Intro to Healthcare Delivery Final Exam!
Question
-A ________ is a prepaid (capitation) health plan in which enrollees pay a fixed fee (often with copayment) for designated health services Health Maintenance Organization (HMO)
Medication Reconcilliation
-A process by which medications are accurately and completely accounted for throughout the care process -Goal is to avoid adverse drug events due to inadequate communication between and among healthcare providers --> especially during transfer process
Within the Medical Home, pharmacists can have
-A role (MTM role) --> typically has been underused -Traditionally: teaching hospitals were poorly staffed and were dispensaries for the poor -Today hospitals/clinics function as group practices: 1. Medical 2. Surgery 3. Specialty -Teaching hospitals: the privacy is lost there because attending physician is rounding with many others --> students are observing --> therefore, lower cost to patients and is usually for low-income patients and follow-up visits
Select All That Apply Q
-ADLs include: Bathing, dressing, toileting
Integrated Ambulatory Care Models
-Accountable Care Organization (ACO): legal entity including providers and suppliers to coordinate care for Medicare beneficiaries -It meets Medicare quality measures -Provider payments combine fee-for-fee service with shared savings, bonuses linked with quality standards Goals: timely, appropriate care, avoid duplications, medical emergencies, and hospitalizations
What are advantages of group practice?
-After hours and vacation coverage -Shared office overhead (personnel and technology) -Peer consultation -Medicare and insurance encouraged group practice
Emergency Department
-Ambulance/life-flight services -Staffed and equipped for life threatening illness and injury -1/3 of visits are injuries, poisoning, adverse drug events -Community "Safety Net" Hospitals: more for uninsured patients, older patients, physician referrals, inappropriate use of ER--> abused it because they did not have insurance--> would go there for common cold, etc. -Three types of cases: Emergent care--> needs immediate medical care --> Urgent: needs medical care within hours --> Non-urgent: (50%) minor or non-acute in severity (freq. used by patients with no physician or insurance)
Ambulatory care T/F Q
-Ambulatory care comprises healthcare services that can be delivered on an outpatient basis and do not require an overnight hospitalization TRUE
Question III
-An affiliation of three or more providers, usually physicians, who share resources and income, is what type of practice? GROUP PRACTICE
Exam Q
-As compared to centralized pharmacy services, decentralized pharmacy services: REQUIRE MORE PERSONNEL
Ch 12 Q III
-As opposed to reusable medical equipment, durable medical equipment is disposable equipment and supplies that are used by patients receiving home health care. FALSE (EX: wheelchairs, walkers, hospital beds)
Types of LTC Available in Community Settings
-Assisted living: care and support services available in tandem with independent living -Adult day services: group programs which allow families relief from care for several hours (facility) -Home health care -Hospice/palliative care: terminally ill patients (death within 6 months_
Retail Clinics
-CVS, Walgreens, etc. -First opened in 2000 -Staff is usually nurse practitioners or PA and doctors are on-call -Strong patient, insurer acceptance
Ambulatory Care
-Care for an individual presenting for personal health services, who is neither bedridden, nor currently admitted to any health care institution -Not requiring overnight hospitalization/outpatient setting -Payer incentives decrease inpatient stays -Majority of diagnoses and prescribed drugs come form a few common disease states (HTN, leukemia, diabetes, depression, cancer, arthritis, obesity, COPD)
Voluntary Agencies
-Cause related, grass-roots missions -Repositories of community values and charity -American Red Cross, Salvation Army, Church missions -Funding: government and private foundation grants, private donations, Medicare, Medicaid, private insurance, sliding fee scale
Centralized vs Decentralized Pharmacy
-Centralized: Single location, fewer professional and technical sources are required -Decentralized: Multiple locations, specialized or satellite locations -Adverse Drug Reaction Monitoring: purpose is to reduce preventable adverse drug reactions, review suspected adverse reactions, alert medical staff about this
Prefer Medigap because
-Co-pays for up to 90 day impatient hospitalization -Co-pays for lifetime hospital impatient reserves -100% of Medicare eligible hospital expenses
