HSMT

What is meant by financing? What are its desirable and undesirable effects?

- Financing refers to any mechanism that gives people the ability to pay for health care services. For most people, financing is necessary to access health care - First, it creates excessive demand from consumers who want to use their health insurance benefits. Consumers are driven to entire price out of their own pockets. Consumer behavior that leads to a higher utilization of care services when the services are covered by insurance is referred to as moral hazard. - . Second, financing exerts powerful influences on supply-side factors, such as how much health care is delivered. Financing also indirectly affects the growth of medical technology, in that technology and services that are when reimbursement is constrained, the supply of services is curtailed accordingly... Financing eventually affects the total health care expenditures (also referred to as health care costs or national health care spending) incurred by a health delivery system. Both moral hazard and provider-induced demand waste health care resources and add to the rising cost of health care. To counter these effects, countries with national health insurance implement supply-side rationing, which focuses on restricting the availability of expensive medical technology and specialty care. Otherwise, the health care expenditures in these countries would be astronomical. Without a centrally managed health care system, the United States cannot ration health care directly

SUBSYSTEMS OF THE US HEALTH CARE DELIVERY

- MANAGED CARE - MILITARY - VULNERABLE POPULATIONS - INTERGRATED DELIVERY

Medicare Part A

- hospital coverage - inpatient hospital care - skilled nursing - hospice - home health

Why are safety nets not secure?

--provider type and availability vary --some people skip the doctor and go to the ER if nearby --providers pressured to see rising number of uninsured --medicaid is primary financial source

1. What are the 2 major objectives of this chapter?

1. The first major objective of this chapter is it, "provides an overview of the large array of health services professionals. It summarizes the training and practice requirements for these professionals, their major roles, the practice settings in which they are generally employed, and some critical issues concerning their professions 2. The second major objective of this chapter is, "the imbalance between primary and specialty care services, the maldistribution of practitioners and the looming personnel shortages

Nanomedicine

A developing area of medicine in which materials are manipulated on the atomic and molecular level (one nanometer is one billionth of a meter)

Advanced practice nurse (APN)

A general name for nurses who have education and clinical experience beyond that required of a registered nurse (RN). APNs include four areas of specialization in nursing: clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), nurse practitioners (NPs), and certified nurse midwives

Osteopathic medicine

A medical philosophy based on the holistic approach to treatment that also emphasizes correction of the position of the joints or tissues and diet and environment as factors that might destroy natural resistance

Allopathic medicine

A philosophy of medicine that views medical treatment as active intervention to counteract the effects of disease through medical and surgical procedures that produce effects opposite those of the disease

Generalists

A physician in family practice, general internal medicine, or general pediatrics

Specialists

A physician who specializes in specific health care problems, for example, anesthesiologists, cardiologist, and oncologists

Hospitalist

A physician who specializes in the care of hospitalized patients

Biologics

Biological products that include a wide range of products such as vaccines, blood and blood components, allergenics, somatic cells, gene therapy, tissues, and recombinant therapeutic proteins

How do American cultural beliefs and values influence the use of medical technology?

Capitalism and limitations on government intervention promote innovation. An economic and political environment in which innovation thrives creates opportunities for scientists and manufacturers to develop new technology. Americans have high expectations of finding cures through science and technology, and they equate use of advanced medical technology with high-quality care.... The desire to have state-of-the-art technology available, accompanied by the desire to use it despite its cost, is called the technological imperative

Discuss the payment method and risk sharing under capitation.

Capitation is another mechanism used by HMOs. Under this reimbursement scheme, a provider is paid a set monthly fee per enrollee (sometimes referred to as per member per month rate), regardless of whether an enrollee sees the provider or not and regardless of how often an enrollee sees the provider. Capitation removes the incentive for provider-induced demand. It makes providers prudent and encourages them to provide only necessary services

Orphan drugs

Certain new drug therapies for conditions that affect fewer than 200,000 people in the United States

What type of medical devices are classified as Class III? What type of approval do they require from the FDA?

