibility and enrollment

-to determine eligibilit, physician and hospice medical director must certify that to the best of their judgment, the patient is more likely than not to die within 6 months -Medicare provides broad guidelines for many medical conditions to assist physicians in prognosticating; not hard and fast requirements -after enrollment, a plan of care is developed in accordance with the needs and wishes of the patient and family -as disease progresses, hospice plans shift to accommodate decreasing independence, alterations in symptoms, and changing psychosocial needs

Questions to consider

-to what extent should hospitals be required to treat patients who can't pay for their own care? -should hospitals be required to assess every person who comes to the ED, even if they don't have an emergent situation? -how much charity care should hospitals have to provide? -mission there to guide behavior, have everyone on the same page on trying to reach the same goal; if don't have a margin (make money), can't achieve your mission

Overview of the drug approval process

-total drug development time has grown over the past 4 decades (now 10-15 years) (clinical trials have gotten more complex and taking longer; FDA has gotten better at quickly reviewing and approving drugs, but the overall process is taking longer because of the increased time in clinical trials and manufacturers doing their part to make sure their drugs are safe and effective) -mean approval time (once data on results of phase I-III clinical trails have been provided to the FDA) has been cut by more than half in the last decade -financial costs to develop a drug estimated to exceed $800 million (estimates ranging from $500 million to over $2 billion)

Hospitals

-total number of hospitals decreased in last 20 years, although investor-owned hospitals has increased slightly, closing non-profit and government hospitals -investor-owned hospitals generally have a lower average length of stay; also have about 1/2 the outpatient visits; also less expensive -increasing demand for inpatient care is reflected in the trend of rising hospital admissions; however, the rate has held steady, indicating that the high # of admissions in part reelects growth in US population

Unmet needs in long-term care

-total unmet need for long-term care is far more often experienced as a lack of sufficient help than as a complete absence of help

4 models of organization among physicians and hospitals

-traditional model -divisional model -independent-corporate model -parallel model

Rx drug advertising

-traditionally directed to providers -meeting face to face with physicians -advertising in professional journals -increasing trend towards direct-to-consumer advertising (regulations in 1997 relaxed requirements for radio and TV ads) rather than direct to provider; if you can't get the provider to choose the drug for the patient, the patient can decide what drug they want - may also increase consumer knowledge -advertising typically focuses on small number of drugs that are extremely safe -tendency to medicalize normal events

Trusted community aids

-train local community members who have experience caring for others to deliver routine services for patients at home -trained to consult with patients over the phone by asking questions devised by experts; supervising nurse makes final decision on care a patient requires -may visit the patient, provide care in the home and send photos or videos back to supervising nurse by cellphone -much cheaper for patient and health care system in general, resulting in less ER or clinic visits

Continuing care retirement communities

-typically offer housing options with a full range of assistance levels -typically non-profit -nursing homes that are part of a continuing care retirement community (CCRC) tend to have higher overall star ratings than nursing homes unaffiliated with a CCRC

Mental health/substance use care

-typiclly episodic (not continued) and makes limited use of evidence-based medical, social and rehabilitative interventions -costly and inefficient pattern of care -CMS commitment to broader service mix, including care coordination, rehabilitative services, and assertive case management and continuing performance evaluation

Future challenges for FQHCs

-underinsured/remained uninsured (newly insured have high deductibles "underinsured"; some of the patients will remain uninsured and have to seek care at these centers continually) -coverage gap in non-expansion states -workforce shortage and burnout (shortage is worse among FQHCs because of lower pay, and complexity of the patients that they see) -access to specialty care -pharmacy services (many do not have pharmacy services at their site, and struggle with getting these services to their patients) -potential solutions: team based care, expanded scope of practice for non-clinicians, providing health center based residency programs (could help with workforce shortage) -new challenges regarding billing as more become insured -referrals have become easier with expansion of coverage - however, still difficult to find specialty care - especially for those who did not get expanded coverage)

Safety net providers in Michigan

-uninsured rate decreased as result of ACA -number of FQHC delivery sites and patients receiving care at these sites grew as result (less of those receiving services at these centers uninsured) -number of free clinics decreased as result (less need care at these clinics as ACA coverage expands and more become eligible for Medicaid or private insurance) -number of patients seeking mental health services increased and has since stabilized -number of Medicaid patients served by FWHCs increased; number of privately insured patients increased as well -in response to ACA, some free clinics changing their structure or service scope, including converting to FWHC or agreeing to served underinsured or Medicaid patients while continuing to see uninsured patients -more FQHCs now offering mental health services as a result of increased funding resources and increased demand for this care -FQHCs increased number of full time equivalent staff across all provider types

Why do ethical analyses?

-unmask normative assumptions to make rationale behind decisions explicit: transparency -> trust -> effectiveness -systematic consideration to take us beyond perceptions/emotions -balance other modes of analysis: economic analyses, clinical analyses, historical analyses -give education, have people talk, then try to come to some consensus about what health offices should do in these situations

Nurse practitioners and primary care

-untapped potential of nurse practitioners to increase access to primary care -127,000 NPs in US in 2012; 60,4000 in primary care -primary care NPs significantly more likely than primary care MDs to practice in urban and rural areas, provide care in wide range of community settings, serve high proportion of uninsured and vulnerable patients -take less time to produce new NP than MD -NPs can do a lot of what primary care physicians do today -NPs in primary care seem more likely than physicians in primary care to work in these areas where there are shortages -NPs can manage 80-90% of care provided by primary care physicians -research shows primary care outcomes are comparable between patients served by NPs and by physicians: disease-specific physiologic measures; improvement in pathological conditions; reductions of symptoms; mortality; hospitalization and other use measures; patient satisfaction -there is competition: resistance from the medical field of allowing NPs to practice at the same scope; physicians think they have more education and should have more authority -conversation/argument often goes to safety; complicated conversation -advance practice nurses are filling a niche; they are going where physicians are not willing to go -HRSA projects 30% increase in primary care NPs 2010-2020; increases in NPs and PAs could reduce shortage of primary care providers in 2020 by 2/3 -ACA authorized $50m for nurse-managed health clinics, as well as funds for nursing schools to increase enrollment in NP and nurse midwife programs -state legislative/regulatory barriers prevent NPs from practicing to full potential

