Health care systems exam 2 questions

Ch. 7 #7) What is community-oriented primary care? Explain?

• Community-orientated care ◦ Advances beyond the medical model to the biopsychosocial model ◦ Emphasizes population health that includes good primary care delivery plus addressing community health problems • WHO guidelines ◦ Reduce exclusion and social disparities in health through universal overage reforms ◦ Organizing health services around people's needs and expectations ◦ Integrating health into all sectors ◦ Pursuing collaborative models of policy dialogue ◦ Increasing stakeholder participation

Ch. 5 #13) Discuss the relationship between technological innovation and health care expenditures

• Cost of adopting technology ◦ Acquisition cost ◦ Labor costs (speciality reminded physicians and other health care professionals ◦ Facility costs (housing and setting for the technology) • Cost of new technology utilization ◦ Adoption of new technology leads to increased utilization (episodic and chronic) and increased costs ◦ Although adoption of new technologies may increase certain utilization costs in one area, they may decrease costs in other areas. ‣ Outpatient treatments reduce hospital admissions ‣ Robotics may replace human personal (and improving accuracy,) reducing labor costs ‣ What is the implication of pharmacy dispensing • The most important question to ask is whether the additional cost is advocated with additional benefit (e.g., effect, quality, etc.)

Ch. 6 #11) What provisions has the federal government made for providing health care to military personnel and to veterans of the U.S. armed forces?

• Department of Defense ◦ Federal Facilities ◦ TRICARE insurance • Veterans Health Administration • Note that there are differences in eligibility

Ch. 5 #14) How was technology affected access to medical care?

• Geographic maldistribution has been improved by ◦ Providing mobile equipment to remote locations ◦ Employing new communication technologies • Structure and processes of health care delivery • The US is a primary exporter of medical technology worldwide

Ch. 5 table 1 Examples of medical technology: Adjunctive therapies

Certain complementary treatments

Ch. 5 table 1 Examples of medical technology: Diagnostic

Computed tomography (CT) scan, Fetal monitor, Computerized electrocardiography, Automated resonance imaging, and Blood pressure monitor

Ch. 7 #2) What implications has the decline in hospital occupancy rates had for hosptial management

Decline in hospital occupancy decreased hospital revenue creating a need for alternative revenues so now have to add another focus

Ch. 5 table 1 Examples of medical technology: Prosthetics

Electromechanical limbs, Artificial heart valves, Artificial kidneys, Dental implants

Ch. 5 table 1 Examples of medical technology: System management

Health information systems, and Telemedicine

Ch. 5 table 1 Examples of medical technology: Cure

Hip joint replacement, Organ transplant, and Lithotripter

Ch. 5 table 1 Examples of medical technology: Facilities and clinical settings

Hospital satellite centers, Clinical laboratories, Subacute care units, and Modern home health

Ch. 5 table 1 Examples of medical technology: Prevention

Implantable automatic cardioverter-defibrillator, Pediatric orthopedic repair, diet control for phenylketonuria, and vaccines for immunization

Ch.5 #2) What role does an IT department play in modern health care organization?

Information technology (IT) Involves the transformation of data into useful information IT includes: determining data needs data gathering data storing data analysis date reporting IT departments play a critical role in decisions to adopt new technologies that: improve healthcare delivery increase organizational efficiency comply with laws and regulations Health and IT includes clinical encounter, radiology, laboratory, pharmacy, scheduling, finance/ accounting data

Ch. 5 table 1 Examples of technology: Survival (life saving)

Intensive care unit (ICU), Cardiopulmonary resuscitation (CPR), Bone marrow transplant, Liver transplant, and Autologous bone marrow transplant

Ch. 5 table 1 Examples of medical technology: Organized delivery system

Managed care and Integrated delivery networks

Ch.5 #1) Medical Technology encompasses more than just sophisticated equipment. Discuss.

Medical technology is the practical application of the scientific body of knowledge for the purpose of imploring health and creating efficiencies as in the delivery of heath care

Ch. 7 #17) Explain the concept of hospice care and the types of services a hospice provides

• A cluster of comprehensive services for terminally ill persons with a medically determined liefe expectancy of 6 months or less • Intended to address special needs of the dying patient and their families • Method of care-not a location • Primary emphasis on: ◦ Pain and symptom management (palliative) ◦ Psychosocial and spiritual support • Less costly than medically intensive care at the end of life • Medicare is the largest source of financing for hospice • Included a substantive volunteer component

Ch. 7 #6) Discuss how the patient-centered medical home advances primary care

• A patient-centered Medical home (PCMH) is: ◦ A multidisciplinary team of physicians and allied health professions who: ‣ Team partners with patients and their families ‣ Assumes responsibly for ongoing patient care ‣ Uses a team approach ‣ Deploys technology and evidence-based protocols to deliver and coordinate care. • Focus on increasing appropriate care ◦ Preventive services, immunization, well-care visits • Focus on decreasing inappropriate cate ◦ ED (emergency department) visits, rates of hospitalization for preventable conditions, use of high cost/inefficient services.