Class III devices that come under the most stringent requirements of premarket approval regarding safety and effectiveness. Devices in this class support life, prevent health impairment, or present a potential risk of illness or injury The type of approval that is required from the FDA is a premarket approval.

Non-physician practitioners (NPPs)

Clinical professionals, such as nurse practitioners and physician assistants, who practice in many areas similar to those in which physicians practice but who do not have an MD or a DO degree

Decision support systems

Computer-based information and analytical tools to support managerial decision making in health care organizations

How does an HMO work?What is managed care?

Designed as a healthcare delivery system organized to manage cost, utilization, and quality

Cost-effectiveness

Evaluation of overall usefulness of medical technology, including evaluation of the safety and efficacy of a technology in relation to its cost

TRICARE

Financed by the military and covers families, dependents, or retired military

1. What impact has technology made on access to medical care?

Geographic access to health care can be improved for many people by providing mobile equipment or by using new communication technologies that allow remote access to centralized equipment and specialized personnel. Mobile equipment can be transported to rural and remote sits, making it accessible to those populations

socialized health ins

Gov mandated contributions by employees and employers health delivered by private providers (Germany)

Residency

Graduate medical education in a specialty that takes the form of paid on-the-job training, usually in a hospital

HITECH

Health Information Technology for Economic and Clinical Health Act provides financial incentives to providers for adopting a meaningful use of EHR technology

What is meant by technology assessment? What is the main practical use or objective of assessment?

Health technology assessment (HTA) refers to the evaluation of medical technology to determine its efficacy, safety, and cost effectiveness... The objective of HTA is to establish the appropriateness of medical technology for widespread use... Efficacy and safety are the basic starting points in evaluating the overall usefulness of medical technology

Briefly explain how insurance functions in relation to risk for individuals and groups.

Insurance is a mechanism for protection against risk. In the context of insurance, risk refers to the possibility of a substantial financial loss from some event. In health care, illnesses requiring expensive treatments and hospitalization pose substantial financial risk to most people... Insurance, in a general sense, is primarily designed to protect people against such eventualities. Health care providers are also subject to substantial risk when they are required to treat the sick and injured who cannot pay. An individual who is protected by insurance against the possible risk of financial loss is called the insured. The insured may also be referred to as the enrollee or member

Discuss how cost sharing applies to health insurance.

Insurance requires some type of cost sharing so that the insured assumes at least part of the risk. The purpose of cost sharing is to reduce the misuse of insurance benefits. Three main types of cost sharing are utilized in private health insurance: premium cost sharing, deductibles, and copayments

What subsystem of the US health care delivery is the most dominant in the US and is financed primarily by the

Managed Care

List three non-physician doctoral level health professionals and describe their roles.

Optometrists - "provide vision care such as examination, diagnosis, and correction of vision problems. They must be licensed to practice. The licensure requirements include the possession of a doctor of optometry (OD) degree and completion of a written and clinical state board examination Psychologist - "provide patients with mental health care. They must be licensed or certified to practice. The ultimate recognition is the diplomate in psychology, which requires a doctor of philosophy (PhD) or doctor of psychology (PsyD) degree, a minimum of 5 years of postdoctoral experience, and the successful completion of an examination administered by the American Board of Examiners in professional psychology Podiatrist - "treat patients with diseases or deformities of the feet, by performing surgical operations, prescribing medications and corrective devices, and administering physiotherapy. They must be licensed. Requirements for licensure include completion of an accredited program that awards a doctor of podiatric medicine (DPM) degree and completion of a national examination administered by the National Board of Podiatry

How does an HMO work?

Patient chooses a PCP from a list of coordinated care who acts as the gate keeper Care can only come from "in-network" providers and facilities

How does a PPO work?

Patients can access "out of network" providers for a higher degree of cost

Why is there a geographic maldistribution of the physician labor force in the U.S.?

Physicians often choose to concentrate in metropolitan and suburban areas rather than in rural and inner-city areas because the former generally offer greater prospects for better living standards, professional interaction, access to modern facilities and technology, and professional growth

What is a PPO?