Medically underserved

-urban or rural -defined in terms of poverty, evidence of unmet need for primary health care, and shortages of primary health care professionals

Trends in mental health institutes/organizations

-used to have many state-operated psychiatric hospitals and centers in Michigan, now only 5 -substance abuse coordinating agencies (CAs) merging with PIHPs in the state, reducing # of CAs in the state -# of CMHs has increased

Percent of population residing in primary care health professional shortage areas

-very expensive and timely to create new primary care physicians - one solution to this shortage was instead to create more options for advance practice nurses -scope of practice of advance practice nurses depends on state -scope of practice is often narrow, even in states that have these shortages -need to broaden scope to give incentives for nurses to go to these areas

After little hospital action in 1930-40s, deficiency in supply is recognized

-very little growth or progress in hospital advancement during the great depression and WWII -no money was available to invest in hospitals -after WWII, stagnation became a pressing problem: working in old facilities; increased technology; growth of private health insurance (largely to attract workers to their business/to work for them); 1,200 counties (15 million people) had no hospital; US bed/1,000 population was <3.5 - needed 4.5

The patent cliff

-very sudden drop off; a lot of companies have patents on drugs that all ended around the same time -when patent expires and they have to sell their drug for much cheaper to compete with generic, their revenue drops; many companies recently have seen their revenues from their main drugs have dropped off the cliffs; generics have largely taken over -patents started ending around 2008, ended for most by 2013

One approach: public engagement

-when science not enough to answer moral questions -when government wants to engender trust and encourage compliance -when conceptions of justice requires public input/scrutiny -use public engagement when science doesn't give a good enough answer

Community health center program

-where medically underserved communities are concerned, the core of the nation's investment is primarily in these -revenues from Medicaid and other public and private insurance provide key operational support, but basic federal health center appropriation anchors the program in thousands of urban and rural communities that otherwise lack access to comprehensive primary care and supports care for uninsured and underinsured -many accredited as medical homes -many had adoption/use of electronic health records

Nursing diagnoses

-while a medical diagnosis deals with a disease or medical condition or pathology, a nursing diagnosis deals with the human response to bio-psycho-social stressors and/or health problems that a licensed nurse is competent to treat -specifically, psycho-social part is very important in nurses - nurses expected/trained to respond to these, even though biological stressor is what often brings patients in -clinical judgment about individual, family or community responses to actual and potential health problems or life processes; assess the individual, support, and community that they live in -provide the basis for the nursing care plan and selection of nursing interventions to achieve health outcomes -every patient that comes into hospital has a nursing care plan - plans that are different from medical diagnosis that are based on the diagnosis of the nurse -patients may not recognize the differences between all of these

NP details and demographics in 2012

-~120,000 practicing, about 1/2 in primary care -11% practiced in setting where no physician on site; over 1/2 work in setting where physician on site most of time -reporting high levels of job satisfaction (nurses overall, including lower levels, have lower levels of job satisfaction, but NPs have higher satisfaction) -86% white non-hispanic, 5% black, 3% hispanic any race -7% male -average age = 48; 18% between 55-59 (not as old as overall nurses, but still fairly old group of practitioners)

14 forces of magnetism in magnet hospitals

1. quality of nursing leadership: knowledgeable, strong nurse leaders willing to take risks, a strong sense of advocacy and support on behalf of nursing 2. organizational structure: nursing departments are decentralized, with unit-based decision-making and strong nurse representation in committees throughout the organization; the nursing leader serves at the executive level of the organization 3. management style: managers involve staff at all levels of the organization; the nurse leaders communicate with staff; feedback is encouraged and valued 4. personnel policies and programs: salaries and benefits are competitive; creative and flexible staffing, with staff involvement; opportunities for promotion, both in clinical and administrative areas 5. professional models of care: nurses have responsibility, accountability and authority in the provision of patient care; nurses are accountable for their own practice and are coordinators of patient care 6. quality of care: nurses believe that they are giving high-quality care to their patients and that their organization sees high-quality care as a priority 7. quality improvement: staff nurses participate in the quality improvement process-see it as education-and believe that it helps improve patient care within the organization 8. consultation and resources: knowledgable experts, particularly advanced practice nurses, are available and utilized; peer support is available and utilized 9. autonomy: nurses are allowed and expected to work autonomously, consistent with professional standards, as members of the multidisciplinary team 10. community and hospital: hospitals maintain a strong community presence that includes a variety of long-term outreach programs 11. nurses as teachers: nurses are permitted and expected to incorporate teaching in all aspects of practice; nurses feel teaching gives a great deal of professional satisfaction 12. image of nursing: nurses are seen as essential to the hospital's delivery of patient care by nursing and other members of the health care team 13. interdisciplinary relationships: nurses, physicians, pharmacists, therapists, and other members of the health care disciplines teat each other with mutual respect and have positive relationships 14. professional development: organizations emphasize orientation, in-service education, continuing education, formal education and career development; personal and professional growth and development are values