Aging in Place
-Continuing Care Requirement Communities: contains independent living, assisted living, and skilled nursing care on a single campus (do not need to relocate) -Program of All-Inclusive Care for the Elderly (PACE): integrates all aspects of care covered by Medicare and Medicaid
Developed vs. Developing
-Developed countries: high income economies --> mostly industrialized, capitalist democracies --> strong health infrastructures -Positive healthcare outcomes -Developing countries: low income economies
Pharmacists Opportunities in LTC
-Distribution: provide specialized packaging, provide delivery services, discuss dosage form alternatives, manage drug related forms -Consulting: perform medication regimen review (MRR), drug utilization evaluation (DUE), and drug utilization review (DUR)
Part D
-Donut hole--> beneficiaries pay 100% of additional costs up to total out of pocket expenditure -Patients always have to pay deductible
DUR
-Drug Utilization Review (DUR) Review of physician prescribing, pharmacist dispensing, and patient use of drugs. -Ensures drugs are used appropriately, safely, and effectively. -Retrospective DUR is an educational tool to inform providers of how to improve their drug therapy.* -Prospective DUR is done at time of dispensing to determine if the prescription is appropriate.*
Compounding Issues
-Drug/Solution Stability: extending expiration date -Packaging: glass vs. plastic -Infusion devices: select appropriate device based on patient's needs and drug -Delivery schedules: less frequent delivery preferred
Home Medical Equipment
-Durable Medical Equipment (DME): wheelchairs, bathroom safety supplies, hospital beds, infusion pumps, ambulatory aids -Respiratory Therapy and supplies -Miscellaneous supplies
Hospital Formulary System
-Ensure appropriate drug therapy and control drug costs -List of approved medications -Process of evaluating and selecting medications to be included in the formulary -Brand of product is determined by pharmacy: quality of manufacturer, cost, dosage forms -In hospital every Thursday...
Ambulatory Surgery Centers
-Established in 1970s -Either hospital-related or freestanding -Anesthesia advances in these centers -Surgeries and procedures not required admission -Patient goes home same day -Less time, lower cost, high level of patient satisfaction -Preferred by 3rd party payers -Accreditation: Medicare, Joint Commision
Governmental Programs: Federally Qualified Health Centers
-FQHC's -1960s: US. Office of Economic Opportunity: urban and rural --> Community Health Centers (CHCs): serve about 20 million patients -2/3 patients are uninsured or Medicaid -High poverty levels and excessive infant mortality -Sliding fee for paying patient
Urgent Care Centers
-First appeared in 1970s -Ownership: for-profit, physician groups, managed care organizations -Provide walk-in, extended hour access for acute illness and injury care that is either beyond the scope or availability of primary care practice -Episodic care, after hours, non-emergency (acute illness) -Staff: PCP, nurse, labs present -Self-payed patients, insured patients --> attract paying patients and poor patients for ER
Drug Distribution Systems
-Floor-Stock distribution: Predetermined number of dosage forms, nurses dispense the medications, reorder from pharmacy as needed -Unit-Dose Distribution: pharmacists reviews all physician orders, medications are dispensed in unit doses
Ch 10 Q
-For which of the following types of care could a patient remain in his/her home? ADULT DAY CARE & HOSPICE
Formularies Information
-Generics -Preferred brands -Non-preferred brands -"Lifestyle" drugs -Non-formulary (100% out-of-pocket)
Example of MCOs
-HMOs: generally do not provide coverage for medical care that is received out of network -They place providers at risk, either directly or indirectly by: -Capitation: Providers are paid a predicted cost of care for a given population for a specified period of time (usually 1 year). -Obligated to provide all needed care for that population -Risk-pools: -Gatekeeper: A primary-care physician that must coordinate and authorize all medical services in order to be covered -Financially at risk so as to minimize unnecessary services
Home Care Industries
-Home health services (Visiting Nurse Association) -Nursing services -Hospice services -Speech and Physical Therapy -Social Services -Homemaker services -Home infusion therapy
Polling Q II
-Home health services are usually associated with what type of care? NURSING, HOSPICE, PHYSICAL THERAPY, SOCIAL SERVICES
Question!