Preferred provider organization; a more open healthcare system that has no PCP

4. What are the major distinctions between primary care and specialty care?

Primary care - "first-contract care and is regarded as the portal entry to the health care system... Primary care physicians serve as gatekeepers - an important role in controlling costs, utilization rates, and the rational allocation of resources Specialty care - episodic, focused and intense, "deals with particular diseases or organ systems of the body. It is limited in its scope to episodes of illness, specific organ systems, or the disease process

Define retrospective and prospective methods. In what way did prospective reimbursement contain perverse financial incentives?

Retrospective reimbursement is defined as, "Reimbursement rates based on costs actually incurred Prospective reimbursement is defined as, "a method of payment in which certain pre-established criteria are used to determine in advance the amount of reimbursement Because the retrospective method was based on costs that were directly related to length of stay, services rendered, and the cost of providing the services, providers had no incentive to control costs. Services were rendered indiscriminately because health care institutions could increase their profits by increasing costs. Because of the perverse financial incentives inherent in retrospective cost-based reimbursement, it has been largely replaced by prospective methods of reimbursement

Cost sharing

Sharing of costs between the insured and the financier or insurer.

Specialty Maldistribution

Specialty maldistribution has become ingrained in the US health system for 3 reasons: 1. medical technology 2. reimbursement method & remuneration 3. speciality-oriented medical eduction Make more money being specialist Hours are better More time off

Meaningful use

Specific criteria in quality, safety, efficiency, etc. that providers are required to meet to comply with the Health Information Technology for Economic and Clinical Health Act of 2009

Clinical information systems

Systems that involve the organized processing, storage, and retrieval of information to support patient care processes

Information technology

Technology used for the transformation of data into useful information. IT involves determining data needs, gathering appropriate data, storing and analyzing the data, and reporting the information generated in a user-friendly format

Remote health services

Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services

Discuss the prospective payment system under DRGs.

The DRG-based prospective reimbursement has forced hospitals to control their costs. To keep the cost of services below the fixed reimbursement amount, this reimbursement method has also forced hospitals to minimize the length of inpatient stay. If the total cost of services is less than the DRG-based reimbursement amount, a hospital gets to keep the difference as profit. Conversely, a hospital loses money when its costs exceed the prospective reimbursement rate. As an example, if the prospective reimbursement rate for a give DRG is $3,500 and the costs associated with each day of hospital stay are as shown, a patient admitted under this DRG should be hospitalized for no more than 4 days when the cumulative costs will equal $3,400

What is meant by technology diffusion? What role does the FDA play in technology diffusion?

The development and dissemination of technology is called technology diffusion The role that the FDA plays in technology diffusion is making sure that all drugs and equipment's are checked for safety and effectiveness.

1. Explain why the health care sector of the U.S. economy continues to grow?

The health care sector of the U.S. economy is continuing to grow because of the growth in population. This is not limited to babies - immigration plays a role as well. Another reason is because the population continues to grow older meaning health care becomes more of a necessity to these people.

What main types of information technology applications are used in medical care delivery?

The main types of information technology applications that are used in medical care delivery are: - clinical informative systems - administrative information systems - decision support systems - clinical decision support systems

3. What factors are associated with the development of health services professionals in the U.S.

There are multiple factors that are associated with the development of health services professionals in the U.S. including: new technology being introduced and used, many people thinking they have an illness that someone else has because of the same symptoms, changes within the financial aspect of health care services.

How are providers paid in an HMO system?