4 stages of drug research and approval process of pharmaceutical companies

1. research -> patent 2. development -> registration (ready to go out in the real world after development) 3. manufacturing -> product 4. promotion (pharmaceuticals unique in how much they emphasize promotion compared to other aspects of health care system) -> sale and profit

Rosenthal quote

a day spent as an inpatient at an American hospital costs on average more than $4,000, five times the charge in many other developed countries

Joint Commission

all hospitals must adhere to these standards in order to receive reimbursement from Medicare, Medicaid and private insurance

Upkeep of hospitals

as the practice of medicine has grown increasingly dependent on sophisticated technology for routine diagnosis and treatment, even smaller acute care hospitals must own or have access to expensive equipment and services

Acute care

consumes 46% of primary care physicians' time; RNs can ddi it

Growth in FQHC patients, 1965-2015

continuous, large growth in number of patients

System

defined by AHA as either a multi hospital or diversified single hospital system -a multi hospital system is 2 or more hospitals owned, leased, sponsored, or contract managed by a central organization -single, freestanding hospitals may be categorized as a system by bringing into membership 3 or more and at least 25%, of their owned or leased non-hospital pre acute or post acute health care organizations -system affiliation does not preclude network participation -has centralized piece

Fee schedule payment

determined by summing the adjusted weights and multiplying by the fee schedule conversion factor

Necessary information and sources

for initial credentialing, most hospitals use primary sources: -references, certifications, portfolio of previous; references sought -committee seeks evidence that negative answers to these "key" questions are rare and unlikely to be repeated other sources: -AMA physician masterfile (anyone who even applies to medical school - has information about schools you went to, where you did residency, where you have worked, etc. -federation of state medical boards' physician disciplinary data bank (tells if they were disciplined in state of MI specifically - need to check for each state) -national practitioner data bank (can see if there were malpractice suits against physician) for recertification, credentialing committee relies on measures, reports of unexpected events, and direct observation

US leads pharmaceutical research and discovery

from most to least on number of compounds in development: USA, rest of world, Europe, Japan

Growth in FQHCs and funding

growth in funding (health center appropriation), number of health centers, and patients receiving care at these centers between 1990 and 2010

Home care

home care is an array of services brought into the home, single or in combination, in order to achieve or sustain the optimum state of health, activity and independence for individuals of all ages who require such services because of acute illness, exacerbated chronic illness, or long term limitations due to chronic disease and disability

Long term care

long term care consists of those services designed to provide diagnostic, preventive, therapeutic, rehabilitative, supportive and maintenance services for people of all age groups who have chronic physical and/or mental impairments, in a variety of institutional and non-institutional health care settings, including the home, with the goal of promoting optimum levels of physical, social and psychological functioning

NPs scope of practice geographic difference

most states allowing independence for NPs have large, sparely populated rural areas where access to physicians is limited

Opposition to AAMC opinion on workforce

others argue producing more doctors will exacerbate health spending growth, and that the expanded use of NPs, Pas, and others teaming with doctors would be a more efficient way to deploy the workforce -want cap on Medicare subsidies for graduate medical education that was imposed by BBA -believe tightly managed care would contain demand for services -aim to make team-based care the norm (e.g. Kaiser) - medical homes, ACOs, bundled payments, etc. -doctors perform many tasks for which they are not uniquely qualified and by which they are overburdened - can be delegated to other qualified personnel

Inpatient days vs. outpatient visits per 1,000 population, 1981-2012

outpatient visits increasing while inpatient days decreasing

Age distribution of RN population

over time, average age of nurses has increased (in 1980's used to be in 20's, now up to 50's) - progressively increasing

Activities of daily living (ADLs)

performance of self-care activities like bathing and dressing

Mental health insurance coverage: community mental health

services for Medicaid patients with serious mental illness and uninsured with a focus on those with severe mental illness

Decrease in mean approval time

the FDAs piece of the approval process is overall taking a shorter time

Why are patients admitted to the hospital, rather than being treated on an outpatient basis?

they need nursing care!

Physicians and Medicare

-1/2 of physicians in Medicare's registry actively bill Medicare -other help professionals can bill Medicare independently or provide services under physician supervision -physician services billed to Part B accounting for 12% of total Medicare spending -almost all beneficiaries enrolled in FFS received at least 1 physician services

Origin of practicing MI physicians

-42% attended MI medical school (most at wayne state medical school) -34% attended medical school in another state -24% attended outside of US -statistics only of actively practicing physicians (some have license but are not actively practicing)

Physicians in Michigan

-44,727 licensed physicians -72% are allopathic, 15% are osteopathic (fully licensed) -those with educational limited license while they are enrolled in a graduate medical training program (medical students or residents), majority MDs rather than DOs again -most DOs tend to go into family medicine

Benefits to magnet status

-5 main benefits in investing time and money to magnet: statistical validation that magnet facilities have better outcomes, its a huge recruiting tool for nurses, investment in steering appropriately toward front-ling employees, a magnet atmosphere leads to more engaged employees, and it gives a hospital competitive advantage -direct financial returns in addition to improved outcomes and more efficient operations -cut vacancy rate -run more efficient organization with more experienced personnel -lower turnover rate leading to savings because training and orienting a new nurse can be expensive -attract high-quality nurses and retain them for longer -because nurses have more control, sometimes cut lengths of stay of patients -majority of savings come from reduced nurse vacancy and turnover rates and use of agency nurses -fewer needlestick and musculoskeletal injuries and decreased numbers of falls and pressure ulcers saving a great deal

Administrative overhead and lack of primary care providers perceived to be barriers to delivery of high-quality care

