C425 Review Finals
Healthy People 2020
- 10-year plans - Key national health objectives - Founded on the integration of medical care and prevention, health promotion, and education • Objectives define new relationships between public health dept and the health care delivery organization such as DHSS. Goals: 1) high quality lives free of preventable disease, injury and premature death 2) achieving health equity, eliminating disparities and improving the health of all groups 3) Creating social and physical environment that promotes good health for all 4) Promoting quality of life, health development and behaviors.
Resource Utilization Groups (RUG)
- A case-mix method to reimburse Skilled Nursing Facilities (SNF) • Case mix: overall acuity level in a facility - Each patient is classified into one of 66 RUGs. - The case mix determines a fixed per-diem rate. • The higher the case mix score, the higher the reimbursement.
Home Health Resource Groups (HHRG)
- A fixed, pre-determined rate for each 60-day episode of care, regardless of services given. - OASIS is used to rate a patient's functional status and clinical severity. - Assessment measures translate into points. - Total points determine the HHRG category.
Balanced approach must emphasize health determinants for individuals and broad policy interventions for populations. • Factors that influence an individual and a population's health:
- A person's genetic make up - Individual Behaviors - Medical Practice - Social and Environmental Factors - Environment • Physical, social, cultural, and economic factors - Behavior/Lifestyle • Diet and foods play a major role in most significant health problems. - Heredity • Genetic factors predispose individuals to certain diseases. • Healthy lifestyles and health promoting behaviors can influence the development and severity inherited disease and can pose a risk for future generation. - Medical care: Access to adequate preventive and curative health care services. • Misallocation can be attributed to many factors, including insurance system, cultural beliefs and traditional medical training and practice. The association of income difference with health indicators such as life expectance, age-adjusted mortality rates and leading causes of death is well documented.
Quality of Life
- A person's overall satisfaction with life during and after a person's encounter with the health care delivery system. - The term is used two ways: how satisfied a person is with experiences while receiving health care - Person's overall satisfaction with life and self-perception of health, after some intervention. Goal: To have a positive effect on an individual's ability to function, meet obligations, feel self-worth.
• Financing is:
- Any mechanism that gives people the ability to pay for health care services. Sources of financing health care: • Private health insurance • Public insurance programs such as Medicare and Medicaid • Uncompensated or charity care Complexity of financing: - Many payers - Many plans - Many programs - Many payment options
Fee-for-Service
- Charges (prices) set by providers. - Each service is billed separately. - "Usual, customary, and reasonable" (UCR) became common. - Main drawback: • Provider-induced demand
Medicare Advantage (Part C)
- Does not specifically include additional medical benefits. - Beneficiaries are given the choice to remain in the original fee-for-service program, or sign up for Part C. - Additional benefits (basic vision and dental) may be offered by the private managed care plans. - Beneficiary receives all Part A, B, and D services through the MCO.
The objective of HTA is to establish the appropriateness of medical technology for widespread use.
- Efficacy and safety are the basic starting points.
High costs of these technology it would be difficulty for:
- Employers extending benefits to part-time workers and - For Insurers lowering premiums.
Medicaid - Title 19 of Social Security Act
- Finances health care for the indigent, but not all poor. - Jointly financed by state and federal governments. - Each state establishes its own eligibility criteria according to: • Income and assets • Medicaid is a means-tested program - Each state administers its own Medicaid program.
Diagnosis-Related Groups (DRGs)
- For acute hospital inpatients - Approximately 500 DRGs - Prospectively set bundled price • according to the admitting diagnosis - The hospital earns a profit by keeping costs below the DRG reimbursement
Beliefs and values in US
- Have remained mostly private, • Not a tax-financed national health care program. - Are strong forces against Fundamental changes in the financing and delivery of health care.
• Social norms explain
- How we view illness and expectations.
Delivering Value
- Improved benefits at lower cost - Value is enhanced by Improving quality, Reducing cost, or Doing both - Benefits of Technology Assessment
The hospital must also:
- Maintain medical records on each patient, - Have pharmacy services available. - Provide food services to meet the nutritional and therapeutic requirements of the patients. Construction and operations of a hospital are governed by: - Federal laws, - State health department's regulations, - City ordinances, - JCAHO, - Fire codes, and - Sanitation
Package pricing (bundled pricing)
- Number of related services bundled in one price.
Group insurance
- Offered through an employer, a union, or professional organization. - Anticipates large numbers of people in a group will buy insurance through a sponsor. - Cost and risk are distributed equally among the insured.
The technological imperative
- The desire to have state-of-the-art technology available and to use it despite its cost. • Medical Training and Practice • Specialists use more technology than primary care physicians. • American medical graduates increasingly choose specialization over primary care.
Health technology assessment (HTA):
- The evaluation of medical technology to determine: Efficacy Safety Cost-effectiveness -
Cost Sharing
- The purpose of cost sharing is to reduce misuse of insurance benefits. There are three main types of cost sharing in private health insurance: • Premium cost sharing • Deductibles • Copayments
Different Forms of Health Policies
- byproducts of public social policies enacted by the government (i.e. expansion of health insurance coverage -pertain to health care at all levels, including policies affecting the production, provision, and financing of health care services. - affect groups or classes of individuals, such as physicians, the poor, elderly and children. Types of organizations, such as medical schools, HMOs, nursing homes, medical technology producers and employers.
-In most developed countries,
-Government plays a central role in the provision of health care. -In the US, -The private sector plays the dominant role because of American tradition, and the desire to limit government.
What Is Health?
-U.S. health care has followed a medical/biomedical model. - It assumes illness or disease thereby emphasizing clinical diagnosis and medical in the treatment of disease or its symptoms. - It emphasizes • Clinical diagnosis and medical interventions to: - Treat disease or its symptoms. - Have a clinical diagnosis and medical interventions. Largely governed by the medical model/biomedical model.
Centers for Medicare and Medicaid Services (CMS) is implementing a new quality reporting program for ambulatory surgery centers that introduces a structural measure on the use of a safe surgery
-organizations must assess effective communication and safe practices during three perioperative periods: -prior to administration of anesthesia; -prior to skin incision; -and prior to the patient leaving the operating room or procedural area. (WHO) and The Joint Commission are specifically cited as resources in the rules. The UP focuses on wrong person, wrong procedure, and wrong site surgery, and includes issues that are addressed in many safe surgery checklists.
Implications of Social Justice:
1) Collective responsibility 2) Everyone is entitled to basic package of benefits 3) Strong Obligation to the collective good 4) Community well being supersedes that of the individual 5) Public solutions to social problems 6) Planned rationing of health care
The goal of EBM is to increase the value of medical care.
1) Consumers fear that reducing costs will result in lower quality of care. Quality of care can be improved while cutting costs thereby increasing the value of medical care by reducing misuse and overuse.
Evidence Based Health Care
1) Geographic variations in the practicing of medicine without clinical justification have both quality and cost implications. 2) Has little evidence that high spending providers deliver better outcomes.
The principles of Social Justice:
1) Health care is a social resource 2) Requires active government involvement i 3) Assumes that the government is more efficient in allocating health resources fairly 4) Medical resources allocation is determined by central planning 5) Ability to pay is unimportant or receiving medical care 6) Equal access to medical services is viewed as a basic right. 7) Planned rationing, supply-side rationing, or nonprice rationing is where a. Government limits the supply of health care services, particularly those who need basic level of care.
Implications of Market Justice:
1) Individual responsibility for health 2) Benefits are based on individual purchasing power 3) Limited obligation to collective good 4) Emphasis on individual well being 5) Private solutions to social problems 6) Rationing based on ability to pay.
3 emerging models of health care delivery
1) Medical Home Model 2) Community Oriented Primary Care Model 3) Accountable Care Organizations.
Recommendations for EBM that can be made for the future.
1) Practitioners, payers and policy makers need to become stakeholders. 2) Computer based models will help incorporate EMB into medical decision making. Models that are easily usable and understandable are essential. 3) Robust research designs, using clinical trials where application can be the backbone of EBM. 4) Guidelines and protocols must be revised and kept current to incorporate with scientific evidence. 5) Future practice guidelines must incorporate economic analysis. Mounting health care expenditures will pressure society to make rational choices about certain types of services because of costs of certain treatments. 6) Financial incentives, including provider payments and patient cost sharing must be restructured. 7) Reimbursement methods should focus on paying for best care instead of paying for services.
Four Principles of Insurance:
1) Risk is unpredictable for individuals. 2) Risk can be predicted with some accuracy for a large group. 3) Insurance can shift risk from the individual to the group by pooling resources. 4) Losses are shared by all members.
Four principles are the foundation of the NCQA Physician and Hospital Quality program:
1) Standardization and sound methodology. Is the methodology standardized, so results can be compared across organizations? 2) Transparency. Can physicians provide input on measurement programs? Is there clear, understandable information about how results will be used? 3) Collaboration. Where possible, does the organization pool data on standardized measures to produce more reliable results? 4) Action on quality and cost. Organizations should not use results of cost measurement alone. Does the organization balance quality and cost considerations so quality is not sacrificed to cost
What issues exists in this system which is driven by medical model of health are unresolved?