Ch. 7 #8) Discuss the two main factors that determine what should be an adequate mix of generalists and specialists

• Degree of gatekeeping employees in the health care system ◦ Increased use of gatekeeping required more primary providers ◦ Training and reimbursement incentives are needed to attract primary care providers • Demand and use of primary care services ◦ 75-85% of the population only requires primary care ◦ 10-12% of the population requires secondary care ◦ 5-10% of the population requires tertiary care

Ch. 8 #9) Explain the factors that affect hospital employment

• Demand for services ◦ Size and nature of the US population ◦ Advances in medial technology ◦ Changes in health insurance • Philosophy in treatment from inpatient to outpatient • Change in reimbursement policy

Ch. 6 #15) Discuss the prospective payment system under DRGs

• Diagnostic-related groups (DRGs) are a prospective party net system for acute-care hospital stays • A set (fixed)payment is made based on per discharge/case regardless from the amount of care provided ◦ Payment may be adjusted for various factors (e.g., geographical region, teaching hospital, disproportionate share of low-income patients, safety net facility, outlier stays) • Creates incentive to reduce costs of care, but can have unintended consequences of excessive readmissions.

Ch. 8 #12) What is a long-term care hospital (LTCH)? What role does it play in health care delivery in the United States?

• One of 2 classifications of hospitals by average length of stay(ALOS) ◦ Short-stay - ALOS <25 days ◦ Long-stay - ALOS>25 days • LTCHs ◦ Special type of long-stay hospitals ◦ Provide post-acute care for patients with complex health medical needs and may have multiple chronic problems requiring long-term hospitalization ◦ Primary revenue source is Medicare

Ch. 6 #1) What is meant by health care financing in its broad sense? How doe financing affect the health care delivery system?

• One of the quad functions of a health care delivery system • Mechanism to pay for health insurance premium • Determines who has access to health care and who does not • Influences both demand-side and supply-side factors ◦ Insurance increases demand for health care drives by lowering patient cost (moral hazard) ◦ When services are covered by insurance, supply will increase • Health Care Expenditures = Price (Insurance/Payment) x Quality of Services (Utilization)

Ch. 5 #8) Which factors have been responsible for the low diffusion and low uses of telemedicine

• Legal/ Licensing issues (reciprocity) • Unclear or unidentified need • Uncertain reimbursement policies • Lack of universal access to technology • Concerns about confidentiality • Liability

Ch. 8 #17) What is a critical access hospital (CAH)? Why was this designation created?

• Created in 1997 as the Medicare Rural Hospital Flexibility Program to save small rural hospitals from closing • A rural hospital with no more than 25 acute care/swing beds and 24 hour emergency services ◦ Must meet a distance test relative to other hospitals ◦ Reimbursed using a cost-plus methodology

Ch. 8 #13) The table gives some operational statistics for two hospitals located in the same community. Use the table to answer the following questions. a. Calculate the following measures for each hospital (wherever appropriate, calculate the measure for each pay type). Discuss the meaning and significance of each measure, and point out the differences between the two hospitals. (i) Hospital capacity (ii) ALOS (iii) Occupancy rate b. Operationally, which hospital is performing better? Why? c. Do you think the nonprofit hospital is meeting its community benefit obligations in exchange for its tax-exempt status? Explain. d. Do you think the hospitals have a problem with excess capacity? If so, what would you recommend?

Operationally, which hospital is performing better? Why? •Hospital B because it has decreased length of stay, higher daily census, and higher occupancy rate •Do you think the nonprofit hospital is meeting its community benefit obligations in exchange for its tax-exempt status? Explain. •Yes, the nonprofit hospital is contributing ~11% to community benefit obligations •See https://www.healthaffairs.org/do/10.1377/hpb20160225.954803/full/ •Do you think the hospitals have a problem with excess capacity? If so, what would you recommend? •The nonprofit hospital has a problem with excess capacity with only a 62.5% occupancy rate

Ch. 5 table 1 Examples of medical technology: Illness management

Renal dialysis, Pacemaker, Percutaneous transluminal coronary angioplasty (PTCA), and Stereotactic cingulotomy (psychosurgery)

Ch. 5 table 1 Examples of medical technology: Enabling (to assist or extend physical capabilities of medical professionals)

Robotic surgery, Cyberknife surgery, Nanoknife procedure, and Laser therapy

Ch. 5 table 1 Examples of medical technology: Monitoring (body functions and vital signs)

Wearable biosensors

Ch. 8 #1) What is the difference between inpatient and outpatient services

• Inpatient services involve and overnight stay in a health care facility such as a hospital • Outpatient services don't involve a overnight stay

Ch. 8 #22) What can a hospital do to address some of the difficult ethical problems relative to end-of-life treatment

• Adhere to the patient's bill of rights ◦ Confidentiality and consent ◦ Right to make decisions about medical care ◦ Right to be informed about diagnosis and treatment ◦ Right to refuse treatment ◦ Right to formulate advance directives • Employ principles of informed consent ◦ Right to make an informed choice regarding medical treatment ◦ Includes concepts of diagnosis, treatment, and prognosis • Ensure each patient has advance directives in place ◦ Do-not-resuscitate orders ◦ Living will ‣ Durable power of attorney

Ch. 6 #17) What is adverse selection? What are its consequences?