-Hospitals react to Medicare reimbursement methods by: IMPROVING PROCESSES OF CARE
Health Maintenance Organization (HMO)
-Identity of practice is independent of the physicians in it --> definition for MCOs -HMO: Health plan that prepays providers, patients provide co-pay at the time of service --> keep you out of the hospital is the goal -Preferred Provider Organization (PPO): Contracted by a health plan to provide services--> negotiated discounts for the services
Reactions to Reimbursement Methods
-Impatient Prospective Payment System: move some surgeries to outpatient setting--> only covers acute phase -Value-Based Purchasing: Measure prescribed processes of care, outcomes measured
Polling Q III
-In addition to nursing and pharmacy services, home care services may include which of the following? PHYSICAL THERAPY, SOCIAL SERVICES, HOMEMAKER SERVICES
Possible Exam Q
-In nonprofit hospitals, the ______ are the primary source of managerial authority. TRUSTEES (BOARD OF TRUSTEES)
Polling Q
-Just like hospitals, home care companies must accept and treat patients without consideration of their ability to pay -FALSE
Hospital Characteristics
-Length of stay (acute care vs. long-term--> 31 days or more) -Type of Service: general hospital, specialty hospital -Ownership: federal or non-federal government -Non-governmental hospitals: non-profit or investor owned (for-profit) ----> most are non-profit
Factors Determining LTC Needs
-Level of disability -Availability of informal caregivers -Financial circumstances -Availability of public programs -Personal circumstances
What do MCOs assume?
-Managed Care Organizations assume financial risk for expenditures and have incentives to control costs and utilization of health services -Kaiser --> provide an entire medical delivery system
Community Health Centers Act
-Mandated Services: Diagnosis, treatment consultation, laboratory and imaging services, medical and dental services, pharmaceutical services
Ch 12 Q
-Many home care nurses work for what nonprofit organization that coordinated nursing services in the home? VISITING NURSE ASSOCIATION OF AMERICA
Paying for LTC
-Medicare: being greater than 65 years of age or disability or end-stage renal disease -Types of LTC covered: SNF, hospice -Pays for up to 100 days in SNF if hospitalization if more than 3 days, rehabilitation is needed, enter LTC within 30 days of discharge (first 20 days is covered) -Medicaid: based on income and assets --> needs based --> SNF and home health care is covered -Private Insurance: provides financial assistance with the cost of LTC care (plans vary greatly) -LTC insurance: type of private insurance, benefits vary, premiums increases as individuals ages -Other options: reverse mortgage, trusts, long term care annuities
Major Accrediting Agencies
-National Committee for Quality Assurance (NCQA) -Main agency for HMOs; submit to accreditation more than any other type of MCO; accredits PPOs as well. -Health Plan Employer Data and Information Set (HEDIS) provides plan sponsors a set of objective measures with which to evaluate MCOs. -Utilization Review Accreditation Commission (URAC) -Main agency for PPOs; accredits HMOs as well. -Detailed process with both on- and off-site components.