-ACA making administrative matters easier -need more primary care providers to improve quality and coordination of care; ACA includes 10% payment bonus for primary care physicians; bundling and medical home add value to primary care -uncertainty surrounding sustainable growth rate policy (payment for physicians) - may lead to dislike of ACA by physicians

Future workforce needs

-disagreements among major stakeholders about who to assess/address future workforce needs

Nurses increasing bachelor's degree

-IOM report recommended that nurses who hold at least a bachelor's degree should increase from 50% to 80% -if not, repercussions in making care affordable, effective and safe for all -at same time, nursing schools declining many people because of budget constraints and faculty shortage

An increase in the number of nurses with baccalaureate degrees is linked to lower rates of post surgery mortality

-IOM reports aims to have 80% of RNs hold bachelors degree by 2020 -increases in the % of nurses with bachelors degree within a hospital were associated with significant reductions in surgical mortality and failure to rescue rates - these findings support the IOM recommendations -no significant reductions in mortality or failure to rescue rates associated with changes in nurse-reported staffing levels, skill mix, or years of experience -many more associate degrees in nursing awarded than baccalaureate - make it difficult to reach IOM goal - 60% have associates, 40% have bachelors -one policy to increase bachelors degrees in nursing is granting of bachelors degrees by community colleges -many employers and physicians prefer nurses with bachelors degree

Funding for graduate medical education

-Medicare is largest federal government contribution - some direct medical education (paying salaries of residents and supervising physicians) and some indirect medical education to subsidize the higher costs that hospitals incur when they run training programs -also included in funding are Veterans Health Administration and Health Resources and Services Administration and Medicaid -some believe this funding is key to addressing physician shortages

Setting of nurses throughout career

-RNs shift from acute care inpatient settings to non hospital settings during the course of their careers (possibly in part because of the heavy physical demands associated with hospital employment); thus an increase in the career longevity of nurses implies a boost to RN employment in the non hospital settings -RN employment has grown 140% in non hospital setting, compared to 54% in hospital -good for ACA when trying to reduce hospital-based care

Challenges to less emphasis on physician expansion

-attitudes: value of individualism and physicians "social identity" prevent them from accepting new ways of relating to/working with others; status inequality between doctors and nurses -health information technology -payments: time spend on phone or email may be useful but not reimbursable; Medicare FFS pays more for services provided by physicians than other providers -distribution: uneven distribution across geographic areas and medical specialities main issue

Nurses and better hospital outcomes

-better staffing, work environments, and educated nurses all work to improve outcomes -better staffing is the most expensive option to improve care, and has little effect on surgical mortality and failure to rescue in hospitals with poor work environments -getting better value for investments in hospital nursing requires better staffing in the context of a good nurse work environment, and a more educated nurse workforce

Specialists/sub-specialists

-board certified in specialty -additional training in a specialty (e.g. cardiology) or subspecialty (e.g. interventional cardiology) -additional training through residency or other training programs after initial medical training and residency -more years of training -in primary care, family care is considered a specialty

Title VII Health Professions Student Loan program

-boost supply of NP and PAs -still gravitate towards more remunerative specialties

Adjustments to payments

-can be adjusted downwards if services furnished by non-physician practitioners or when services are furnished by physicians not participating in Medicare -can be adjusted upwards if in a health professional shortage area -can also make payment modifications in special circumstances such as assistance or multiple procedures

Resource stewardship and appropriate care

-choosing wisely is a campaign started by the ABIM foundation in 2010 to encourage doctors and physicians to have conservations about care choices; specialties pick things that members might do when unnecessary and cost the system more with little to no benefit that they can aim to cut back -endorsed by 50+ specialty societies and includes 100s of recommendations for "what not to do" -emphasizes that in some cases "less is more" -focused on safety, quality, and cost savings -example recommendations include: don't image for acute low back pain within first 6 weeks; don't prescribe antibiotics for sinus infections or bronchitis where infection is likely a viral infection -considering quality of care, not only quantity of care

Health technicians and technologists

-clinical lab technician -dental hygienist -EMT -LPN medical records technician -lower levels of training, less autonomy

5 wedges combine to meet the growing nee for primary care services

-clinicians -non-clinician licensed practitioners -non-licensed personnel -patients themselves -technology

Population health

-definition: health outcomes of a group of individuals including the distribution of such outcomes within the groups -includes health outcomes, patterns of health determinants and policies and interventions that link these 2 -for physicians, it means caring for a patient as an individual but with a focus on outcomes for a larger group -population health outcomes are increasingly being incentivized -focus on overall population, and get physicians out of individualistic 1-on-1 view of providing health care

Health service occupations

-dental assistants -medical assistants -nurses aids and psych aids -pharmacy assistants -PT aides -more administrative roles rather than considered professionals

How many providers (in this case, physicians) do we require)

-depending on who you talk to, you will find different answers about the possible shortage -this is a very complex estimation process

Health assessment and treating

-dietitians & nutritionists -pharmacists: many new innovative programs working closely with pharmacists ensuring that patients are adhering to medication schedule; want to coordinate more with pharmacists -physician assistants -registered nurses -therapists -want to engage these kinds of professionals to improve patients health -often overlooked played in healthcare -characterized with less training and less autonomy

Medical students vs. residents

-difference in relative value of and time devoted to services received and services provided differs dramatically -medical students mostly observe -residents receive some direct educational benefits and practice during training can incur costs for the hospital, but provide substantial amounts of services to patients, generate revenues (especially after 1st year)

14 forces of magnetism

-differentiating characteristics of organizations that were best able to recruit and retain nurses during nursing shortages: -quality of nursing leadership -organizational structure -management style -personnel policies and programs -professional models of care -quality of care -quality improvement -consultation and resources -autonomy -community and the health care organization -nurses as teachers -image of nursing -interdisciplinary relationships -professional development

