PM 508 Midterm Study Questions

problems with traditional (non-integrated) health care models?

-1' focus is addressing acute illness -no emphasis on wellness/prevention -FFS payment --> emphasizes volume not quality -lack of integration -inidivids lack access to 1' care, overuse of ED -financial incentives are not aligned w quality -no cost containment tools other than denial of services -littte ctrl over tech -no capacity o assess efficacy

how are ACOs different from managed care of the past?

-ACO works with providers -focus on reducing per member cost, not increasing revenue -particular focus on taking care of neediest high-risk pts

health policy initiatives/regulations that have focused on access to care/quality of care/cost of care

-FDA testing for safety and efficacy of drugs and medical devices -licensing improves quality of profession -medicare and medicaid -EPA, OSHA, Veterans Affairs -US HC sys: focuses on improving efficiency and redistributing income in a more equitable manner (ex. increase reimbursement for medi/medi, or be more involved in price control)

TRIPLE AIM

-Improve the health of the population -Enhance the patient experience of care -Reduce or control the per capita cost of care

ideas for controlling cost/regulating hc industry

-change payment to prepaid -value-based purchasing -controlling price (wage + price ctrl) -ctrl supply -shift risk to individuals -competition -more transparency in pricing -integration of services and bundling of payment -increasing primary care rate -focus on quality

What is care management?

-coordination or managing care for individuals with multiple health care needs. usually by a nurse who coordinates all care you need wich MAY INVOLVE disease management -goal is to improve care coordination and f/us

what is medicaid expansion?

-covers ppl w incomes of up to 138% of the federal poverty line including adults without children -higher incomes up to 400% FPL can receive subsidies to purchase private insurance via insurance exchanges -expansion funded by the govt -states can opt out -controversy = how are we gonna pay for this/ what about undocumented immigrants?

Key features of the Affordable Care Act

-expand health insurance coverage -improve coverage for those with insurance -improve access and quality of care -control rising health care costs

why do some states refuse medicaid expansion

-medicaid needs reform w state flexibility -risk of bait n swithch in federal matching funds -large state budget impacts... fiscal costs are too high -TAXES!

components of a PCMH

-personal clinician in physician-directed team-oriented medical practice -emphasizes whole-person orientation and is patient-centered -care is coordinated and integrated -emphasis on quality and safety -enhanced access -payment reform

3 phases of Healthcare history

1. infectious disease 2. chronic illness 3. wellness + pop health, integration of HC delivery systems

what implication does increasing health care spending have on the government, employers, and individuals?

1. rising HC spending lowers GDP and overall employment while raising inflation. also tax increase 2. growth in HC spending leads employers to reduce, eliminate, or change coverage they offer to workers 3. fewer individuals can afford private coverage; difficult to cover out of pocket costs. affect household finances.

Phase 2: chronic illness

1920s-1980s; advancement of penicillin; obesity/diabetes; flu TB and pneumonia; emergence of chronic illnesses. Pure Food and Drug Act of 1906. first calls for national health care. declining mortality rate after 1920s. improved hospital care but it was wards not rooms. HEALTH INSURANCE INTRODUCED. vets admin was introduced.

Phase 3: wellness and Pop health, integrated health care delivery systems

1980s+; intro to focus on wellness and pop helath. emphasis on preventative medicine. we began to integrate HC systems. improved health status; ppl lived longer, surgical/tech/drug advancements. SDOH. HIV and terrorism. disaster prep, abx resistance, pandemic. challenges: growth in cost of care, IT, global health, health disparities, health reform

Veterans Administration

A federal agency that administers benefits provided by law for veterans of the armed forces.

medicare

A federal program of health insurance for persons 65 years of age and older

MEDICARE PART A

HOSPITAL SERVICES inpt, Skilled home health, hospice financed by employer + employee taxes

MEDICARE PART C

Medicare Advantage (A+B+D) private plans. financed by medicare payments, monthly beneficiary contributions. you can choose to buy this one.