1) inadequate emphasis on wellness, disease prevention and health promotion 2) a rise of chronic conditions and ensuing disabilities, the current health care system focuses on acute illnesses. 3) Inadequate access to primary care resulting in patients overutilizing the ER 4) increases the costs of health care w/o any improvement in health care 5) The delivery of care is fragmented instead of continuous and coordinated.
Teamlet Model
1) refers to two-person team consisting of a PCP, nurse practitioners or physician assistant and an allied health professional who will function as a health coach. The main function of health coach: · is to assist patient in gaining the knowledge and skills, confidence to self manage their chronic conditions. · Assist in coordinating appts · Help patients adopt a healthy lifestyle · Help patients understand and adhere to medication regimen
Connected Health Care Model
1) uses communication technology 2) patient self management and distant home monitoring Main objective is to keep chronically ill patients connected to necessary clinical expertise in between office visits
If ACA fails: Patient choice act, Health Care Freedom Plan, Empowering Patients First Act were proposed by republican legislatures and the main features for these plans are.
1. Established state-based health care exchanges to facilitate individuals to buy private health insurance and create a market where private health plans compete for enrollees based on price and quality. 2. Create a national market for health insurance to allow individuals to purchase health insurance plans across state lines which are currently prohibited. 3. Allow automatic enrollment in employer plans and create tax incentives for small business for auto enrollment. 4. Give tax credit or vouchers to individuals to purchase health insurance. High risk pools that enable hard to insure people to purchase subsidized covered. • . Replace Medicaid with a program to provide grants to state for: a) Acute Medical Care Assistance to the blind, foster care children, low income women with breast cancer or cervical cancer, TB infected individuals; b) long term care services and support disabled and elderly populations 6). Establish and implement a bidding mechanism to promise competition among Medicare Advantage plans (Part C). 7) Prevent Medicare fraud and abuse. 8) Supplement the costs of Private health insurance for low income families by distributing debit cards which may be used for costs and accessing health care. 9). Repeal CHIP because options for this program may not be necessary. 10) Reform the Tort System by developing mechanism for the resolution of disputes concerning injuries allegedly caused by health care providers. Reduce frivolous lawsuits. 11) Assure consumers have access to price information prior to treatment so that they can make their own decisions about the care.
• Health policy concerns regarding medical technology include:
1. Its role in health costs 2. Its health benefits to people (although not always)
Requires four developments:
1. Primary care must be central in delivery. 2. Biomedicine must include social and behavior sciences. 3. Primary and secondary prevention must be linked. 4. Public health must have clinical interventions in conjunction with: • Schools, social service agencies, churches, and employers, to strengthen public health programs
HI-TECH act
21st Century Cures Act (Cures Act) that will improve the flow and exchange of electronic health information. ONC is responsible for implementing those parts of Title IV, delivery, related to advancing interoperability, prohibiting information blocking, and enhancing the usability, accessibility, and privacy and security of health IT. ONC works to ensure that all individuals, their families and their health care providers have appropriate access to electronic health information to help improve the overall health of the nation's population.
"Medical Center"
A hospital that has achieved specialization and offers a wide scope of services. Medical centers often engage in teaching and research.
managed care
A system of health care delivery that: 1) integrating the basic functions of healthcare delivery. 2) employs mechanisms to control (manage) utilization of medical services. 3) determines the price for services that are purchased and how much the providers get paid. 4) Is the most dominant health care delivery system 5) Employers and government are the primary financiers
PORTS
AHRQ established funding that focuses on medical condition medical treatmetn effectiveness program that has 4 element 1) medical treatment effectivness research 2) development of databases for such research 3) development of clinical guidelines 4) diseemination of research findings and guidelines
All Americans are not "entitled" to routine and basic health care services.
Access also requires an adequate health delivery infrastructure. There is a shortage of primary care physicians mostly in the southern and mountains region. Obesity, chronic disease and aging population will create a much greater demand for medical services and the size of physician workforce will decline. 50 % of PCP accept Medicaid and Participation in Medicare by PCP 36% why PCP are reluctant to accept Medicaid insured patients because of low reimbursement to providers and delays to receive payments after the services.
Health Information Technology for Economic and Clinical Health (HITECH)
Act through notice and comment rulemaking, as required by the Administrative Procedure Act. These provisions include: business associate liability; new limitations on the sale of protected health information, marketing, and fundraising communications; and stronger individual rights to access electronic medical records and restrict the disclosure of certain information.
IHR (International Health Regulations)
Aim is to help prevent and respond to acute public health risk that can potentially cross borders. ·Apply to other public health emergencies such as chemical spills, leaks and dumping or nuclear melt downs.
Access and Minorities
All have difficulties accessings health care low income and minorities creates difficulties
• Opposition from the AMA
American beliefs and values: Capitalism Self-determination Distrust of big government tax aversion
According to Dishman, the three personal pillars of health include:
Care anywhere Care networking Care customization Though new technology is integral to what Dishman refers to as "a personal health system," perhaps the most primary component of this model is improved health literacy for both patients and providers.
How does competition in healthcare markets benefit consumers?
Competition in health care markets benefits consumers because it helps contain costs, improve quality, and encourage innovation. The Federal Trade Commission's job as a law enforcer is to stop firms from engaging in anticompetitive conduct that harms consumers. the agency also provides guidance to market participants -- including physicians and other health professionals, hospitals and other institutional providers, pharmaceutical companies and other sellers of health care products, and insurers -- to help them comply with the nation's antitrust laws.
Connected Health Care Model
Connected health care incorporates the use of communication technology, patient self-management, and distant home monitoring technology
In a free market for health care:
Consumers make decisions about the purchase of health care services. Limits patients ability to make health care purchasing decision Decisions about the utilization of health care is determined by price based demand Need has generally defind as the amount of medical experts believe a person should have to become healthy. Delivery of health care can result in creation Moral hazards leads to greater utilization
Health Care Quality Act
Creation of national database within the U.S. Dept of Health and Human Services to provide data on legal actions against health care providers
Foundation of US Health Care Delivery
Curative Medicine decreasing returns on health improvement while health care spending increases. There is increasing recognition of benefits to society that can result from promotion of health and prevention of disease, disability and premature death. Health care money has been focused on curative medicine, slow progress toward health promotion and disease prevention. The slow progress has been d/t the insurance system, cultural values, and medical practice that emphasize disease rather than health.
Universal Access
Developed countries have national health insurance programs. It provides routine and basic health care. It is ran by the government and financed-through general taxes.
Two main types of Allocative Tools
Distributive • Policies spread benefits throughout society. Redistributive • Takes money or power from one group and gives it to another. • Therefore, health policy can be politically charged.
GLOBAL THREATS AND INTERNATIONAL COOPERATION
Early identification of infectious threats and rapid response to prevent further spread of disease - a goal that is often difficult to achieve without international cooperation. Efforts to strengthen global health security includes disease surveillance of outbreaks of international importance and urgency, exchange of technical information on new pathogens and control animal disease.
These five key areas (determinants) include:
Economic Stability Education Social and Community Context Health and Health Care Neighborhood and Built Environment
The Food and Drug Administration (FDA) is An agency of the US Department of Health and Human Services (DHHS). The FDA is responsible for
Ensuring that drugs and medical devices are safe and effective for their intended use. • Regulation of Drugs and Devices • Three classes of devices: Class I: Pose the lowest risk. Require general controls regarding fraudulent claims. Class II: Subject to labeling and performance standards, and post-market surveillance. Class III: Devices that support life, or present a potential risk of illness or injury. Require premarket approval regarding safety and effectiveness.
Critical Policies Issues re: financing
Financing is available to: Medicare, the elders Medicaid, the children, Medicaid and local general assistance, the poor adults Medicaid/Medicare, the disabled VA Native Americans Patients with ESRD (Medicare and Social Security Benefits)
• Evidence from other countries to curtail the use of high-tech procedures:
Fixed payments to providers (e.g., salary). Limited payments to hospitals . • Competition • Specialization has been used as an enticement to attract insured patients and to recruit specialists.
The VA health care system
Focuses on • Hospital, mental health and long-term care. • Is to provide medial care, education and training, research, contingency support and emergency management for the Department of Defense medical care system. • -Organized into 23 geographically-distributed Veterans Integrated Service Networks (VISN). Each VISN: o Coordinates its own services. o Receives federal funds.
ACA proposed interventions to control costs but few provisions on addressing control of health care expenditures.
If the US does not cut expenses in the bloated government, US may be left with no choice except to take drastic "austerity measure" a term used to describe spending cuts, including cuts in social program. To save Medicare from bankruptcy, changes to reduce costs are proposed in the ACA. Medicare benefits and allow a government panel to make decisions about end of life care. Medicaid, the push to enroll beneficiaries to managed care and paying MCO capitated monthly fees to cover all health care expenses for Medicaid beneficiaries. Taxes will increase for Americans to pay for the health care programs to be expanded.