Direct vs. indirect medical education funding

-direct may do little to offset the cost of training physicians -indirect is controversial because paying institutions more because they spend more rather than because they provide higher value

Doctors payment and spending

-direct most health care spending, making decisions for their patients, but they are not the beneficiaries of it -bulk of most procedures payments goes to hospitals and device manufacturers, not physicians -decreasing physician prices could inadvertently increase prices because they would just perform more procedures -can't expect people to fill shortage if it is a career that doesn't pay well -to make more money, may become consultants to medical device manufacturers and pharmaceutical companies to make extra money; self referral to physician owned facilities; etc. -have historically maintained their income in 2 ways: restricting supply and prohibiting competition (scope of practice laws) -time to make a bargain with physicians: they can maintain their traditional role, payment methods and scope of practice OR their income, but not both

Gender and race/ethnic distribution of healthcare personnel

-dominant profession: more prestige, more autonomy, more training/education = physicians & surgeons -there is a disparity in the dominant professions -physicians and surgeons: 35% women, 5% AA, 21% asian, 3% hispanic -HC practitioners & technical occupations: 80% women, 15% AA, 7% asian, 12% hispanic -HC support occupations (nursing, psychiatric home health aids, OT assistants and aids, PT assistants and aids, massage therapists, medical and dental assistants): 90% women, 28% AA, 4% asian, 18% hispanic -more asian professionals - international medical graduates are a whole section of providers that come from international graduate schools (the larger proportion of these come from countries that count as "Asia")

Supply of primary care physicians vs. specialty physicians

-during the last decade, the supply of primary care physicians was lower than the supply of specialty physicians -big disparity -more medical students choosing to go into specialties compared to primary care physicians -specialists income significantly higher than primary care providers -Medicare factors many things to decide how to pay providers; uses some things that are very subjective (training, cost of running practice, malpractice insurance) -many argue that these are not objective values -when considering value, those who are in primary care and family medicine, and what they contribute to the system, is largely undervalued

How ACA likely to affect practice of medicine

-focused care around exceptional patient experience and shared clinical outcome goals -expanding the use of electronic health records with capacity for drug reconciliation, guidelines, alerts, and other decision support -redesigning care to include a team of non-physician providers, such as NPs, PAs, care coordinators, and dietitians -establishing, with physician colleagues, patient care teams to take part in bundled payments and incentive programs, such as accountable care organizations and patient centered medical homes -proactively managed preventive care - reaching out to patients to assure they get recommended tests and follow-up interventions -collaborating with hospitals to dramatically reduce readmissions and hospital-acquired infections -engaging in shared decision-making discussions regarding treatment goals and approaches -redesigning medical office processes to capture savings for administrative simplification -developing approaches to engage and monitor patients outside the office -incorporate patient-centered outcomes research to tailor care appropriate for specific patient populations

Nurse shortage?

-forecasters predicted large nurse shortage due to low enrollment in nursing schools and the baby-boomer RN cohort retirees -nurse workforce has actually grown more rapidly; difficult to assess if this has erased previously forecast shortages; actually difficult for some to find jobs there are so many nurses -may change with expansion from ACA, populating growth and aging

Primary care physicians

-generalist/general medicine: mostly adult patients -internists/internal medicine: mostly adult patients -pediatricians -family medicine: hybrid - treats the whole family -first point of contact in health care system -coordinating function to other healthcare delivery

Primary medical care health professional shortage area designations

-geographic area: 1 physician for every 35,000 residents; may be rural area; geographic dispersion makes it hard to get access to care -population group: 1 provider for 3,000 residents; high proportion of low-income residents; may have higher need in this area -these based on ratio of providers -the needs are largely in a rural area, not the most populous areas like SE Michigan

APRN roles and education

-health care reforms call APRN's to fill a range of new roles in primary care, prevention, and care coordination on top of many tasks they already do -graduation rate has stalled even with good employment opportunities -to qualify for positions, must return to school after obtaining basic education and licensure to acquire 2 or more additional academic degrees (prospect that is simply not feasible for most practicing nurses) -current graduation rates not enough to replenish workforce for faculty and APRN -those with bachelors degree in nursing more likely to go on to advance degree than those with associate's degree -to change patterns of additional education, first need to change pattern of initial education -need to increase funding for nursing education to achieve this goal; make all become bachelor's programs - most would want bachelors rather than associates if it was feasible

Occupational classification/healthcare practitioners and technical occupations

-health diagnosing occupations -health assessment and treating -health technicians and technologists -health service occupations -healthcare is hierarchy - less training and less autonomy for each lower level

Health professional shortage areas and medically underserved areas/populations

-health professional shortage ages (HPSAs): shortages of primary medical care, dental or mental health providers -may be geographic, demographic, or institutional -medically underserved areas: too few primary care providers, high infant mortality, high poverty and/or high elderly population (4 measures create score from 0-100) -identify these areas so that policies can prioritize physicians located in these areas - programs to incentivize physicians to move to these areas

Healthcare job growth

-healthcare workforce is largest growing sector in terms of jobs -compared to all other jobs during the recession, they were the only profession that maintained modest growth -projected that most of job growth for next 10 or so years will be in healthcare -of 9.3 million new service sector jobs (capturing 94.6% of jobs added in next 10 years), 3.8 million will be added to the healthcare and social assistance major sector -healthcare projected to increase its employment share from 12.0% in 2014 to 13.6% in 2024