• Adverse selection occurs when high-fish individuals enroll in a health insurance plan in great numbers compacted to people who are healthy • Overall health costs increase and thus result in increased premiums for everyone • In turn, health insurance becomes less affordable

Ch. 7 #21) What is complementary and alternative medicine? What role dies it play in the delivery of health care?

• Aka "nonconventional therapies" working with conventional medicine or "alternative medicine" which is used without conventional medicine • Refers to the broad domain of all health care resources other than those intrinsic to biomedicine • Wide range of treatments that include homeopathy, herbal formulas, other natural products, acupuncture, meditation, yoga, biofeedback, spiritual guidance/ prayer, chiropractic (sometimes) • Often sought by patients who believe conventional medicine had failed • Somewhat unregulated (depending on the treatment) and not commonly evidence based • In 2012 - Americans spent $30.2 billion out-of-pocket on CAM • There is more to created a more rigorous evidence based for CAM

Ch. 6 #7) Briefly describe the Medicare Advantage program

• Also known as Medicare part C and formerly Medicare+Choice • Option combines Medicare part and part b benefits through managed care organization ◦ May also include Medicare part d in some cases ◦ Provides additional health care plan choices • Includes a supplemental premium in addition to that paid for Medicare Part B ◦ some additional benefits ◦ Lower out of pocket costs • Enrollments have risen since 2004

Ch. 7 #14) What are mobile health care services? Discuss the various types of mobile services

• Ambulance service (emergency care) ◦ Most common ◦ often integrated with emergency medical systems (ED/Transportation>Communication) • Routine health services ◦ Eye, pediatric, and dental care services to nursing home/retirement centers • Mobile diagnostic services ◦ Mammography and MRI to isolated and rural areas • Health screening ◦ Health fairs, health promotion

Ch. 7 #3) All primary care is ambulatory, but not all ambulatory services represent primary care. Discuss.

• Ambulatory care - outpatient services ◦ Any services provided that does not involve an overnight stay ‣ Care in physicians offices, hospitals outpatient departments, health centers ◦ Out patient services intended to serve to the surrounding community ◦ Outpaitent services transported to the patient • Primary care ◦ Subset of ambulatory care (a foundation) ◦ Health care provided in the community setting ◦ May provide prevention, diagnostic. Therapeutic services, health education/ counseling, and minor services ◦ Comprehensive, coordinated, and continuous care ◦ Distinguished from secondary and tertiary care by duration, frequency, and intensity.

Ch. 8 #7) What are inpatient days? What is the significance of this measure?

• An inpatient day is a night spent in the hospital ◦ When accumulated (or added together) represent days of care • When days of care are divided by the number of discharges, the average length of stay (ALOS) is calculated • The ALOS serves as an indicator of illness severity and resource use.

Ch. 5 #9) Generally speaking, why is medical technology more readily available and used in the US than in other countries?

• Anthro-cultural beliefs and values • Medical specialization • Financing and payment • Technology-driven competition • Expenditures on research and development • Supply-side controls • Government policy

Ch. 5 #3) Provide brief descriptions of clinical information systems, administrative informative systems, and decision support systems in health care delivery

• Clinical information systems ◦ Organized processing, storage, and retrieval of information to support health care for delivery • Administrative Information Systems ◦ Assist health care staff in carrying out financial and administrative support activities • Decision Support Systems ◦ Managerial ‣ Information and analytical tools to forecast patient volume, staffing requirements, and scheduling to optimize utilization of patient care/ facilities ◦ Clinical ‣ Information and analytical toos to improve clinical decision-making and care

Ch. 7 #11) Discuss the main hosptial-based outpatient services

• Clinical services ◦ Acquisition of group practices • Surgical services ◦ Ambulatory surgery centers • Emergency services ◦ Care available 24/7 ◦ Emergent, Urgent, and non-urgent ◦ Subject to overuse • Home healthcare ◦ Post-acute and rehabilitation • Women's health centers ◦ Specialty care for women ◦ see next slide

Ch. 7 #20) Describe the main public and voluntary outpatient clinics and the main problems they face

• Community health centers: ◦ Private, no profit organizations funded through federal grant programs ◦ Intended to address areas with limited access to primary health care (medically underserved areas) ◦ Limited access may be a function of economics, geography, or culture ◦ Tailor services to family-oriented primary/ preventive health care and dental services ◦ Typically have significant expertise in managing health care and dental services ◦ Typically have significant expertise in managing health care needs fo vulnerable populations and serve as models for screening, diagnosing, and managing chronic disease • Free clinics: ◦ Intended to address the needs of the poor, uninsured, and homeless ◦ Services provided at no charge ◦ Not directly supported by government agencies ◦ Care delivered by volunteer staff

Ch. 8 #16) How do you differentiate between a community hospital and a non community hospital?