Free market characteristics explain why U.S. is not a true free market.
In a free market, • Multiple patients (buyers) and providers (sellers) act independently. • Patients should be able to choose their provider based on price and quality of services. • Medicare, Medicaid, or MCO are the payors, prices are set by these agencies to the market, therefore it is not free and it is governed by supply and demand.
Most States are experiencing increases in Medicaid enrollments under the ACA mostly in the southern and mountain regions.
In these regions, there is shortage of MD who accept Medicaid patients and the rate of participation is low due to low reimbursements to providers and delays in receiving payments from Medicaid after delivery of services.
• Primary care should be the • Usual and preferred route of entry, but it is not the only route of entry into the system. • The provision of integrated, accessible health care services by • Clinicians who address health care needs, developing a partnership with patients, the family and community.
Institute of Medicine on the Future of Primary Care
Allocative Tools
Involves the direct provision of income, services or goods to a group of individuals or organizations.
Health Care Delivery System
Is Prevention of disease and health promotion are relegated a secondary status . It is a term used often in a population that lacks health.
Tools for the practice of EBM is
Is formed of practice clinical guidelines. Evidence based practice guidelines are intended to represent "best practices" and "proven therapies." Many MD thinks the guidelines and protocols are too simple or too complicated, promote cookbook care, authors lack credibility or evidence are biased, decreases flexibility, reduces autonomy and are not applicable to the practice population.
Health Care Reform
Is the extension of health insurance to the uninsured. For system to remain solvent, it must be accompanied by control costs measures. To control costs: · Manage utilization · Limit reimbursement to providers · Employ some sort of rationing for supply of health care services Only the government can control costs in a single payer system because they finance the healthcare system for all citizens.
• The development and dissemination of technology is called technology diffusion.
It addresses when technology will be made available for use, and where it can be accessed.
• The US health care industry is the largest and most powerful employer in the nation.
It employs more than 13% of the total labor force in the United States. The growth of health care services is closely linked to the demand for health services professionals. • Physicians • All states require physicians to be licensed to practice. The licensure requirements include: • Graduation from an accredited medical school. • Awards a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
Legislative Health Policy • Policy Cycle
It involves both private and public sectors, including multiple levels of government. The formation and implementation of health policy occurs in a policy cycle comprising five components: 1. Issue raising 2. Policy design 3. Building of public support 4. Legislative decision making and building of policy support and, 5. Policy implementation - These activities are shared by Congress and interest groups.
The US system is different from other developed countries.
It is not centrally-controlled. • Central systems are less complex, less costly. • Has different payment, insurance, and delivery mechanisms. • Health care is financed both publicly and privately.
Access and Low Income
Low income mothers and their children have problems accessing the health care system Lack of insurance and live in medically undeserved areas Pregnant women in low income families are far less likely to receive prenatal care then are women in higher income Limited access for children creates problems of untreated chronic health conditions
Magnet Recognition Program
Magnet status conferred by the American Nurses Association, based on: • Quality standards being met. • Leadership that promotes nursing excellence and innovation. • Healthy work environments that attract and retain qualified nurses.
information technology
Main categories: • Clinical information systems • Administrative information systems • Decision support systems • Internet and e-health • Electronic Health Records Four basic components: • Collection and storage of health information on individual patients • Access to information by authorized users. • Knowledge and decision-support to enhance quality, safety, and efficiency. • Improve the efficiency of health care processes. • Electronic Health Records
In a single payer system,
Medicare, Medicaid, CHIP and VA are no longer needed. The government will have the right to over the availability of services, utilization and payments to providers. This will be opposed by many Americans and it is not seen as an alternative for the future.
medical tourism or health tourism
National Health Services largest concerns i means when an individual gets treated in another country, escaping monetary fees and costs.
Exclusion Statute [42 U.S.C. § 1320a-7]
OIG is legally required to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: (1) Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare or Medicaid; (2) patient abuse or neglect; (3) felony convictions for other health-care-related fraud, theft, or other financial misconduct; and (4) felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
The Systems Framework is an
Organized approach to understanding the components of the US health care delivery system.
Future workforce challenges
PCP need to be trained to function as a comprehensivist to address the needs of growing number of people with chronic conditions. PCP must be prepared to manage complex pharmacology to address end of life issues and medical ethics and lead health care teams PCP need to be trained to function as a comprehensivist to address the needs of growing number of people with chronic conditions. PCP must be prepared to manage complex pharmacology to address end of life issues and medical ethics and lead health care teams. There is a shortage of health professionals trained in geriatrics which is a challenge because of shortage of faculty in colleges and universities who are trained in geriatrics. The elderly uses most home health care services and nursing homes, accounts for hospital inpatient days and ambulatory care visits. Elderlies suffer from chronic conditions complicated by comorbidities, the use of many prescriptions and increased in mental conditions and dementia. These trends demand will have shortage of MD, nurses, therapist, social workers and pharmacists who are trained in geriatrics. Integration of a racially and culturally diverse workforce will be a challenge as the U.S. Healthcare System itself becomes more complex in taxing both patients and workers.
Free market requires
Patients have information available of various services. operates best when consumers are educated about the product they are using and patients are well informed about the decisions that need to be made regarding their care. Patients must make choices on technology, diagnostic methods, medications and interventions can be difficult because it requires an MDs input. Act as advocates, primary care providers can help reduce these gaps Health consumers have begun to take the initiatives to learn information on the internet and pharmaceutical companies advertise medications and consumers think they are available and paid by insurances. there are hidden costs making it difficult for patients to determine expenses of services ahead of time.
Provider induced demand:
Practitioners who have financial interest in additional treatments may also create artificial demand.
Improving health care services includes increasing access to and use of evidence-based preventive services. Clinical preventive services are services that:
Prevent illness by promoting healthy behaviors in people without risk factors (e.g., diet and exercise counseling) Prevent illness by providing protection to those at risk (e.g., childhood vaccinations) Identify and treat people with no symptoms, but who have risk factors, before the clinical illness develops (e.g., screening for hypertension or colorectal cancer)
Provider-induced demand:
Providers ability to create demand for additional services often deliver little or additional benefits.
Access in Rural Areas
Purchasing high tech is not efficient Reimbursements systems are based on average costs make it difficult for rural hospitals with few patients survive financially MD shortage National Health Service Corps affects only the percentage of graduating physicians who practice in shortage
There are 8 types of medical technology that affect the future of delivery of patient care:
Rational Drug Design: refers to the development of medications based on the study of the structures and functions of target molecules. The role of rational drug design, besides developing effective drugs, is to avoid having to wait for pure luck to design a new drug or to use a shotgun approach in drug design. 2) Imaging technologies: focuses on finding new energy sources and focusing an energy beam to avoid damage to tissues; detects abnormalities; faster accurate analysis using 3 D technology and higher resolutions displays 3) Minimally invasive surgery 4) Genetic mapping: to determine genes complex disease 5) Gene Therapy insertion of functioning gene into target cells to correct an inborn defect 6) Vaccines; for prophylactic basis 7) Research and developing of fluids and artificial bloods 8) Transplantation of organs such as xenotransplantation; animal tissues used to transplant humans
• Non-Physician Practitioners (NPP)
Receive less advance training than physicians. But more training than registered nurses (RN). • They do not: Engage in the entire range of primary care, or Deal with cases requiring the expertise of a physician. • Value of NPP Services Studies have confirmed the efficacy of NPPs as health care providers. Demonstrated that NPPs can provide Both high-quality and cost-effective medical care. • Show greater personal interest in patients, and Cost less. Value of NPP Services Issues that need to be resolved before NPPs can be used to their full potential are: • Legal restrictions on practice, • Reimbursement policies, and • Relationships with physicians
Cost Containment Quality of Care
Research and Policy Development -Critical Policy Issues - Government health policies are enacted to resolve or prevent deficiencies in health care delivery.
Policy Interventions:
Social or public policy affects the health of the population. - Product safety regulations, screening foods and water sources and enforcing safe work environment guards the welfare of the nation. - Vulnerable populations - Are uniquely dependent upon social and public policy to develop and implement programs that addresses basic nutritional, safety social and health care needs. - Prevention strategies to change the dynamics linking social factors to poor health.
AHRQ (Agency for Healthcare Research and Quality)
Supports research that improves the quality of health care and helps people make informed health care decisions, develops partnerships that create long term improvement in America health care, research goals measure improvements in terms of client outcome, decreased mortality, improved quality of life and cost effective quality care, and focus on safety and quality, effectiveness, and efficiency
• Allied Health Professionals
Technicians and Assistants - Receive less than two years of post-secondary education and are trained to perform procedures. - Require supervision from therapists or technologists. Ensure that care plan evaluation occurs as part of treatment. • Technologists and Therapists Learn how to: Evaluate patients, Diagnose problems, and Develop treatment plans • Education for the technologist or therapist includes: Skill development in teaching procedural skills to technicians. • Health Service Administrators • Health services administrators are
Anti-Kickback Statute [42 U.S.C. § 1320a-7b(b)]
The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients)
• However, homeland security created a new respect and recognition for public health.