Freestanding Facilities
-Non-hospital based facilities -Owned and operated by hospitals, physician groups, corporate chains -Ex: urgent care, retail clinics, ambulatory surgery care, federally qualified health centers, public health ambulatory services
Home Infusion Therapy
-Nutrition (parenteral) -Anti-infective therapy -Pain management (cancer patients)--> opioids -Chemotherapy -Biologicals and Related Plasma Derived Therapies -Miscellaneous Therapies
Patient Centered Medical Home
-PCMH -Team based model of care lead by a personal physician providing coordinated care throughout a patient's lifetime with other professionals for preventative, acute, and chronic illness and end of life assistance -Comprehensive care of the whole patient, from preventative care to chronic care -Address patients values and preferences -Team based care -Patient-Centered Primary Care Collaborative (PCPCC): this is collaboration with physicians, pharmacists, insurers, etc. -In PCMH we have highly motivated physicians that redesign staff roles and care processes, health information technology and payment reforms
Medicare Eligibility
-Part A: 65 or older--> do not need to pay premium if US citizen or permanent resident AND spouse worked greater than 10 years in Medicare -Eligible to receive benefits from Social Security -Receive disability benefits & end stage renal disease -Part B: eligible for part A and pay premium --> not required but most people have this -SS recipients have premium deducted from their checks -Part C: have to be eligible for Part A and have to choose from approved MCO --> may need to pay -Part D: eligible for part A and pay a premium --> but not required
Medicare
-Part A: Hospital Insurance--> pays for care provided to patients in hospitals, skilled nursing facilities, hospices, and home healthcare programs -Part B: Supplementary Medical Insurance--> provides coverage for physicians' services, outpatient hospital care, and many others--> this is not necessary -Part C: Medicare Advantage--> added in 1997, expanded ability to to participate in a wide variety of private health plans, including HMOs and PPOs -Part D: Prescription Drug Benefit--> Medicare Prescription Drug, Improvement, Modernization Act of 2003 established a new drug benefit --> optional!
Government Role in Healthcare
-Payer/Insurer: Medicaid jointly funded program with state and government, Medicare, -Direct Service provider: military has this, federal bureau of prison, Indian Health Service, NIH -Regulator: Affordability Act, FDA, DEA -Research: Grants, National Science Foundation, NASA, Department of Defense
Question Ch 10
-Paying for long-term care include: Medicare, Medicaid, Private insurance, out-of-pocket
Another type of MCO is
-Preferred Provider Organizations (PPOs): -PPOs are affiliations of providers that seek contracts with insurance plans!!!!!* -Nonexclusive arrangements -Individuals are free to see any provider, but have a financial incentive to see those within the preferred network. -Providers accept a discounted FFS rather than capitation. -Providers bear no risk, but, along with the discounts, they are subject to utilization management and review to control costs. -Exclusive Provider Organizations (EPOs) are a form of a PPO that strictly limits participation among providers.
Formularies Incented
-Prior authorization (PA) program: physician must request prior approval from PBM in order to be covered; usually for non-preferred tier or below. -Step-therapy: less expensive first-line drugs must be used and shown ineffective before more expensive second-line (third-line, etc.) are covered.
Types of Ambulatory Care
-Private Medical office practice -Non-physician practitioners: PA, nurse practitioner, nurse midwife -Hospital-related: clinics, emergency departments -Free standing services include: primary care, urgent care (compete with ER), retain clinics (CVS), ambulatory surgery (same day surgery centers), community health centers and public health
Types of Medical Practices
-Private practice: solo (one physician--> not common), partnership (2), and group (3 or more) -Group practices are most common because they share work responsibility, formal sharing of resources and income -Managed Care Organizations (MCOs): Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) --> more common
Factors that influence Home Care Industry