• Community hospitals are non-federal, short-stay hospitals whose primary mission is to serve the general community. ◦ 87% of all US hospitals ◦ May be private for-profit or not-for-profit ◦ Can be owned by state or local government, but not federal government ◦ May be general or specialty facilities • Non-community hospitals include ◦ Federal facilities (VAMCs) ◦ Hospital units of institutions such as prisons ◦ Infirmaries of colleges/universities ◦ Long-stay hospitals

Ch. 5 #16) Why is it important to achieve a balance between clinical efficacy and economic worth (cost-effectiveness) of medical treatments

• Economic resources are finite • In the absence of balancing cots and effects, the most efficient treatment alternatives will not be identified • Will requires a chance in the American mindset ◦ Health Technology Assessment is predominantly conducted in the private sector ◦ Centers for Medicare and Medicaid Services (CMS) does not allow for cost-effectiveness to be used in care decision for Medicare and Medicaid-covered attends ◦ There is a fear of lawsuits for not using efficacious/ effective technologies even if cost-effectiveness is in question

Ch. 5 #15) Discuss the roles of efficacy, safety, and cost-effectiveness in the context of health technology assessment

• Efficacy ◦ Can the technology work under all ideal conditions? • Effectiveness ◦ Does the technology work under "real world" conclusions • Safety ◦ Does technology's primary benefits outweigh any negative consequences? • Cost-effectiveness ◦ Integration of both costs and benefits ◦ Asks the question, are the additional effects worth the additional costs

Ch. 6 #12) What are the major methods of reimbursement for outpatient services?

• Fee for service ◦ Charge vs rate ◦ Balance billing ◦ Unbundled • Bundled payments ◦ Package pricing - related services in one price • Medicare Resource-Based Relative Value Scale ◦ Time, skill, intensity for care ◦ Medicare Physician Fee Schedule • Value-Based Reimbursement ◦ Reimbursement tied to quality and cost

Ch. 5 #5) According to the Institute of Medicine, what ate the four main component of a fully developed electronic health record (EHR) system?

• Four Main Components of an EHR System ◦ 1) Collection and storage of health information on individual patients over time ◦ 2) Immediate election access to person and population level information by authorized users ◦ 3) Availability of knowledge and decision support that enhances the quality, safety, and efficiency, of patient care ◦ 4) Support efficient processes for health care delivery

Ch. 7 #5) Critique the gatekeeping role of primary care

• Gatekeeping ◦ Patients do not visit a specialist or go to a hospital unless first seen by a primacy care provider (PCP) ◦ Think UK's National health service • What are some potential challenges with this approach?

Ch. 8 #3) What were the main factors responsible for the growth of hospitals until the latter part of the 20th century?

• Government funding ◦ Hill-Burton Act (the Hospital Survey and Construction act of 1946) provided federal grants to states for the constriction of new community hospitals ‣ Based on bed population ratio with a goal of 4.5 beds/1000 population ◦ Greatest single factor to increasing bed supply ◦ Promoted the growth of nonprofit, community hospitals because it required the provision of a certain amount of charitable care • Public health insurance (indirect effect) ◦ Medicare and Medicaid greatly expanded access to care for the elderly and poor ◦ In turn, admission and inpatient days increased

Ch. 5 #6) What are the main provisions of HIPPA with regard to the protection of personal health information? Which provisions were added to HIPPA under HITECH Act?

• Health Insurance Portability and Accountability Act (HIPPA) ◦ Enacted in 1996 ◦ Prohibited access to a patient's personal health information (PHI) for reasons other than health care delivery, operations, and reimbursement. • Health Information Technology for Economic and Clinical Health (HITECH) Act ◦ Enacted in 2009 ◦ Earmarked $19 billion in direct grants and financial incentivized to adopt government certified EHRs by hospitals and physicians ◦ Penalties for non-implementation )tied to reimbursement) ◦ Established standards for ERs and their use (aka, meaningful use) • Extends HIPPA protections to include "business associates" of providers and restricts use of PHI in marketing, patient authorization for research, use of genetic information, and patients' right to receive election copies of PHI

Ch. 7 #10) Why is it important or hosptial administrators to regard outpatient care as a key component of their overall business strategy?

• Historically , the outpatient department was the least popular area of the hospital ◦ Served as a safety net fr-voiding indinigent care • Currently, outpatient care services as a keep profit source for hospitals as reimbursement for inpatient services has been reduced • Emergence of managed care has focused attention on preventative and outpatient care • As a result, outpaitent care has expanded to competent in the health care marketplace ◦ Having robust inpatient and outpatient services can be complementary and provide a continuum of care • See figure 7-4 • Pre-1985: outpatient care = 15% of patient revenue for hospitals • Post-1985: outpatient care = 46% of the patient revenue for hospitals

Ch. 5 # 10) How does technology-driven competition lead to greater levels of technology diffusion? How does technology diffusion, in turn, lead to greater competition? How does technology-driven completion lead to duplication of services?