The CDC will continue to play a vital role in recognizing and dealing with unexpected threats. • Public Health agencies need to forge partnerships with communities and all levels of government.
Physician Self-Referral Law [42 U.S.C. § 1395nn]
The Physician Self-Referral Law, commonly referred to as the Stark law, prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.
False Claims Act [31 U.S.C. § § 3729-3733]
The civil FCA protects the Government from being overcharged or sold shoddy goods or services. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent.
Accountability Clinicians and patients are accountable.
The clinical system is accountable for • Providing quality care, • Producing patient satisfaction, • Using resources efficiently, and • Behaving in an ethical manner.
Integrated Delivery:
The hallmark of the US health care industry or health networks represents various forms of ownership and other strategic links from hospitals, physicians, and insurers. Objective: To have one health care organization deliver a range of services. Integrated Delivery -A network of organizations that provides or arranges to provide a coordinated continuum of services to a specific population held clinically and accountable for outcomes and health status. Quality Improvement and cost control Have shown that hospitals provide higher quality of care compared to non integrated hospitals.
• Efficacy is:
The health benefit to be derived from technology. How effective technology is in diagnosing or treating a condition. • If a product or service actually produces some health benefits, It can be considered efficacious or effective.
Quest for Integration and accountability
The ideal role for primary care would be integrated health care delivery in the form of comprehensive, coordinated and continuous services offered with a seamless delivery (also termed medical home and health home for patients. Accountability means providing quality health care in an efficient matter.
Types of Outpatient Care Settings and Methods of Delivery
The myriad outpatient care and community based services that currently exist sometimes make it difficult to differentiate between structural settings in which services are provided. For example: Home health agencies may provide services that are free standing, hospital based, or nursing home based.
The fusion of market and social justice.
The principles of market justice places the responsibility for fair distribution of health care on market forces in a free economy . The principles of social justice looks at the well=being of the community over an individual needs; thus, the inability to obtain medical services because of a lack of financial resources is considered unjust. These two theories often work well together contributing into both theories in the private and public resources.
Outpatient treatment cost less than inpatient care.
The quicker discharge of patient from hospital beds under prospective and capitated reimbursement create substantial markets for outpatient services. This offset declining inpatient income.
Mortality
The supply of primary care physicians has been shown to have a direct influence on: • Life expectancy • Stroke • Postneonatal health • Total mortality
• Advanced - Practice Nurses (APN)
There are four areas of specialization for APNs: - Clinical nurse specialists (CNS), - Certified registered nurse anesthetists (CRNAs), - Nurse practitioners (NPs), - Certified nurse-midwives (CNMs)
Two patient deaths occurred at a nearby hospital when nitrogen was accidentally connected to a medical grade oxygen supply system. How will compliance with FDA regulations ensure that a similar situation does not occur in your hospital?
These kinds of Federal Register notices ask for public comment on broad issues or questions and seek data or other information. We use the information provided by the public comments to help us formulate the specific policy to be put forth in a subsequent proposed rule. Once we have issued a proposed rule and received and reviewed the public comments, we decide whether further action is needed. Based on the comments, we might decide to end the rulemaking process, to issue a new proposed rule, or to issue a final rule. If we decide to issue a final rule, we publish the final rule in the Federal Register. The final rule explains the regulatory requirements (also known as the "codified" portion), the impact of these requirements on industry or the public, and responds to the comments on the proposed rule. These regulatory requirements, or codified portion of the final rule, also are published under Title 21 of Code of Federal Regulations.
Access and the Elderly
Two main concerns: 1) Spending must be restrained to keep the Medicare program 2) Add services not currently covered or covered inadequately (i.e. nursing home coverage)
Which operating divisions does HHS oversee, and what regulations do they enforce?
U.S. Department of Health & Human Services (HHS) to enhance and protect the health and well-being of all Americans. We fulfill that mission by providing for effective health and human services and fostering advances in medicine, public health, and social services.
Justice in the US Healthcare systems
US health care system is not a market justice-based system because American health care delivery does not follow a free market principle because it also has Medicare and Medicaid. Private, employer-based health insurance for middle income Americans is driven by Market justice. Publicly financed Medicaid and Medicare coverage for certain disadvantaged groups and workers compensation programs are based on social justice. Public system reflects on organized efforts to delivery public health services within its community with a goal of improving well being of a population.
Imperfect Market Conditions
Under national health care programs, • Patients have a choice in selecting providers. Even though the delivery of services are mostly in private hands, health care is partially governed by free market forces.
Medical Model:
Under the medical model, health is defined as the absence of illness or disease. The problem with this is health exists when a person is free of symptoms and does not require medical treatment. The reason does not provide the definition of health but defines what health is not.
The delivery of quality healthcare is dependent on the myriad stakeholders in the healthcare industry.
Understanding the role of each stakeholder and the influence they have on the delivery of care is critical for understanding how the U.S. healthcare system works. The primary stakeholders can be divided into the four Ps: Patient Provider Payer Policymaker
Future of EBM
Will exceed what MDs do and will incorporate all caregivers. For example, it infuses the practice of nursing, pharmacology or disciplines associated with the practice of medicine. EMB will become the standard that will govern the multidisciplinary process of health care delivery.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
Stark Law
actually three separate provisions, governs physician self-referral for Medicare and Medicaid patients. T Physician self-referral is the practice of a physician referring a patient to a medical facility in which he has a financial interest, be it ownership, investment, or a structured compensation arrangement. Critics of the practice allege an inherent conflict of interest, given the physician's position to benefit from the referral. They suggest that such arrangements may encourage over-utilization of services, in turn driving up health care costs. I n addition, they believe that it would create a captive referral system, which limits competition by other providers. (see physician self-referral)
Critical Policies Issues re: Access to Care
aimed primarily at providers and financing, with the purpose of expanding care to the most needing and underserved population, including elderly, minorities, rural residents, low income and person with AIDS.
Government will need to cut Medicare benefits
and allow them to decide about end of life care
What types of medical procedures and discriminatory practices are protected under the Federal Health Care Provider Conscience Protection Statutes?
apply to providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds. Federal statutes protect health care provider conscience rights and prohibit recipients of certain federal funds from discriminating against health care providers who refuse to participate in these services based on moral objections or religious beliefs.
What is Health Policy?
are Public policies made by legislative, execute or judicial cours, including Supreme Court DEFINED AS: the aggregate of principles stated or unstated that characterizes the dristribution of resources, service and political influences that impact on the health of the population. are public policies that pertain all levels of health care, including policies affecting: 1) Production 2) Delivery 3) Financing of health care services Policies may affect groups or classes of individuals such as physicings, the poor, the elderly or children.
Centers for Medicare & Medicaid Services (CMS) Rulings
are decisions of the Administrator that serve as precedent final opinions and orders and statements of policy and interpretation. They provide clarification and interpretation of complex or ambiguous provisions of the law or regulations relating to Medicare, Medicaid, Utilization and Quality Control Peer Review, private health insurance, and related matters. are binding on all CMS components, Medicare contractors, the Provider Reimbursement Review Board, the Medicare Geographic Classification Review Board, and Administrative Law Judges (ALJs) of the Social Security Administration (SSA) who hear Medicare appeals. These Rulings promote consistency in interpretation of policy and adjudication of disputes.
Social Policy and Community Level Interventions
are designed to address social problems in health.
Safety Net Providers
are public health insurance programs (Medicare and Medicaid, community health centers, free clinics and hospital ER Dept. Offers comprehensive medical and enabling services (language translations, transportation outreach, nutrition and health education, social support services, case management and child care for the vulnerable populations. • Medicaid, the primary financial source for the safety net, does not allow much cost shifting.
Policy and community level interventions
are unable to reduce either social determinants.
Regulatory Tools
call on government to prescribe and control the behavior of a target group by monitoring the group and imposing sanctions if it fails to comply Some health policies are self regulatory; when MD set the standards of a medical practice and public health decides which courses should be part to graduate..
Illness vs. Disease: are not the same. Disease
can be acute, subacute or chronic.
For health care to be free,
competition exists among health care providers. T he consolidation of buying power into private health plans, however is forcing providers to form alliances and IDSs on the supply side.
To counter these effects, financing and insurance:
countries with national health insurance implement supply-side rationing that focuses on restricting the availability expensive medical technology and specialty care. Not all Americans have insurance coverage. This indirect taupe is rationing is called demand side rationing because they lack insurance and people face barriers to obtain health care that they would need. • End results: • 1. Increased health care expenditures. • 2. Some resources are wasted.