They are paid a captivated fee regardless of what services are provided

Technological imperative

Use of technology without cost considerations, especially when the benefits to be derived from the use of technology are small compared to the costs

telemedicine

Use of telecommunications technology for medical and Dx & patient care when the provider and patient are separated by distance

Allied health

a segment of healthcare professions comprised of specialized occupations that require certification, including physical therapists, dental hygienists, social workers, speech therapists, nutritionists, etc., but not including doctors, nurses, and dentists

Military medical system is free to

active duty military personnel and certain uniformed nonmilitary services (public health service and national oceanographic and atmospheric association [NOAA])

MCR Part C

allows private ins to provide MCR benefits

Maldistribution

bad or unsatisfactory distribution, as of wealth, among a population or members of a group

pre industrial medicine

considered a trades men job little prestige clergy often doubled as physician

MCR PART B

covers servies and supplies that are medically necessary to treat condition: - OP - Ambulance - Preventative services - Durable medical equipment

desirable effects of financing

enables people to access health care and pay providers for services rendered

National health ins

financed by taxes gov also manages delivery providers are gov employees

Blue shield

first form of INS to cover physician fees

blue cross

first form of ins to pay hospital costs

pest houses

government houses used to isolate those w/ contagious diseases

alms house

house for sick (nursing homes today)

MCR PART C. ADD INFO

in reality, not a program that offers specifically defined medical services. The program was formerly called Medicare+Choice, which took effect on January 1, 1998, and was mandated by the Balanced Budget Act of 1997. The law expanded the role of private managed care health plans such as HMO and PPO plans. To participate in Part C, a beneficiary must first be enrolled in both Part A and Part B. The beneficiary must pay Part B premiums to Medicare and an additional premium to the MCO (some plans have no premium). Beneficiaries, however, do have the choice to remain in the original Medicare fee-for-service program

fee for service

itemized billing and payment based on individually distinct services

post industrial medicine

many advances made hospitals established adopted the European medical model John Hopkins required college degree to study medicine

MCR Part D

prescription drug benefit

EHR

replace the traditional paper medical records

Geographic Maldistribution

shortages outside metropolitan areas

Meaningful use refers to

specific criteria in quality, safety, efficiency that providers are required to meet

national health ins

taxes pay for health ins delivery by private sector

Medicare Part A. Add info

the hospital insurance portion of Medicare, is financed by special payroll taxes paid equally by employers and employees. These taxes are paid by all working individuals, including those who are self-employed. All earnings are subject to the Medicare tax. Part A is designed to cover hospitalization, short-term convalescence and rehabilitation in a skilled nursing facility (SNF), and home health care. For terminally ill patients, Medicare pays for care provided by a Medicare-certified hospice

MCR PART B. ADD INFO

the supplementary medical insurance portion of Medicare, is a voluntary program, financed partly by general tax revenues and partly by required premium contributions from the beneficiaries. Almost all persons entitled to hospital insurance also choose to enroll in SMI because they cannot get similar coverage at that price from private insurers. Coverage includes physician, ambulance, outpatient rehabilitation, an annual wellness exam, and medically needed preventive services; hospital outpatient services such as outpatient surgery, diagnostic tests, radiology, and pathology; emergency department visits; renal dialysis; prostheses; and medical equipment and supplies. Part B also covers limited home health services that are not associated with a hospital or SNF stay

undesirable effects of financing

total health care expenditures are greater than if the same services were to be paid by patients

MCR PART D. ADD INFO

was added to the existing Medicare program under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and was fully implemented in January 2006. The program is available to anyone, regardless of income, who has coverage under Part A or Part B. Coverage is offered through two types of private plans approved by Medicare. Standalone prescription drug plans that offer only drug coverage are available to those who want to stay in the original Medicare fee-for-service program. Alternatively, Medicare Advantage prescription drug plans are available to those who want to obtain all health care services through MCOs participating in Part C

Military medical system is

well organized, highly integrated, comprehensive (covers preventative care)

Although medical technology brings numerous benefits, what have been some of the main challenges posed by the growing use of medical technology in the United States?

•New technology has raised consumer expectations about what may be possible. •Technology influences the organization and financing of medical services. •The introduction of advanced technology has influenced the scope and content of medical training and shaped the practice of medicine, fueling a trend toward specialization in medicine at the expense of public health, preventive medicine, and primary care. •Although some medical technology may reduce costs, as a whole technology has contributed to health care cost escalation. Technology has raised complex moral and ethical dilemmas in medical research and decision making