• Hospitals/outpatients centers compete to attract insured patients • Patients seek "quality" care and are influenced by advertising of state of the art technology - Ex; speciality hospitals • Medical arms race ends to hospitals to offer new service lines that required advanced technology • To enhance perceptions of "quality", institutions/ practices must recruit specialists who have been trained and require to advance technology to provide care • As a consequence, institutions/ practices duplicate services

Ch. 5 #17) What are some fo the ethical issues surrounding the development and use of medical technology?

• How to provide the latest and best in health care within limited resource parameters • Conflicts of interest by providers who have stake in a technology and are responsible for its evaluation • Insurers deciding when to cover novel treatments • Conduct of clinical research

Ch. 5 #4) Distinguish between information technology (IT) and health informatics

• In contrast with health IT, health informatics... ◦ Is the application of information science to improve efficiency, accuracy, and reliability of health care services ◦ Requires the use of health IT ◦ Emphasizes the improvement of health care delivery

Ch. 7 #4) What are the main characteristics of primary care?

• Initial point of entry into the health care system (gatekeeping) • Coordination of care for inpatient, speciality, surgical, and diagnostic services ◦ see figure 7-1 from the text book shown below • Essential care to optimize population health ◦ Reduce disparities (equal access)

Ch. 8 #21) In the contest of hospitals, what are the difference between licensure, certification, and accreditation?

• Licensure ◦ regulatory requirement set by individual states to legally operate a health care facility ◦ primarily physical plant requirements ◦ not tied to quality • Certification ◦ provides authority to participate in Medicare and Medicaid programs ◦ focus on quality and outcomes of care • Accreditation ◦ voluntary private review to ensure health care facilities meet certain basic standards ◦ Joint Commission, American Osteopathic Association ◦ Accreditation meets the certification standards, but certification does not imply

Ch. 6 #2) Discuss the general concept of insurance and its general principals. Describe the various types of private health insurance options, pointing out the differences among them

• Mechanism for protection against risk of catastrophic event ◦ Determined through underwriting • Four Principals of Insurance ◦ Risk is unpredictable for the individual insured ◦ Risk can be predicted with a reasonable degree of accuracy for large groups ◦ Insurance provides a mechanism for transferring or shifting risk from the individual to the group through pooling of resources ◦ All members of the insured group share actual losses on some equitable basis • Private Health Insurance ◦ Group ◦ Self-Insurance ◦ Individual Private Health Insurance ◦ Managed Care Plans ◦ Stop-gap Coverage ◦ Medigap Coverage

Ch. 6 #10) How did the Supreme Court's ruling on the ACA affect Medicaid? How did the ACA affect the Medicaid program in terms of coverage and cost?

• Medicaid was designed to finance health care services for the indigent. Eligibility includes: ◦ Families with children residing support through Temporary Assistance for Needy Families ◦ People receiving supplemental security income (some elderly, blind, and disabled with low incomes) ◦ Children and pregnant women whose family income is at/below 133% of poverty level - states have some discretion here • The ACA sought to mandate/incentivize all states to expand eligibility of those <65 years at/below 138% of poverty level to increase the number on insured • The Supreme Court struck down the mandate and gave the states the option ◦ 31 states chose to expand Medicaid • The ACA increased access to care, utilization, and cost

Ch. 6 #9) What are Medicare trust funds> Discuss the current state and the future challenges faced by the Medicare trust funds. Which main factors pose these challenges?

• Medicare if funded through general/payroll taxes and premiums • There are 2 trust funds: ◦ HI Trust - provides the money pool for Medicare Part A ◦ SMI Trust - provides the money pool for Medicare Parts B & D • Deficit financing leading to fund depletion over time • Influential factors include ◦ Increasing costs of care ◦ An aging population ◦ Decreasing workforce size funding the trusts

Ch. 7 #16) What are the conditions of eligibility for receiving home health service under Medicare?

• Medicare pays for home health care obtained from a medicine certified home health agency when a person is home-bound and requires intermittent or part time skilled nursing care rehabilitation. • Payment made for 60-day episodes of care ◦ Unlimited episodes allowable • No copayment for visits • 20% coinsurance for durable medical equipment • Medicare Part A benefit • See Ch. 6 page 234/235

Ch. 6 #19) Which type of illegal activities constitute health care fraud and abuse?

• Medicare/Medicaid are particularly vulnerable to fraud • Examples of fraud: ◦ Billing of services that are not provided ◦ Delivery of unnecessary services ◦ Providing compensation to others or receiving kickbacks for participating in a fraud scheme ◦ Misrepresenting services to increase reimbursement • Numerous laws have been enacted to identify and detect fraud

Ch. 7 #9) What are some of the reasons why solo practitioners are joining group practices?