Capitation
covers all services an enrollee may need during an entire year.
• WHO
defines Health as: " A complete state of physical, mental and social well being, not merely the absence of disease." • Referred to as the biopsychosocial model of health. • defined a health care system as - All the activities whose primary purpose is to promote, restore, or maintain health.
WHO
defines health as "a complete state of physical, mental and social well-being and not merely an absence of disease defines health care system as all of activities aimed at promoting, restoring or maintaining heath
Health Care Interventions:
designed to improve the quality and efficiency of services provided and reduce disparities across groups. • Examples include: - Integrated electronic medical record systems to coordinate care for populations with multiple chronic and acute conditions. - Continuing education for pediatricians to target developmental services to children. - Educating pregnant mothers to receive regular prenatal care.
American Hospital Association Certification Center (AHA-CC)
designs and administers Certification Programs to recognize mastery of well-defined bodies of knowledge within health care management disciplines. Achieving an AHA certification demonstrates to patients, health care organizations, and the public, that the health care professional has met national performance standards specific to their job role.
In a free market for patients
directly bear the costs of services received. Moral hazard exists after an enrollee have purchased insurance that a health plan will tell you it is covered but are covered even if they don't have health insurance.
Package pricing covers s
ervices that are bundled together for one episode of care.
NCQA's Physician and Hospital Quality Certification program
evaluates how well health plans measure and report the quality and cost of physicians and hospitals.
OBRA (Omnibus Budget Reconciliation Act)
federal law that includes minimum standards for nursing assistant training, staffing requirements, resident assessment instructions, and information on rights for residents
• To overcome pluralistic interests and maximize policy outcome, diverse interest groups,
form alliances among themselves and with members of the legislative body to protect and enhance the interests of those receiving benefits from government programs. • Each member of the alliance receives benefits.
• Corporatization medical care
has become the domain of large corporations. • Managed care has become the primary vehicle for insurance and delivery. • Consolidation of purchasing power.
Package Pricing and capitated fees:
help overcome the draw backs by providing a bundled fee for a package related services.
Medicare financing
is a generation transfer system, in which current taxpayer pay for the benefits of current beneficiaries. Financing will be short.
ACA
is a major reform to achieve universal coverage.
Society for Academic Medicine:
is an independent, not-for-profit organization that has been established to identify, define and address the unmet educational needs of today's healthcare professionals.
Certification
is earned by programs or services that may be based within or associated with a health care organization. For example, a Joint Commission accredited medical center can have Joint Commission certified programs or services within neurological or orthopedics. These programs could be within the medical center or in the community.
· Chronic condition
is less severe but of long and continuous duration. The patient may not fully recovery fully. i.e. asthma, dm, htn
Health Care reform
is used to describe the extension of health insurance to the uninsured. For a system to remain solvent, expansion of coverage must be accompanied by cost control measures. • Cost control requires: • Management of utilization • Limit reimbursement to providers • Supply-side rationing of health care services • Only the government can control all three, particularly the single payer system.
· Subacute Condition
lies between acute and chronic extremes on the disease continuum but has not acute features. Requiring further treatment after a short stay in the hospital. (i.e. vents, head trauma)
Medicaid Catastrophic Act of 1988
mandates coverage for pregnant women and infants below income poverty guidelines.
Medicaid covers
many of the poor including children, low-income household and is one of the main features of Patient Protection and ACA.
NIH's
mission is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability.
CMS regulatory issuances involve
modifications to prior regulations. Compliance systems and instructions already exist for the prior regulations, and are revised as regulations are amended. For example, there are rules establishing "Conditions of Participation" for most types of Medicare providers. These rules are intended to assure patient safety and quality care. Although rules are periodically modified, affected providers are already used to, and competent in complying with the existing rules, and the inspection and other administrative mechanisms used in their enforcement. Genuinely new regulatory requirements that create brand new sets of "compliance" burdens on providers are rare.
Major change in Health policy environment was
new system of paying hospitals for medicare clients the PPS method of reimbursement
• Managed Care Organizations (MCO) consist of:
o Health Maintenance Organizations (HMO) o Preferred Provider Organizations (PPO) § They assume the risk in exchange for an insurance premium. § They assume the responsibility for obtaining health care services by contracting with providers.
E-health
o Information and services over the Internet. o Empowered consumers.
Telemedicine reduces the need for patients to travel to physician's offices
o Integration of telecommunication systems into distant care giving.
Self-insurance
o Large employers' workforces are large and diversified enough. o They can predict their own medical experience. o They can assume risk and pay all claims. o High losses covered through reinsurance.
Ambulatory Payment Classification (APC)
o Medicare's Outpatient Prospective Payment System (OPPS) o 300 procedure groups o A bundled rate to include: § Anesthesia, drugs, supplies, recovery
The Flexner Report :
pointed to widespread inconsistencies in medical education. Council on Medical Education created by the AMA: Accreditation of medical schools.
Special Vulnerable Populations
poor, uninsured, minorities and immigrants living in disadvantaged communities and receive care from "safety net" providers.
OSHA
protects the employees of companies from potential dangers of an unsafe environment. OSHA established the injury and illness prevention program that require employers to implement a system that would ensure employee compliance.
McCarran-Ferguson Act (1945)
provides that even though the insuring or provision of healthcare may be national in scope, the regulation of insurance is left to the states.
Cultural Competence:
refers to knowledge, skills, attitudes and behavior required of a practitioner to provide optima health care services to persons from a wide range of cultural and ethnic backgrounds. Health care providers need to understand the different belief systems, cultural biases, ethnic origins, family structures and many other culture-based factors that influence people who have illnesses in compliance with medical advice and respond to treatment.refers to knowledge, skills, attitudes and behavior required of a practitioner to provide optima health care services to persons from a wide range of cultural and ethnic backgrounds. Health care providers need to understand the different belief systems, cultural biases, ethnic origins, family structures and many other culture-based factors that influence people who have illnesses in compliance with medical advice and respond to treatment.
Cultural Competence:
refers to knowledge, skills, attitudes, and behaviors required of a practitioner to provider optimal health care services to persons from a wide range of cultural and ethnic backgrounds.
Access
refers to the ability of an individual to obtain health care services when needed. It's restricted in the US to those who: 1. Have health insurance through an employer. 2. Are covered under a government program. 3. Can afford to buy insurance out-of-pocket. 4. Are able to pay for services privately 5. Can obtain services through safety net providers (public health, community
Item-based pricing
refers to the costs of ancillary services that often accompany major procedures such as surgery.
EMTLA (Emergency medical treatment and Labor Act)
requires that every patient evaluated in the ER, provisions of necessary stabilizing treatment, and hospital admissions when necessary, regardless of ability to pay. Unfortunately, the use of ER depts result in cost shifting, whereby patients are unable to pay for services, privately insured individuals employers and government covers the costs of medical care provided in the uninsured ER.
Holistic Health
seeks to treat the individual as a whole person. It incorporates spiritual dimension as fourth element with physical, mental and social aspects necessary for optimal health. Literature shows that: - Religious and spiritual beliefs and practices have been shown to positively influence a person's physical, mental and social well-being they may affect incidences, experiences and outcomes of medical problems. - It affects the incidence, experience, and outcomes of common medical problems. - approach to health also is incorporated with alternative therapies into medical models.
National Ambulatory Medical Care Survey (NAMCS)
states that there are higher visits to their PCP in the metropolitan areas than rural areas; reflecting poorer access to primary care in rural area. Access to care remains problematic for these rural areas.
The American Hospital Association (AHA)
supported group hospital plans and coordinated them into a Blue Cross network. • First Physician Plan and the Birth of Blue Shield • In 1939, the California Medical Association started the first Blue Shield plan. o It was designed to pay physician fees. • By 1974, Blue Cross and Blue Shield merged. • Today they are a joint corporation and are in almost every state.
single-payer system
the government finances health care for all citizens under the Medicare, Medicaid, CHIP and VA will be no longer needed.
Coordination of care role,
the provider refers patients to specialty care; gives advice regarding various diagnosis and therapies, discusses treatment options, provide continuing care for chronic conditions. Coordination of individual health needs is meant to ensure continuity and comprehensiveness. Desire is to have a relationship over time.
Critical Policies Issues re: Providers
there are enough providers An increase of MD may result in increased health care expenditures because of provider induced demand An increase of MD will also help alleviate the shortage
The concept of planned rationing or supply side rationing is
when the government find ways to limit the availability of certain health care services by deciding how technology will be dispersed and who will be allowed access to certain types of high tech services even though basic services may be available to all.
In future, EBM
will also transcend what physicians do and will incorporate all caregivers. For example, it will permeate the practice of nursing, pharmacology, and other disciplines allied with the practice of medicine. Eventually, EBM will become the standard that will govern the multidisciplinary process of health care delivery.
Individual Private Health Insurance
§ For those who do not have group coverage § Farmers § Early retirees § Self-employed individuals § Risk is individually determined. § High-risk people are often unable to get insurance.