Association of American Medical College workforce opinion

-if current trends continue, nation will have shortage of physicians -most medical schools increasing enrollments, and without Medicare's help hard to image creating enough new residencies to meet AAMCs goal of increasing number of new doctors

Policy recommendations for primary care shortage

-increasing primary care reimbursement, improving the stressful primary care work life, and graduating more NPs and PAs -even with change in attractiveness, would take decades to fill the gap

Physician payment in Medicare

-list of services and their payment rates for Medicare (CMS considers amount of work, expenses related to maintaining practice, liability insurance, etc. - further adjusted for by provider characteristics, geographic area, etc.) -update payment factor every year according to sustainable growth rate system - want spending consistent with economy growth -unit of payment generally the individual service but range from narrow services to broader bundles of services associated with surgical procedures Medicare pays provider 80%, beneficiary responsible for other 20%

ACA objective: improving information and creating incentives to change clinical practice

-major provisions: free preventive care; creation of the patient-centered outcomes research institute; incentives to create patient-centered medical homes and accountable care organizations; pilots of bundled and alternative payment models; funding to adopt electronic health records; incentives to reduce readmissions and hospital-acquired infections; expands access to physician, hospital, drug and device quality and safety data -physician implications: to meet the quality, productivity, information transparency and payment reform requirements must focus care around exceptional patient experience and shared clinical outcome goals; engage in shared decision-making discussions regarding treatment goals and approaches; proactively manage preventive care; establish teams to take part in bundled payments and incentive programs; expand use of electronic health records; collaborate with hospitals to dramatically reduce readmissions and hospital-acquired infections; incorporate patient-centered outcomes research to tailor care

ACA objective: removing barriers

-major provisions: removes unnecessary administrative and billing complexity; expands national services corps and increases amount of loan repayment; expands primary care residency slots; increases funding for medical and allied health professional training; increases pay for primary care by 10% -physician implications: to capture value, redesign medical office processes to capture savings from administrative simplification

ACA Objective: guaranteeing access to health care for all Americans

-major provisions: subsidized coverage and Medicaid expansion; eliminates Medicare drug "doughnut hole"; removes annual and lifetime limits on coverage; outlaws rescissions; eliminates preexisting condition exclusion for children; temporarily high-risk insurance pool -physician implications: to meet expanded demand for health care must redesign care to include a team of non-physician providers, such as NP, PAs, care coordinators and dietitians and develop approaches to engage and monitor patients outside of the office

Reports and laws regarding physician supply: most important = Flexner report (1910)

-many policies have been created regarding what the right physician supply is, flexner report is one -in history of medicine as a profession, physicians and practice of medicine was not always a noble/respected value field -around 1910, more and more people becoming doctors and science is taking more hold, and more medical schools were popping up because it was a more lucrative field - still don't have science of medicine keeping up with education -Flexner studied the state of medical education in early 20th century finding that there were not consistent standards; some large establishments that had good programs, but some small schools also popping up just to make money and did not have good standards -decided that they needed to shut down some of the schools/cut the number of medical schools -needed to make more rigorous requirements to get into medical school -increase power of states to license and monitor physicians -went from 151 schools to 31 - less spots, much more competition - before this it was possible for women and people of color to go to medical school, but with reduction of spots, less of them accepted to medical school

US fails to deliver reliably high-qualit care

-many unplanned readmissions, medical errors, and hospital-acquired infections -fall short of delivering effective primary and secondary prevention

International medical graduates (IMGs)

-medical school graduates from outside the US -to practice must complete 4 steps: certification of training (AMA certifies that the medical school that they went to is consistent with standards of US medical school - certification process), complete residency (even if completed in home country, must do one in US), state licensure, immigration status

Relationship between nurses shift length and burnout, job dissatisfaction, intention to leave the job and patient outcomes

-most nurses satisfied with scheduling practices at their hospital -% reporting burnout and intention to leave the job increased as shift length increased -% dissatisfied with the job similar for most shift lengths, but higher for those working 10-11 or 13+ hours -increases in shift length associated with significant increases in odds of burnout, job dissatisfaction and intention to leave the job -more hours, high patient dissatisfaction -the longer the shift, the greater the likelihood of adverse nurse outcomes such as burnout -patients less satisfied with their care where high proportions of nurses working shifts of 13+, more satisfied when they were working 11 hours -despite poor nurse outcomes with longer shifts, nurses seem to be satisfied with their schedules -12 hours is preferred shift length among nurses, but nurses working 12-13 hour shifts more likely to intend to leave the job -perceived benefit of only working 3 days, but rest and recovery time needed offsets any perceived benefit -need to encourage respect for days off, prompt departure at end of a shift, and allow nurses to refuse to work overtime without retribution -hospitals need to establish practices designed to comply with IOMs recommendations to limit nurses work hours to 12 hours in a 24 hour period and 60 hours a week, at minimum

Chronic care

-most of time required to are for patients with chronic conditions is needed for health coaching -25% of care could be reallocated to non-clinician health coaches -the patients also have significant improvements compared to those receiving physician only care

Qualifying for magnet status

-must file an interim monitoring report every year and may reapply for the credential every 4 years -application cost and time are very large, but cost not prohibitive in the context of what it takes to run a hospital -trying to make a quick fix to meet a requirement without changing the culture is the biggest mistake organizations make -interviews don't only focus on the leadership, but talk a lot at the clinician level -magnet hospitals almost always get recertified -large investment in labor to apply for Magnet status - almost impossible for small size hospitals, but suggest hospitals at least buy manual for magnet application to improve in nursing excellence even if they don't apply