• Most physicians today are affiliate with group practices or insitiuation due to: ◦ uncertainty due to rapid chances in the health care delivery system ◦ Contracting by managed care organizations with consolidated organizations rather than solo entities ◦ Competitions from larger health care delivery organizations ◦ High cost of operations a solo practice ◦ Complexity of billing in a multiple-payer system ◦ Increased external demands (e.g., Healtt IT) ◦ See figure 7-3 shown below • Group practice provides... ◦ Referral networks ◦ Negotiating leverage ◦ Sharing of overhead expenses ◦ Time-off coverage from colleagues ◦ Attractive salaries, benefits, and profit-sharing

Ch. 6 #16) Distinguish between national health expenditures and personal health expenditures

• National health care expenditures are the aggregate amount a nation spends for all health services and supplies, public hearth services, health-related research, administrative costs, and investment in structure and equipment • Personal health expenditures are a subset of nation health expenditures that are directly related to patient care

Ch. 8 #19) Discuss some of the issues relative to the tax-exempt status of nonprofit hospitals. What does the Internal Revenue Service require from these hospitals in terms of documentation?

• Non-profit hospitals ◦ do make a profit to support ongoing development ◦ are required to provide some public good and not distribute profits to any individuals ◦ are subject to the community-benefit standard (24 hour ED care, guidelines for treating the uninsured, and community health promotion) • IRS requires detailed financial documentation from non-profit hospitals in their community benefit expenditures • ACA requirements for non-profit hospitals ◦ written financial assistance and emergency care policies ◦ limit charges for those eligible under financial assistance policies ◦ limit certain billing and collection actions for those eligible under financial assistance policies ◦ Conduct a Community Health Needs Assessment and adopt an implementation strategy every 3 years

Ch. 8 #5) What is voluntary hospital? How did voluntary hospitals evolve in the United States?

• Nonprofit, community hospitals financed through local philanthropy as opposed to taxes ◦ Accepted both indigent and paying patients ◦ Required charitable contribution from private citizens • Origins in the mid-1700s • Recognized need for hospital care for the poor • Initially inspired by influential physicians and governed by a chapter and board of trustees who are usually lay people.

Ch. 7 #18) What are some of the main requirements for Medicare certification of a hospice program?

• Physician certification that patient prognosis for life expectancy is 6 months or less • Making nurse, physicians, drugs/ biological available 24 hours • Nurse care provided under registered nurse supervision • Ability to arrange inpatient care if needed • Provision of social work services under physician direction • Counseling services available to the family including bereavement support • Provide needed medication for pain management/palliation • Provide physical, occupational, and speech therapy when necessary • Provide home health aide and homemaker services when needed

Ch. 6 #3) Discuss how the concepts of premium, covered services, and cost sharing apply to health insurance

• Premium ◦ Amount chargers by insurance to insure against specificed risks • Covered Services ◦ Benefits or services offered by an insurance plan • Cost Shaking ◦ Deductible - amount the insured must first pay before any benefits are payable by the insurance plan ◦ Copayment - flam amount the insured must pay each time health services are received ◦ Coinsurance - a set of proportion of the medical costs the insured must pay out of pocket for a health service

Ch. 8 #2) As hospitals evolved form rudimentary custodial and quarantine facilities to their current state, how did their purpose and function change?

• Primitive institutions of social welfare: ◦ 1800s ◦ Charitable gifts/ local government funds ◦ Almshouse (poorhouses) ‣ Social Welfare Function (food, shelter, minimal nurse in care for the poor) ‣ Longer lengths of stay ◦ Pesthouse ‣ Quarantine the sick who had contagious diseases(e.g. smallpox, yellow fever) ‣ Intended to protect the healthy public • Distinct institutions of care for this sick ◦ Late 1800s ◦ Infirmaries/ hospital departments separated from the almshouses ◦ Independent medical institutions ◦ First public hospitals serving the indigent ◦ Marked by poor hygiene, inadequate ventilation, and untrained workers. • Organized institution of medical practice ◦ Late 19th/ early 20th century ◦ Advances in medical sciences, technology, and training organized around the hospital ◦ Improvements in facilities advanced to profit generating ◦ Development of district units of service within the hospital emerged ‣ Business model, need for efficiency, and early stages of accreditation • Advanced institutions of medical training and research ◦Enhanced biomedical knowledge required training in hospitals ◦ Hospitals aligned with universities (teaching hospitals) • Consolidated systems of health services delivery ◦ By the late 1900s, hospitals became major cost centers ◦ Changes in financing - prospective/ capiated payment led to decreased length of stay ◦ Hospitals had excess capacity and less profit ◦ To address this problem: ‣ Multihousptal

Ch. 8 #11) What are some fo the differences between private nonprofit and for-profit hospitals?