There is widespread consensus that the existing model of health care delivery in the United States must change. Several issues in the existing system, which is driven by the medical model of health, remain to be resolved:
· 1. There is inadequate emphasis on wellness, disease prevention, and health promotion. · 2. Despite a dramatic rise in chronic conditions and ensuing disabilities, the existing health care system focuses primarily on addressing acute illnesses. · 3. Inadequate access to primary care results in the overuse of costly emergency room services. · 4. Undue emphasis on specialization increases the cost of health care without being accompanied by noteworthy improvements in the health status of the U.S. population. · 5. The delivery of care remains fragmented, instead of continuous and coordinated.
Insurance: Its Nature and Purpose • Insurance
· A mechanism to protect against risk. Risk is the possibility of substantial financial loss from some event. • Insured (enrollee or beneficiary) o An individual protected by insurance. • Insurer o An insurance agency that assumes the risk. • Underwriting • Evaluates, selects/rejects, classifies, and rates risk. • Premium • Amount charged by the insurer to provide coverage. • Cost sharing by employers and employees. • Insurance: Its Nature and Purpose
Medicare Hospital insurance (Part A) SNF benefits:
· Eligibility begins after 3 consecutive days of hospital stay. · 100 days maximum in SNF. · First 20 days at no charge to the beneficiary; copayment applies from day 21. · Public Financing
Medicare Hospital insurance (Part A) Covers:
· Inpatient services, · Short-term convalescence and rehabilitation in a skilled nursing facility (SNF), · Home health · Hospice · Public Financing
Medicare Home health benefit:
· Patient must be homebound, and · Require intermittent or part-time skilled nursing care or rehabilitation care.
Medicare Hospice benefit
· Patient must be terminally ill. · Only a token copayment is required.
• Medicare Supplementary Medical Insurance (SMI) - Part B Covers:
· Physician services · Hospital outpatient services (surgery) · Diagnostic tests · Radiology, etc. - Also covers certain screening and preventive services. - An Annual Wellness exam is provided for under the ACA of 2010 (no out-of-pocket costs are incurred) - For most services: » An annual deductible must be paid. » 80:20 coinsurance.
Indicators of Health:
· Self-reported health status · Life Expectancy · Morbidity · Mental Well-being · Social Functioning · Functional limitations · Disability · Spirit wellbeing. • Absence of illness and disease • Optimum health exists when - A person is free of symptoms and does not require medical treatment. - " A state of physical and mental well-being that facilitates the achievements of individual and societal goals"
Future work force challenges
· Shortage of health care professionals · To have a successful model of health care delivery system to be highly effective must have trained professionals. · Nurses should practice to their full extent through education and training. · Licensing requirements rules governing scope of practice should be allowed across states for nurses who have masters or doctoral degrees · Residency programs for nurses need to incorporate training in community health, public health and geriatrics
Medicare
· Title 18 of Social Security Act An Entitled Program for o People contribute through taxes and are entitled regardless of income and assets. · A federal program Administered by CMS, an agency under the U.S. Department of Health and Human Services (DHHS) Finances medical care for: 1) Those 65 years or older 2) Disabled people who are entitled to Social Security benefits 3) Those with end-stage renal disease
Acute Condition
· is relatively severe, episodic for short duration often treatable.
Illness vs. Disease: are not the same. Illness is
· is what a person may feel like pain, discomfort, weakness, depression or anxiety.
Alternative Medicine
• "Complementary or alternative medicine" • Not endorsed by Western medicine • Nontraditional Treatments include: • Homeopathy • Herbal formulas • Products as preventive and treatment agents • Acupuncture • Meditation • Yoga exercises • Biofeedback • Spiritual guidance • Prayer • Chiropractic
U.S. health care is mainly a private industry, but receives a large amount of government financing.
• -Government finances health care mostly for the poor (Medicaid) and the elderly (Medicare). • -The middle class must depend on private insurance.
Urgent Care Centers
• Accept patients without appointments. • Wide range of routine services. • First come, first serve basis.
Countries with health systems oriented toward primary care:
• Achieve better health levels, • Higher satisfaction with health services, • Lower expenditures in the delivery of health.
• International Health Regulations are binding on 194 countries
• Aimed at preventing and responding to acute public health risks that can threaten people in other countries.
Deductibles
• Amount the insured pays first before benefits are paid by the plan • Paid annually - Copayment • Money paid out-of-pocket each time health services are received • % share is referred to as coinsurance
• MDs
• Are trained in allopathic medicine, which views medical treatment as • Active intervention to produce a counteracting reaction in an attempt to neutralize the effects of disease.
Individual-level Interventions
• Attempts to intervene and minimize the effects of negative social determinants on health status. • Altering behaviors that influence health is often the focus of these individual-level interventions - (e.g., reduce smoking and encourage exercise)
• Americans have long rejected national health care, mainly because it runs contrary to traditional American beliefs and values.
• Capitalism • Individual achievement • Little involvement from the government • Disenchantment with national programs such as the public education system
• Ambulatory Care:
• Care rendered to patients who come to the: • Physician's office, • Clinics • Outpatient surgery • Mobile diagnostic units and home health • Take services to patients. There has been extraordinary growth in the: • Volume of outpatient services and • Emergence of new types of settings • Type and ownership of non-hospital-based facilities offering ambulatory care
Main types of outpatient services in hospitals:
• Clinical (typically for uninsured or research) • Surgical (same day surgery), • Home health (post-acute care and rehabilitation), • Women's health, and • Traditional emergency
Public and Voluntary Clinics
• Community Health Centers • Authorized in the 1960s to serve the medically underserved. • Operates under the Bureau of Primary Health Care, U.S. Public Health Service, U.S. Department of Health and Human Services. • Free Clinics • Modeled after the 19th-century dispensary. • Provides general ambulatory care serving the poor. • Three characteristics: • A. Services provided at no or a nominal charge. • B. Not directly supported or operated by the government or the health department. • C. Services delivered by trained volunteers.
Integrated cares concept of:
• Comprehensive • Addresses health problems at any stage of a patient's life cycle. • Coordinated • Combines health services to best meet the patient's needs. • Continuity of Care • Care over time by a single provider or a team of health care professionals that provide a seamless process of care. • Delivered care over time by a single provider
long term care
• Consists of medical and nonmedical care that is provided to individuals who are chronically ill or who have a disability. • Provides support services for ADLs, and is delivered across venues, including patients' homes, assisted living facilities and nursing homes. • LTC services is not covered by Medicare. • Medicaid covers different levels of LTC • By 2020, more than 12 million Americans are projected to require LTC.
Medicare • Prescription Drug Coverage (Part D)
• Created under the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003. • Available to those who have Part A or B. • Monthly premium must be paid. • Annual deductible applies.
Medical Services in Postindustrial America (Overview)
• Development and growth of the medical profession. • Development and growth of hospitals. • Emergence of private health insurance. • Creation of public health insurance programs: Medicare and Medicaid. • American Medical Association • Educational Reform • Development of Hospitals • Urbanization led to the concentration of medical practice in cities and towns. • Office-based practice began to replace house calls. • Medical Services in Postindustrial America • Medicine became driven by science and technology, • Lay people could no longer deliver legitimate medical care.
• Ambulatory care constitutes:
• Diagnostic and therapeutic services and treatments provided to the "walking" (ambulatory) patient. • The term can be used synonymously with "community medicine." • The geographic location of ambulatory services is intended for the purpose of serving the surrounding community, providing convenience and easy accessibility.
Employer based health insurance
• During World War II, employees accepted employer-paid health insurance to compensate for the loss of raises. • The US Supreme Court ruled in 1948 that employee benefits were a legitimate part of union-management negotiations. • In 1954, Congress made employer-provided health coverage nontaxable. o This was equivalent to getting more salary without having to pay taxes. • Failure of National Health Care in the US • Relative political and labor stability in the US. • Anti-German feelings and criticism of social insurance during World War I in 1917. • Rhetoric that equated national health insurance to socialized medicine—large-scale government-sponsored expansion of health insurance.
Social and Market Justice Approaches
• Equal production, distribution, and, consumption of health care • No society - Has a perfectly equitable method to distribute limited resources. • Any method of resource distribution leaves some inequalities.
World Health Organization's Definition of Primary Health Care
• Essential health care based on scientific methods. • Universally accessible and acceptable. • Affordable cost to maintain health at every developmental stage. • The first level of contact. • Bringing health care as close as possible to where people live and work. • Part of a continuing health care process.
Employer-based Health Insurance
• Failure of National Health Care Proposals • Creation of Medicaid and Medicare • Workers' Compensation: was the first broad-coverage health insurance in the United States. • Was originally designed to make cash payments to workers for wages lost because of job-related injuries and disease. • Later became compensation for medical expenses, and death benefits for survivors were added. Was a trial balloon for the idea of government-sponsored health insurance.