MEDICARE PART B

PHYSICIAN SERVICES out pt, preventative, and some home health. durable medical equipment financed by general revenues, beneficiary contributions

MEDICARE PART D

PRESCRIPTION DRUG COVERAGE; voluntary to enroll; monthly premium and cost sharing

CHIP

State-federal Children's Health Insurance Program

indian health service IHS

The federal agency within HHS that is responsible for providing federal healthcare services to American Indians and Alaskan natives

copayment

a small fixed fee paid by the patient at the time of an office visit

major components of US HC sys

a. public health b. ambulatory care c. inpt care d. longterm care e. ancillary care f. auxiliary care g. palliative care and hospice

how do SDOH impact social gradient in morbidity and mortality

can impact health, well being and quality of life. things like transportation, food deserts, health disparities, etc.

long-term care

care to ppl after an acute episode that requires long term intervention. skilled nursing facilities (SNFs), home care, rehab

how has medicare changed since passage of ACA?

categories eliminated; now eligibility is largely based on income alone (depends on where you live after medicaid expansion state or not) -poor kids, pregnant women, parents, and other non elderly adults, disabled adults, and seniors (dual eligible, MediMedi's)

Phase 1: infectious + communicable diseases

colonial thru mid 1900s; hospitals not well established for care. US was more rural/agricultural. Slavery! large epidemics like cholera, plague, yellow fever, and syphilis; malnutrition and vitamin disorders. primitive medicine where barbers did surgery; few tools and no medicine. herbal therapies. most care occurred in homes

SDOH

conditions in places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes -economic stability -education access and quality -social and community context -health care access and quality -nbhd and built environment

public health

disease prevention, health promo, pop helath. target things like HIV, clean water, vaccines, chronic disease; WHO, UN, NGOs. USPHS and CDC. coordinated at state level and nationally

role of state govt in shaping health policy

governer sets agenda, approves/vetos bills, oversees implementation of laws. create budget, interact with federal agencies. appellate process can go to supreme court if necessary

inpt care

hospital care. tertiary and quaternary care facilities

why are we moving away from FFS model?

limit overuse and overtreatment

role of local govt in shaping health policy

local govt = instruments of state policy. sets agenda, creates budget, passes policies that govern HC infrastructure

What is disease management?

looking @ your specific condition and ensuring that you are receiving the correct care/checking all the boxes. prevention of future episodes. etc. -helps to manage an individ w a chronic disease over time bc it can prevent the conditions from getting worse

auxiliary care

mental health and oral health

how is the HC market different than other industries?

need for health care is unforseen. consumers dont know when illness will strike. asymmetry of information. there are inefficiencies in the medical market bc important assumptions are violated; consumers and providers lack perfect information. pts and providers lack incentive to minimize their cost of purchasing/providing treatment.

ambulatory care

outpt services

Prospective Payment System

payment amount or reimbursement is known in advance implemented in fall 1938; pay hospital per case basis, not per item/service basis. inpt services were targeted bc hospital and ER care is most $$$. set fixed-budget for each pt. fixed price per admission by diagnosis. outcome: length of hospital stay decreased and didn't really lead to worse outcomes. this was effective strategy

capitation model

performance-based system where caregivers who contract with independent practice associations (IPAs) are financially incentivized to provide appropriate care and treatment designed to increase health and wellness rather than excessive treatment and profits

Population health model

preventative, focus on upstream, rewards/incentivizes cost reduction, health + wellbeing + coordinated care

what is hotspotting in health care?

process to identify high-cost individuals in a defined region in the health care system. it is used to guide targeted intervention and follow-up to better address patient needs, improve quality, and reduce costs

FFS payments

providers receive fees for each serviced they provide. inherent incentive to focus on # of services, conflict of interest

palliative care + hospice

relieve the suffering of pts and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms

rising health care costs due to

rise in chronic illness, overuse of resources, overtreatment, asymmetry of info, lack incentive to minimize cost of purchasing/providing medical treatment

ancillary care

services provided to support/enhance care delivered thru the basic medical care delivery system. physical + occupational therapy, dialysis centers, hospice, labs + imaging centers, medical device facilities (like wheelchair or bed or O2 providing services). chiropractic care and naturopathic medicine

health care spending trend in the past decaede

sharp increase; 18% GDP, 5/50 rule then spending stabilized more in line with our economic growth

medicaid

state and federal public-assistance program that helps pay health care costs for low-income and disabled persons

adverse selection

tendency of individuals who have more serious illnesses/health challenges to purchase coverage; the effect of purchasing health insurance as a voluntary choice rather than a mandated obligation. if fewer ppl buy insurance, those who do will have hella costs, which will drive costs up

moral hazard

tendency to use a service when available regardless of need. individuals may exert less effort in their personal health maintenance if health insurance covers majority of the cost of treatment

deductible

the amount a person has to pay out of pocket before the insurance benefits are paid

insurance premium

the amount of money that an individual or business must pay for an insurance policy

coinsurance

the percentage of costs of a covered health care service you pay (for ex, 20%) after you've paid your deductible

why is an integrated system important?

there is an extension of care and smooth transition and connection between primary care, specialists, hospitals, and post acute care. integration means that there is a continuum of care while trying to control the costs of health care