• Private non-profit hospitals ◦ Owned and operated by community associations or other non-government institutions ◦ Mission - to benefit the community ◦ Funded through patient fees, theirs-arty reimbursement, donation, and endowments to meet operating expenses ◦ Accounts for 51.1% of all US hospitals • For-profit hospitals ◦ Proprietary or investor-owned hospitals (corporate) ◦ Mission - to benefit the shareholders who own them ◦ Accounts for 18.7% of all US hospitals ◦ Recent trend in physician-owned speciality hospitals

Ch. 7#22) Briefly explain how a telephone triage system functions

• Provides 24/7 access to expert medical opinion ◦ Particularly used during off hours • Uses trained nurses and clinical decisions support to field and triage patient calls • Nurses provide instruction and referral when necessary

Ch. 8 #10)Discuss the different types of public hospitals and the roles they play in the delivery of health care services in the United States

• Public hospitals are owned by the agencies of the federal, state, or local government • Federal hospitals are a subset of public hospitals that serve explicit groups (i.e., native Americans, military personal, veterans) • Countries and cities often operate hospitals open to the general public ◦ Important safety net providers who serve indigent and disadvantaged populations ◦ May often partner with academic institutions and serve as training environments • Public hospitals are often at-risk for increased lengths of stay given high risk populations served • State mental health institutions

Ch. 5 # 12) Provide a brief overview of how technology influences the quality of medical care and quality of life

• Quality ◦ Provide more precise diagnoses ◦ Offer quicker more complete cures ◦ Reduce risks • Quality of life ◦ Improve ability to lead a normal life ◦ Relieve pain and suffering

Ch. 7 #13) Why do patients sometimes use the hospital emergency departments for non-urgent conditions? What are the consequences?

• Reasons include: ◦ Unavailability of primary care ◦ Erroneous self-assessment of illness severity ◦ 24 hr open door ◦ Convenience ◦ Socioeconomic stress ◦ Psychiatric comorbidities ◦ Lack of social support • EDS function as a public safety net ◦ Emergency Medical Treatment and Active Labor Act (EMTALA) • Results are increased costs and overcrowding

Ch. 7 #12) What are some fo the social changes that led to the creation of specialized health centers for women?

• Recognition that women are the major users of health care • Change in American culture toward gender equality • Recognition that the female majority will continue to grow

Ch. 8 #15) What criteria does Medicare use to classify a ups total as a rehabilitation hospital?

• Rehabilitation hospitals specialize in therapeutic services to restore the maximum level of functioning in patients who have suffered recent disability due to an episode of illness or an accident • Can be a freestanding hospital or specialized rehabilitation unit within a general hospital • Medicare requires: ◦ 75% of patients must require intensive (3 or more hours/day) rehabilitation for conditions such as stroke, spinal cord injury, major multiple trauma, brain injury. ◦ Provide a variety of care including PT/OT and speech-language pathology ◦ Arrangements for psychological, social work, and vocational services as well as medical/obstetric, and surgical care not offered within the facility

Ch. 7 #1) Describe how some fo the changes in the health care services delivery system have led to a decline in hospital inpatient days and growth in ambulatory services

• Reimbursement ◦ Historically, health insurance was more generous for inpatient compared to outpatient services ◦ Mid-1980s shift to prospective payment system for hospitals using DRGs created ◦ Implementation of managed cate stressed lower impatient use and emphasized outpatient services • Technological Factors ◦ New technology with less invasive methods ◦ Expanded outpatient diagnostic, treatment, and surgical services • Utilization Control Factors ◦ Prior authorization for admission with close monitoring • Physician Practice Factors ◦ Health system consolidation threatens physician autonomy ◦ For examples, development of physician-owned ambulatory surgery and cardiac care centers • Social Factors ◦ Patient preference for in-home and community-based settings

Ch. 6 #13) What are the differences between the retrospective and prospective methods of reimbursement?

• Retrospective reimbursement ◦ Payment based on actual costs incurred using cost-plus methodology ◦ Perverse incentive to provide excessive services • Prospective reimbursement ◦ Forward-looking model where payment is based on set criteria to determine reimbursement in advance ◦ Concept of diagnosis-related groups (hospitality) ◦ Provides strong incentive to control/ reduce cost

Ch. 6 #4) What is the difference between experience rating and community rating?

• Risk rating = Actuarial assessment of risk • Experience rating. = based on groups's own medical claims experience ◦ Higher risk groups are charged higher premiums • Community rating = spreads the risk among all members of a population ◦ All members are charged the same premium • Adjusted community rating = applies community rating but adjust for various demographic characteristics (e.g. age, gender, geography, and family characteristics)

Ch. 8 #4) Name the three main forces that were responsible for hospital-downsizing. How did each of these forces affect the decline in inpatient hospital utilization?

• Shift from inpatient to outpatient care ◦ See figure 8 • Changes in reimbursement ◦ Move from cost-plus reimbursement to the prospective payment statement based on diagnosis-related groups ◦ Incentive to minimize patient length of stay and use of alternative delivery settings (e.g. home health, subacute long-term care, rehabilitation) • Impact of manager care ◦ Emphasized cost-containment and efficient delivery of services using alternative delivery settings ◦ Increased penetration of HMOs • By decreasing use of inpatient care, all three factors have led to a significant number of hospital closures both rural and urban

Ch. 8 #18) What are some of the main differences between teaching and non teaching hospitals?