Decentralized Role of the States States develop and implement health policies involving:
• Financial support (care and treatment) for the poor and disabled o Medicaid, SCHIP • Quality assurance, practitioner and facility oversight o Licensure and regulation • Regulation of health care costs and insurance carriers • Health personnel training • Authorization of local government health services
Surgi-centers
• Freestanding, independent of hospitals • Full range of services for surgeries • Outpatient, no overnight
AHRQ (Agency for Healthcare Research and Quality)
• Funds patient outcomes research teams (PORTS): That focuses on certain medical conditions That are part of the medical treatment effectiveness program which has 4 elements: 1. Medical treatment effectiveness research 2. Development of databases for research 3. Development of clinical guidelines 4. Dissemination of research findings and clinical guidelines
Principle Features of US Health Policy
• Government as Subsidiary to the Private Sector · It's fragmented, (the employed are covered by voluntary insurance provided by their contributions) · Incremental · Piece-meal reform, (Medicaid program mandates coverage for pregnant women, children in two parent families meeting income eligibility requirements and mandates coverage for children aged 5 or younger who meet income eligibility requirements) · Pluralistic (special interest), · Decentralized role for the states, · And the impact of presidential leadership. ·
Conflicting Realities of Cost and Access
• Health care costs will escalate further under the ACA. Many will remain uninsured and falls short of addressing the issue of access. • The dream of Universal access cannot be done without supply-side rationing to control costs. • Access also requires the adequate health delivery infrastructure will be overburdened: • Shortage of primary care physicians. • Many physicians currently do not accept Medicaid. • Obesity epidemic rise in chronic conditions, and an aging population.
Effects on Health Care Financing and Insurance
• Health care financing produces effects that goes beyond providing access and paying the providers of care. Economic perspective of financing: • Working Americans finance their own health care and subsidize it for those who cannot afford it. • Employer-paid insurance is an exchange for more salary. • Taxes support public programs. • Effects of Financing and Insurance demand for services • Consumers will have higher utilization of health care when the services are covered by insurance referred to as moral hazard (excessive demand) • Covered services expand rapidly • Growth of medical technology
If the ACA of 2010 Fails
• Health care reform will no longer remain a dead issue. • Possible alternatives would likely come from the three bills or proposals that were introduced by Republican legislators in 2009. • 2009 Republican proposals included: • State-based or national exchanges to create competition for the purchase of health insurance. • Auto enrollment and tax incentives • Tax credits or vouchers • Block grants to states to cover Americans with preexisting conditions • Medicaid reform • Competition among Medicare Advantage plans • Subsidies for low-income families • Tort reform • Assure that consumer have access to price information prior to treatment so they can make informed decisions about their care.
Morbidity
• Higher primary care physician supply has been associated with • Higher birth weights and • Lower infant mortality • Early detection of colorectal cancer • Better-controlled hypertension
Scope of Outpatient Services
• Hospital inpatient services continues to decline. • Executives see Ambulatory Care as an essential, no longer a supplemental, service line. • Hospital survival can depend heavily on Ambulatory Care. • Competition from home health agencies, Ambulatory Care, urgent care, outpatient surgery.
Expected that specialist would perform better than generalist and achieve better outcomes for those conditions • Evidence exists that:
• Hospitalizations for ambulatory care-sensitive conditions are less frequent when primary care is strong.
Outpatient and Primary Care Services
• Hospitals were major players in outpatient services as the range of services expanded. • Health care delivery has increasingly shifted outside of expensive acute care hospitals. • Hospital labs and diagnostic services are better equipped. • Solo practices consolidated to cope. • Government agencies have sponsored limited outpatient services to meet the needs of underserved populations.
• Challenges of access:
• If the Patient Care Act and Affordable Care Act survives, cost and access problems will pose challenges: • A mere expansion of health insurance will not adequately address the issue of access without a significant reform of the delivery infrastructure. • A new model of care delivery that emphasizes prevention of disease, management of chronic conditions, and individual responsibility is urgently needed. • • The nation also faces critical workforce challenges. Moreover, the United States must enhance the role of public health and bolster preparations to protect Americans against local, national, and global threats, both natural and human-made. • Medical technology presents numerous opportunities, but its development and use must be judicious, with the goal of achieving greater cost-effectiveness in health care delivery. These daunting challenges cannot be met unless the nation gets serious about putting its financial house in order.
l Future Workforce Challenges - 1
• In light of workforce shortages, integrate talents and expertise of trained professionals. • Nurses should be allowed to practice to the full extent of their education and training. • Unify licensing requirements across states for advanced practice nurses. • Nurses need to be trained in community health, public health, and geriatrics. • PCPs need training to function as comprehensivists. • PCPs need preparation to managed complex pharmacology, understand end-of-life issues and medical ethics, and lead health care teams.
Future of Health Care Delivery: Issues with the current system because of:
• Inadequate emphasis on wellness and prevention. • The existing health care focuses primary on addressing acute illnesses. • Inadequate access to primary care - overuse of ERs. • Undue emphasis on specialization increases the cost of health care without being accompanied by noteworthy improvements in the health care status. • Delivery of care remains fragmented instead of continuous and coordinated.
• Cost-Effectiveness
• Initial medical treatment - benefits generally exceed costs. • Additional treatments begin to lower the benefits in relation to costs. • At some point (optimal point), additional benefits equal the additional costs. • Beyond the optimal point, additional interventions become wasteful.
• Utilization Controls
• Inpatient hospital stay has been strongly discouraged by various payers. • Prior authorization (pre-certification) required, minimizing length of stay.
Insurance Coverage
• Insurance insulates both patients and providers from the utilization and cost of health care. • Lack of checks and balances in the U.S. to determine the appropriateness of high-cost services.
Global Threats and International Cooperation
• Intensified efforts will be necessary to combat infectious diseases. • Immigration • International travel • Shipments from overseas • International cooperation will be necessary on two fronts: • Early identification of infectious threats and rapid response to contain spread of disease. • Disasters will call for international assistance and cooperation.
The first two are suppliers of policies demanded by the third.
• Interest Groups • Most effective demanders of policies. • Adamant about resisting any major change. • They combine and concentrate the resources of their members. Examples of health care interest groups: • American Medical Association (AMA), • American Association of Retired Persons (AARP) • American Hospital Association
point of entry
• Into the health care system where health care is organized around primary care. • The first contact a patient makes with the delivery system. • Domains of Primary Care • Role of a gatekeeper • Patients cannot see a specialist or be admitted without a physician referral. • This protects patients from unnecessary procedures and overtreatment. Goal: • Bring point of entry as close to the population as possible. • "Community-based" • Convenience • Accessibility
Medicare
• It covers anyone over the age of 65. • covers disabled on Social Security and those with ESRD, regardless of age.
• Cost-effectiveness or cost-efficiency:
• It evaluates the safety and efficacy of a technology in relation to its cost.
American Medical Association
• It helped galvanize the profession and protect the interest of physicians. The concerted activities of physicians through the AMA is referred to as "organized medicine": • Gained power by controlling medical education. • Supported states in establishing medical licensing laws. • Discouraged employment of physicians by hospitals and insurance companies.
Medicaid benefits vary from state to state.
• It is means-tested. • Confines eligibility to those below an income level.
Long Term Care (LTC)
• LTC services are provided in both institutions and community-based settings. • Most LTC is provided informally by family and friends. LTC includes: - Home health brought to a person's home. - Home-delivered meals - Minimal assistance in residential settings. - Care in a nursing home
States have broad, legal authority to regulate the health care system. The state can:
• License and regulate health care facilities and professionals. • Restrict the content, marketing, and price of health insurance. • Set and enforce environmental quality standards. • Enact controls on health care costs. States finance much of the health care for the poor. Most incremental policy actions originate at the state level. 24 states created special program called insurance risk. State-initiated programs address vulnerable populations. • Some argue there is too much state control over health policy decisions.
stop loss
• Limits total out-of-pocket costs.
The Patient Protection and Affordable Care Act (ACA)
• Mandates individuals to have health insurance or pay a tax penalty. • Employers with 50 or more employees are mandated to offer insurance coverage or pay a "free rider" tax. • Medicaid is expanded to cover all people at or below 133% of the federal poverty level. • Mandate states to establish health insurance exchanges. • Tax credit for small businesses with fewer than 25 workers. • It is illegal to deny health insurance to people with preexisting medical conditions. The Patient Protection and Affordable Care Act (ACA) • To cost at least $150 billion in 2016 • Approx. 21 million will still be left uninsured • Reimbursement Methods • Third-party payers o Insurance companies, managed care organizations, BlueCross BlueShield, government o Reimbursement o Payment made by third-party payers to the providers of services.
Medical Services In Preindustrial America
• Medical education was not grounded in science. • Practice of medicine had a domestic rather than a professional character. • Medical practice was more a trade than a profession. • Medical institutions were primitive. • A few isolated hospitals could be found in the largest cities. • Health insurance did not exist.