-Reimbursement issues -Legal, regulatory and professional standards -Advances in technology -Reimbursement Issues: insurance carriers (third-party payers)--> government (Medicare & Medicaid) -Managed Care Organizations -Private Sector
1932 Committee on the Costs of Medical Care
-Report recommended group practice as economically efficient --> promoted insurance to improve access
Preparing to Practice in LTC
-Rotations -Residences -Fellowships -Geriatric Pharmacist Certification -Training Programs
Responsibilities of Hospital Pharmacy
-Safe and effective use of drug therapy: --> product selection, product procurement, product distribution, prescribed appropriately, follow guidelines
Patient Protection and Affordable Care Act
-Seeks to improve healthcare and lower costs -Coordinates care through a patient-centered medical home and community services -Aging in place: staying in same home and community as care needs change
Question II
-Services such as urology and orthopedics are generally included in the medical care provided by ________ clinics at teaching hospitals SURGICAL -Medical is primary care or internal medicine -Specialty: diabetics
Long Term Care
-Set of health, personal care, and social services delivered over a sustained period of time to persons who have lost or never acquired some degree of functional capacity -Also provided to chronically disabled persons -In LTCs help is given with activities of daily living (ADL) or instrumental activities of daily living (IADL) -Example of ADL: bathing, dressing, toiletries -Ex of IADL: shopping, food preparation
More Questions
-Shriner's Hospitals for Children is an example of: SPECIALTY NON-GOVERNMENTAL NON-PROFIT HOSPITAL
Types of LTC Available in Institutional Settings
-Skilled Nursing facilities: (SNF) patients needing medical care, nursing care, and therapy -Specialized institutional care: patients with cognitive decline -Long term Acute care: (LTAC) patients needing care that may not be available in SNFs -Continuing care retirement communities -Psychiatric institutions -Correctional facilities
State Flexibility
-States must operate Medicare programs within broad guidelines and adhere to: 1. Statewideness: in effect throughout state without variation 2. Freedom of choice: 3. Comparability of Services: equal for all
Ch 13 Q II
-States often have the responsibility of administering federal programs, including many that are related to health care TRUE
Accreditation of Hospitals
-The Joint Commission -Sets standards -Based upon clinical processes and outcomes of care -Unannounced site visits
True/False Q
-The PCMH is a team-based model of healthcare delivery in which the team is led by a case manager employed by the medical home FALSE --> not case manager (should be physician)
Types of MCOs
-The differentiating feature between fee-for-service plans (FFS) and managed care is the use of provider networks -Provider network: group of providers contracted to supply a full range of primary and acute health services
Fill in the blank
-The goal of __________, or palliative care, is to provide humane and compassionate care to patients with terminal illness HOSPICE (6 months or less to death)
Ch 13 Qs
-The government's role in healthcare has: A.supported research that has created new drugs and cures for disease. B. improved public health through oversight of air and water quality. C. increased access to care for underserved populations. ALL OF THE ABOVE
Ch 13 Q III
-The primary role of the government in healthcare is to: PROTECT THE PUBLIC HEALTH
Ch 12 Q II
-The requirements of statutory laws, regulations, and professional standards improve patient care in the home care industry, and they also: INCREASE THE COST OF PROVIDING THERAPY
True or False Q
-The responsibilities of technicians in a hospital pharmacy department may include filling unit-dose cassettes, preparing intravenous mixtures, and monitoring inventory. TRUE but pharmacist needs to supervise
Chapter 13 Q
-The three sides of the Iron Triangle are: CONGRESS, BUREAUCRACY, SPECIAL INTERESTS
Government Programs: Indian Health Services (IHS)
-Treaties signed with Native American tribes stipulated the provision of certain medical and hospital services -Operate hospitals and ambulatory health centers throughout US -Covers American Indian and Alaskan Natives on or near reservations -Majority of pharmacists are commissioned public health services (PHS) -Fill prescriptions directly from patient's chart -Private counseling rooms -Primary care to ambulatory patients with acute and chronic diseases
Who needs LTC services?