Delayed retirement

-not unique to the nursing profession -trend may be due to shift away from defined-benefit retirement plans and toward defined-contribution plans -longer life expectancy, reduced likelihood of health benefits if workers retired before Medicare eligibility, being married, being in managerial and professional occupations, cuts in employment and compensation, etc. -may also continue working due to satisfaction from position/contribution they make towards society or financial necessity

Long shifts for nurses

-nurses often put in unplanned overtime beyond the schedule shift length due to fluctuations in patient needs and unanticipated staffing changes -those rotating between night and day shifts at particular risk for fatigue and burnout, which may compromise patient care -no work-hour policies for RNs -nurse shortage, coupled with a weak economy, have motivated nurses to work past the end of their scheduled shift or to work additional shifts

Nursing staffing

-nursing is one of largest categories in hospitals' budgets -association between lower nurse workloads and better patient outcomes -lower patient-to-nurse ratios, higher proportions of nurses with baccalaureate level education, and better nurse work environments are associated individually and additively with lower mortality and failure to rescue

What is nursing?

-nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities and populations -***protection, promotion, and optimization of health -not about diagnosing the condition, but understanding the experience of the patients health based on the diagnosis of the patient -nurse has a more holistic view of the patient and also has a role as patient advocate -nurse may focus on managing and controlling pain, disease, etc. -nurses have a big role educating patients and their families

Traditional domains of nursing vs. medicine

-nursing: health maintenance, prevention, patient education, patient advocacy -medicine: curative, diagnostic, prescriptive

Study on the effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments

-objective to determine the conditions under which the impact of hospital nurse staff, nurse education and work environment are associated with patient outcomes -effect of decreasing workloads by one patient/nurse on deaths and failure to rescue is virtually nil in hospitals with poor work environments, but decreasing the odds on both deaths and failures in hospitals with average environments; effect of 10% more BSN nurses decreases the odds of both outcomes in hospitals regardless of work environment -while the positive effect of increasing % of BSN nurses is consistent across all hospitals, lowering the patient-to-nurse ratios markedly improved patient outcomes in hospitals with good work environments, slightly improves them in hospitals with average environments, and has no effect in hospitals with poor environment

Health care system will evolve into 1 of 2 forms

-organized around hospitals -organized around physician groups

Allopathic v. osteopathic

-osteopathic medicine was developed in the late 1800s as an alternative to allopathic medicine (reaction against interventionist type of medicine - medicine not always scientific, rigorous standards - reaction to toxic medications given out) -training today is virtually identical but underlying philosophy is different -osteopathic medicine tends to focus on more whole patient approach rather than focus on the specific disease or illness -tends to useless interventionist approaches (i.e. medications) -allopathic is what you consider a "doctor" commonly - MD; most dominant in profession -DO looks at the body as an entire thing and is more holistic -training today between these 2 is virtually identical today, although they do take different exams

Primary care shortage area

-particularly affects primary care for adults more so than for children -need for adult primary care comes from baby boomers, insurance expansion, and diabetes and obesity epidemics -only 9% of medical students choose family medicine and general internal medicine (adult primary care careers)

Physician time and resulting patient relationship

-patient-physician relationship not good -patient satisfaction for nurses or PTs is higher

Barriers inhibiting high-quality care

-patients utilization of primary prevention -patient financial responsibility as a substantial barrier to utilization of prevention, poor reimbursement, and underdeveloped clinical reminders at the point of care that assure patients are getting appropriate preventive services

Relative value units

-payment rates based on RVUs -account for relative costliness of the inputs used to provide physicians services (physician work, practice expenses, liability insurance) -adjusted for cost of these things in local market (geographic practice cost indexes) -multipliers Medicare puts in to decide how they will pay different providers

Policy solutions to physician shortage (other than more doctors)

-payment reform away from FFS -scope of practice changes (specifically for RNs) -training non-clinicians for new roles (ex. training administrator to be a life coach) -insufficient technology (need to address this - if we had one system of a system that could talk to each other, it would help with communication; help with time physician has available rather than trying to track down past results)

Health diagnosing occupations

-physicians: takes about 11-16 years to become physician; essentially entirely autonomous -dentists -optometrists -veterinarians -considered dominant professions - greatest degree of training

Clinical preventive services

-primary care practices can delegate many preventive services to non-clinical team members; 60% of these services can be performed by non-clinicians -this would increase the percentage of patients who receive preventive care

How can we determine what is an adequate supply?

-professional norms (e.g. american academy of pediatrics, american nurses association; consensus of what the profession considers a good provider to patient ratio) -empirically determined ratios (benchmarks) (based on "good" system, kaiser permanent HMO, canada, etc.) -demand-based ratios (based on demographic characteristics & MD visits) -need-based ratios

Physician supply

-projections of physician supply assume that current patterns of new graduates, specialty choice, and practice behavior continue -many more women going into medical school but where/how they choose to practice different from male counterparts - generally go into more primary care and have less continuous relationship with employment sector (ex. have children) -unknowns: physicians pool age-distributions and patterns of retirement; economic changes & move from clinical to other non-clinical fields; changes in gender distribution and in number of hours worked; adequacy of supply by geographic region & specialty

ACA

-providing physicians with incentives and information to change the way that they deliver care -offering patients new and better information about practitioners and treatment options -creating strong incentives to improve qua lit and reliability both in hospitals and throughout the continuum of care -implementing policies that will slow the rate of cost growth to make health care more affordable -make it easier for physicians to get their patients the right tests and treatments -2 HUGE incentives: financial support/incentive to use electronic health records and encouraged to coordinate care

What are the solutions to the physician "shortages" beyond training more physicians?