• Teaching Hospitals ◦ Must have at least 1 AMA-approved residency program • Provide medical training to physicians, research opportunities to health services researchers, and specialized care to patients ◦ Receive additional payments from Medicare to fund training programs • Have a broader and more complex scope of services than non-teaching hospitals ◦ Advanced medical technology ◦ More complex patient cases • Typically located in economically depressed, older inner-city areas and are owned by state or local governments ◦ Provide disproportionate amount of uncompensated care

Ch. 5 # 11) Summarize the government's role in technology diffusion

• Technology diffusion (how it gets out to be used in practice) vs technological imperative (the latest need developed such as the newest iPhone) • US has more high tech equipment than most other nations ◦ US lacks a central planning and utilization process to evaluate, limit, and control costs ◦ US lacks a central budgeting process ◦ Politicians, medical professional, and other have not embraced the concept of supply-side rationing • Private insurers tend to follow Medicare decision to determine what technology is covered under payment ◦ Medicare reimbursements seek "value" in reimbursement decisions ◦ More generous insurance plans are associated with increased spending for new technology • The US government foes not play a significant role in deciding which drugs, devices, and biological are made available to Americans ◦ Primary focus on safety and efficacy (not cost) ◦ Review table 5-4 • Certificates of need, research of technology, research funding

Ch. 5 #7) What is telemedicine? How do the synchronous and asynchronous forms of telemedicine differ in their applications?

• Telemedicine (aka, distance medicine) is... ◦ A component of telehealth ◦ The use of telecommunications technology for medical diagnosis and patient care when the provider and client are separated by distance ◦ Examples include teleradiology, telepathology, telesurgery, clinical consultation • Synchronous telemedicine occurs real-time • Asynchronous telemedicine employs store and forward technology to allow for later use of information • How could a pharmacist use "telehealth" in their practice setting? ◦ Would it be synchronous or asynchronous? ◦ Must consider the legal implications in the jurisdiction where you practice

Ch. 8 #6) Discuss the role of government in the growth, as well as the decline, of hospitals in the United States

• Through legislation, financial incentives, and public health insurance programs, the federal government expands the hospital capacity in the US • Through financing reimbursement mechanisms, the federal government caused a downsizing of hospitals in the US

Ch. 7 #15) What is the basic philosophy of home health care? Describe the services it provides

• To "maintain" people in the lest restrictive environments possible ◦ Bring health care series isn't the home • Includes a wide variety of service such as skilled nursing/aides, physical therapy, occupational therapy, speech-language • Levering medical technology • Typically improves patient outcomes subsequent to discarded and less costly then skilled nursing facilities, inpatient rehabilitation, or long term care.

Ch. 8 #14) Why have physicians developed their own speciality hospitals? What main circumstances have these hospitals faced?

• To address a service niche (e.g., orthopedics, cardiac care, oncology, etc.) • Advantages for physicians include: ◦ Ownership and opportunity to increase income ◦ Improved efficiency ◦ More control over hospital operations ◦ Time flexibility • Criticisms include: ◦ Decreased proportions of Medicaid patients ◦ Less severe, more profitable cases ◦ Drawing patients from general hospitals ◦ Do not offer lower costs per severity-adjusted discharge

Ch. 8 #20) Discuss the governance of a modern hospital

• Tripartite structure ◦ Board of Trustees ‣ Legal responsibility for managing the hospital ◦ Chief Executive Officer ‣ Receives delegated authority from the Board of Trustees ‣ Responsible for managing the organization ◦ Medical Staff ‣ Organized body of physicians who provide medical services to the hospital's patients and perform related clinical duties ‣ Organized by medical specialties and headed by the chief of staff ‣ Often include numerous committees (e.g., credentialing, medical records, utilization review, infection control, and quality improvement) • Many of the nursing and allied health staff are administratively responsible to the CEO and professionally accountable to the medical staff

Ch. 7 #19) Describe the scope of public health ambulatory services in the United States

• Typically provided by local health departments • Generally include: ◦ Well baby care ◦ Sexually transmitted disease clinics ◦ Family planning services ◦ Screening and treatment for tuberculosis ◦ Ambulatory mental health • Health programs provided in public school related to vision, hearing, and learning impediments • Ambulatory prison clinics

Ch. 6 #14) Discuss the concept of value-based purchasing, as required by the ACA

• Value based reimbursement ◦ Reimbursement tied to quality and cost • Two different tracks ◦ Merit-based Incentive Payment System (MIPS) that ties bonuses to quality measures, resource uses, care coordination, and electronic health record use ◦ Advanced Alternative Payment models used accountable care organizations and patients centered medical homes where groups of providers agree to be held accountable for the cost and quality for care for a group of beneficiaries. • Shifts significant responsibility to the provider

Ch. 6 #18) What is the relationship between reimbursement cuts and cost shifting? How did hospitals react in different markets to cuts in reimbursement?

• When reimbursement to a provider becomes inadequate (or uncompensated care is provided), producers can charge extra payers who do not exercise strict cost control • In competitive market, providers focus on cutting costs to stay competitive • In non-competitive markets, providers raise process to private insurers • Consolidation of providers reduces competition in the market in which they excist