-Usually elderly patients who need help with IADLs or ADLs due to chronic disability -Patients with chronic disease (dementia, Parkinson's) -Patients with rehabilitations needs -Terminally ill patients
Multiple Choice Q
-What is one of the reasons for a hospital formulary system? TO CONTROL DRUG COSTS
More Qs
-What is the primary source of managerial authority in a for-profit hospital? THE BOARD OF DIRECTORS -If non-profit= TRUSTEES
Fill in Blank Q Ch 12
-When classifying hospitals by length of stay, acute care or short-term hospitals are generally defined as those that have an average length of stay of less than ______ days. 30 DAYS or less
Ch 13 Q
-Which branch of government is responsible for the administration of federal agencies? EXECUTIVE -Which branch of government is responsible for enforcing federal laws? EXECUTIVE -Which branch is responsible for interpretation of the law? JUDICIAL -Which branch of government is responsible for making the law? LEGISLATIVE
Exam Q II
-Which of the following statements concerning automated dispensing machines such as Pyxis® is correct? THEY ALLOW THE PHARMACIST TO ENGAGE IN MORE PATIENT CARE ACTIVITIES
Q
-Which one of the following would be considered DME? A HOSPITAL BED
Government Programs: Health Department Services
1. Communicable disease control: STDs or contagious diseases 2. Maternal and Child Health: low income families, prenatal care, well-baby care 3. Chronic diseases: preventative care, screening (HTN, smoking) 4. General Ambulatory Care: low-income patients in underserved areas
What is the Government
1. Congress 2. Administration (President/Bureaucracy) 3. Courts 4. Citizens -Administrative agencies on federal side: FDA, DEA, and from state side you have Board of Pharmacy, DPH,
Evolving Role of Government in Healthcare
1. Data and evidence for government role 2. National legislation and regulation 3. State legislation and regulation 4. Health policy concepts 5. Alignment of data, policy, and legislation to create Affordable Care Act
Three Broad groups may be covered by Medicaid
1. Mandated categorically needed: families below state-determined maximum limit on income and resources 2. Optionally categorically needed: determined by states --> must receive same benefits as mandated even though they do not meet all requirements of mandated 3. Medically needed: optional, determined by states --> exceed income or asset limits --> for institutionalized persons,
Free Clinics Characteristics:
1. Physical facility 2. Trained health personnel (volunteers) 3. Available to all 4. Specified hours of operation 5. No set payment required --> small fees or donations may be requested -Financing major issue
Models Continued
1. Principles guiding healthcare system: portability of benefits, comprehensiveness, universality, accessibility, public administration 2. Germany: principles include self-governance, social partnership, social solidarity 3. Universality, comprehensiveness, little charge at point of service, nationalization of hospitals 4. Healthcare is right, responsibility of state, preventive services are integrated
Four characteristics that differentiate types of MCOs
1. Risk-bearing: amount of risk borne by the provider--> which can range from full risk to no risk 2. Physician Type: relationship between MCO and physician 3. Relationship exclusivity: whether physician provides care to patients from one MCO or multiple MCOs 4. Out-of-network coverage: whether care received from a provider who is not in the MCO's network is a covered benefit
Four Broad Models
1. Socialized Insurance Program --> in Canada aka National Health Insurance Model --> when a signal government runs healthcare services 2. Decentralized National Health Program--> Germany aka Bismark Model--> employers required to obtain private health insurance 3. Socialized Medicine--> United Kingdom --> Beveridge Model --> healthcare provided and financed by government 4. Out of pocket: in developing countries
Four Types of HMOs
1. Staff-model: HMO directly owns facilities and providers are employees. -Physicians bear no risk, but are subject to utilization review; therefore may influence care. 2. Group model: HMO contracts with large, multispecialty medical groups offering services exclusively to the HMO. -Capitated 3. Network Model: physicians bear risk 4. Independent Practice Association Model (IPA)
The Iron Triangle
A close relationship between an agency, a congressional committee, and an interest group 1. Congress (Legislative Body) 2. Bureaucracy (Administration/President) 3. Special Interests (Citizens)
MRR, DUE, DUR
MRR: evaluation of a patient's medication regimen with the goal of promoting positive outcomes and minimizing adverse effects -DUE: criteria based, on-going, planned, and systemic review of medications, their uses, and contribution to outcomes (prospective) -DUR: review past patters of medication misuse, monitor current medication therapy, and offer patient counseling (retrospective)
Chapter 10 Q
Pharmacy services in long term care can be divided into two categories: _________________ and _________________ DISTRIBUTION and CONSULTING
Questions!
The individual usually most responsible for managing the hospital pharmacy's budget is the: DIRECTOR OF PHARMACY