-rather than a 'crisis' it should be viewed as a demand-capacity mismatch -training more physicians may not be the answer (expensive to train and use, takes a lot of support and time to train) -expand scope of practice laws for nurses -move to more team based care and expand use of non-physicians in care delivery, especially for preventive and chronic conditions (many people who help keep a practice open/take work off of the physician)

Balanced Budget Act

-reduced direct and indirect medical education payments but didn't result in reductions in residents' salaries -capped number of residency positions supported by Medicare to curb financial incentives for hospitals to add more residency positions -this evidence consistent with view that residents bear cost of their own training; other strategies may be more effective to encourage more graduates to go into primary care practice (loan forgiveness, vouchers, etc. that benefit physician instead of training institution)

Resident training

-residents bear full cost of their education because they accept lower wages during training that offset training's significant costs -training they get is general training that can be used anywhere (not only the hospital training them) - therefore, does not make sense to invest because once trained physicians can practice wherever they want; therefore, training should not be subsidized -despite changes in graduate medical education funding, residents' salaries have remained constant over time

Annual updates to Medicare payment

-review of changes in medical practice, coding changes, new data, and addition of new services -annual updates for conversion factor made according to SGR system to keep spending on services consistent with growth in national economy

Physicians key workforce issues

-shortages in primary care: expansion of insurance under ACA -reimbursement - reimbursement trying to be addressed through ACA -primary care v. speciality care

Physicians opinion and happiness

-suggest patient care could be improved by decreasing the utilization of low-value and harmful care - "less is more" -evidence that physicians are unhappy and burned out despite being well-paid

Age of nursing workforce

-supply in the older age groups grew dramatically after 2000; aging of the large cohorts of baby boomers and increased work effort among older RNs relative to earlier years -RNs more likely to stay in the workforce or work longer hours during recession

Emphasis on care coordination

-the ACA had many provisions to encourage better care through improved coordination: patient center medical homes (medical home where care is delivered and make sure care is coordinated), ACOs (considered medical neighborhood; going beyond physicians office but even looking at hospitals), and primary care transformation (trying to better coordinate care for patients so we have better outcomes; make sure patients are getting other education and support to take care of their condition) -common theme to these programs is emphasis on population health and care coordination -team based approach - coordinate care across whole system (primary care to specialist)

Nursing focus and activities

-the central concern of nursing is the holistic person -the focus of nursing is health promotion, maintenance, curative, restorative, supportive and terminal care to individuals and groups of all ages, taking into consideration the factors that influence them in the total environment -nurses carry out physician orders and nurse-initiated activities

Will we have too many or too few physicians?

-there will be a major shortage of physicians -if physician supply and use patterns stay the same, the US will experience a shortage of 124,000 full-time physicians by 2025 (AAMC) -the HRSA in the DHHS released a report in 2006 projecting a shortfall of approximately 55,000 physicians in 2000 -how many are estimated in shortage varies from report to report; not in agreement on shortage of physicians -in 2006, AAMC recommended a 30% enrollment growth in medical school over 2002-03 levels by 2016 (2012 enrollment put medical schools on track to meet this goal; ~half of growth comes from new schools) -because suggested by AAMC need to think about it because it could be self-servicing - more medical schools would benefit them -many new medical schools coming into existence (17 new US medical schools have received preliminary accreditation since 2005 after no newly accredited schools from 1986-2004, 11 new schools opened between 2007-2012, and 4 in 2013 -some think that there should be more medical schools opened/more spots (have come full circle since Flexner report)

Medically underserved area/population designations

-these are based on ratio scale of 0-1 -if it is below 0.62, it is considered an underserved area

Sustainable growth rate

-threatening to cut physician payment in order to restrain Medicare costs -ongoing approach to target physician fees as a way to control costs

SGR and payment

-ties fee schedule payment updates to a number of factors such as growth in input costs, growth in fee-for-service enrollment, and growth in volume of physician services relative to growth in the national economy -congress passed legislation to override SGR formula averting the formula's negative updates

Indicators of magnet hospitals

-what kind of culture organizations have and whether they are able to change it over time -culture is one of empowerment, shared decision-making and accountability -must excel at 14 forces of magnetism

Race/ethnicity of US physicians

-white 55% -black 4% -hispanic 5% -asian 14% -other 1% -AI/AN 0.2% -unknown 20% (did not report their race) -based on membership survey in AMA

Physicians adopting to the change

-will hold onto obsolete work to maintain their incomes unless payment reform -currently little incentive to redistribute work to non-clinicians who increase expenses but do not produce revenue -even if they are ok with distributing work, many scope of practice laws restrict their ability -personnel limitations in small practice will soon be less of a problem as small practices increasingly join hospital systems or loose practice networks -physicians need to learn/accept the 5 wedge model and general public needs to shed its dependence on physician-only care

Physician demand

demand is how many patients who actually need the healthcare regardless of specialty -projections assume that patterns of healthcare use and delivery of care remain unchanged over the projection horizon and that changing demographics are the primary driver of changes in physician requirements -projections looking at patterns such as who are using what types of physicians, what they are going in for (chronic diseases that require more attention than simple yearly checkup), demographics (age, gender), etc. -unknowns: technological changes (people looking up symptoms on google and worrying they are more sick than they are -cybercondria; but also makes self-diagnosing and knowing what to do easier; may create more demand or less); non-physician clinicians (number and extent of services provided - because physicians expensive and hard to get appointment with, nurses, PA's, etc. can go through checklist to see if patient needs to see a physician); public expectations (people want to be seen immediately); policy changes (expansion of insurance coverage)

National Health Service Corps

provides incentives/support for new physicians who agree to practice in underserved areas -unfilled positions largely in most unattractive but neediest settings