3 emerging models discussed previously in the book:
• Medical home model: Patient-centered care that emphasizes chronic care by employing evidence-based guidelines, using appropriate health information technology, and consistently and reliably meeting the needs of patients while being accountable for the quality and value of care provided. • Community-oriented primary care: Blending primary care delivery with a population-based approach to identify and address community health problems. • Accountable care organizations: Integrated groups of providers who take responsibility for improving the overall health status, efficiency, and satisfaction with care for a defined population.
Resource-Based Relative Value Scale (RBRVS)
• Medicare developed the program to reimburse physicians according to a "relative value" assigned to each service. • Based on time, skill, intensity • Managed care approaches • Discounted fees Used by PPOs
Medical Practice
• Medicine was a trade without today's prestige. • It did not require a rigorous course of study, clinical practice, residency training, board exams, or licensing. • Anyone, trained or untrained, could practice as a physician. o E.g., barbers did bloodletting • The clergy often combined medical services and religious duties. • Many physicians had a second occupation because income from medical practice alone was inadequate to support a family.
Medicare
• Medigap: Private insurance used to cover gaps in Medicare. • Medicare has four parts.
Public Health's mission is to improve and protect the community. The National Public Health Performance Standards programs identifies 10 essentials in the public system needs to deliver:
• Monitoring health status to identify and solve health problems. • Diagnosing and investigating health problems and hazards. • Informing and educating people about health problems and hazards. • Mobilizing the community to solve health problems. • Developing policies to support individual and community health efforts. • Enforcing laws and regulations to support health safety. • Providing people with access to necessary care. • Assuring a competent and professional health workforce. • Evaluating the effectiveness, accessibility, and quality of personal and population-based health services. • Performing research to discover innovative solutions to health problems.
Tertiary care
• Most complex level of care for conditions that are uncommon • Usually institution-based • Highly specialized • Technology-driven • Rendered in large teaching hospitals • May be long-term care • (i.e., Trauma, burn treatment, NICU, transplants, open heart surgery)
Partnership between a patient and a clinician.
• Mutual trust, respect, and responsibility are the hallmarks of this partnership.
Community-Based Interventions
• Neighborhood poverty, the presence of local health and social welfare resources, and societal cohesion and support contribute to the level of inequalities in a community. • Community partnerships - Reflect the priorities of a local population and are often managed by members of the community they minimize cultural barriers and improve community buy-in to the program. - Addressing the problems using community approaches (i.e. resources that directly help the needy member of the community can provide business and local partners great incentives - Community solutions benefit from participatory decision making
• Technologic Factors
• New diagnostics and treatments and less invasive surgical methods has made it possible for provide some services in an outpatient settings which has become cost effective.
The main characteristics of U.S. Health Care System:
• No Central Governing Agency; Little Integration and Coordination • Technology-Driven and Focuses on Acute Care • High on cost, Unequal in Access, and Average in Outcomes • Delivery of health care under imperfect market conditions • Fusion of Market Justice and Social Justice • Multiple players and balance of power • Integration and accountability • Access to health care services selectively based on insurance coverage • Legal risks influence practice behaviors.
Ambulatory Long-Term Care Services
• Nursing homes • Case Management • Coordination and referral • Find most appropriate care • Adult Health Day Care • Complements informal care provided at home at a center during the day.
. Private practice
• Office-based physicians • Form the backbone of ambulatory care. • It's most primary care services. • Limited examination and testing. •
• Social factors
• Patients have a strong preference for • Receiving health care in home and community-based settings. • Giving people a sense of independence and control over their lives and important for quality of life. • Primary Care
• Generalists and Specialists
• Physicians trained in • Family medicine/general practice, • General internal medicine • And general pediatrics • Are considered primary care physicians or generalists. • Specialists must seek certification in an area of medical specialization. • This requires additional years of advanced residency training, followed by several years of practice in the specialty.
Primary Care
• Plays a central role in a health care delivery system. • Focuses on the type or level of services.: • Prevention • Diagnostic • Therapeutic services • Health education • Counseling, and • Minor surgery • An approach to providing health care. • Not a set of specific services.
Countries with weak primary care infrastructures incur:
• Poorer health outcomes and • Higher health care costs.
Evidence-Based Health Care
• Practice variations have both quality and cost implications without clinical justification. • The goal of EBM is to increase value medical care. • Quality can be improved while reducing costs, thereby increasing the value of medical care, by reducing misuse and overuse. • The tools used for practice of EBM is mainly a form of clinical practice guidelines - 'best practices' or 'proven therapies.'
For Primary Care to be effective:
• Preventive interventions should be carried out in primary care. • Continuity of care with one provider is positively associated with primary preventive care. • The likelihood that disadvantaged children will be brought for regular health visits is greater with a good primary provider. • Early detection of breast cancer is enhanced with an adequate supply of primary care physicians.
History of Health Insurance
• Private health insurance is also called "voluntary health insurance." • Publicly financed Medicare and Medicaid were created to meet the medical needs of the elderly and the poor respectively. • Workers' Compensation • Rise of Private Health Insurance • First Hospital Plan and the Birth of Blue Cross • First Physician Plan and the Birth of Blue Shield
Hospice
• Provides services for the terminally ill with life expectancy of six months or less. • Provides services that address the special needs of dying persons and their families. • A method of care, not a location. Services include: • Medical, psychological, and social services • Provided in a holistic context and • Access to supplies • Two Areas of Emphasis • Palliation - Pain management • Psychosocial and spiritual support
l Future Workforce Challenges - 4
• Racially and culturally diverse workforce • More than ½ of U.S. will be nonwhite by the middle of this century. • Skills in cultural competence will be necessary. • Implications for outcomes of care due to: • Differences in belief systems • Cultural biases • Family structures • Ethnic origins • Other factors that affect how people experience illness, comply with medical directives, and respond to treatment
Retrospective reimbursement
• Rates are set after evaluating the costs retrospectively. • Historical costs are used to determine the amount to be paid. • Perverse incentives.
Frontiers in Clinical Technology
• Rational drug design • Imaging technologies • Minimally invasive surgery • Genetic mapping • Gene therapy • Vaccines • Artificial blood • Xenotransplantation
Social and Medical Points of Intervention
• Reductions in health disparities are obtainable through interventions in both social and medical domains. • Interventions are grouped according to four strategies: 1) Social or medical care policy interventions. 2) Community-based interventions. 3) Health care interventions. 4) Individual interventions.
• Safety
• Safety considerations are designed to: Protect patients against unnecessary harm from the use of technology. • Primary benchmark: Benefits must outweigh any negative consequences.
Home Health
• Service brought into the home • Nursing care; • Change dressings • Medication monitoring; • Bathing • Short-term rehabilitation (PT, OT, ST) • Homemaker services (meal prep, shopping, transportation, medical equipment, chores • Durable medical equipment (wheelchairs, oxygen, beds, walkers, commodes) • Alternative would be institutionalization • Maintaining people in the least restrictive environment possible
Future Workforce Challenges - 3 • With the aging of the population, training in geriatrics for a variety of health care professionals has become a critical challenge.
• Special challenges in eldercare: • Chronic conditions and comorbidities • Use of multiple prescription drugs • Increased prevalence of mental conditions and dementia
• Physicians
• Successful completion of a licensing examination governed by either the National Board of Medical Examiners, or the National Board of Osteopathic Medical Examiners. • Completion of a supervised internship/residency program.
Future Model of Care Delivery • Lesser-known models being tested:
• Teamlet Model: A two-person team consisting of a clinician and an allied health professional who functions as a health coach and coordinates the patient's overall care. • Connected Health Care Model: Delivery of health care that combines communication technology, patient self-management, and distant home monitoring technology. • Objective: Avoid unexpected crises for chronically ill patients.
Virtual visits
• Telemedicine and Remote Health Services • Distance medicine • Issues: Licensure across state lines. Who is legally liable. Lack of reimbursement.
Virtual visits
• Telemedicine and Remote Health Services • Distance medicine • Issues: Licensure across state lines. Who is legally liable. Lack of reimbursement. Unsubstantiated cost effectiveness . • Remote in-home monitoring is proving to be cost-effective. • Utilization of Medical Technology • High-tech procedures are
Telephone Access
• Telephone triage • Giving expert opinion and advice to the patient, especially during hours when a physician's office is usually closed. • Nurses have: • Access to patient records. • Guidance using protocols. • Consults with physicians.
Community Oriented Primary Care
• The 1978 International Conference on Primary Health Care: • Concluded that people in the world had little control over their health, • Positive outcomes occur when people have ownership of programs that address their needs. • Positive outcomes require a partnership between health providers and the communities. • Incorporates primary care with a population-based approach to identify and address community health problems.
l The Future of Health Reform The Cost Control Imperative:
• The ACA has few provisions in the legislation addresses control of overall health care expenditures. • Some companies feel that they are better off under the ACA, current trends, will lead to unsustainable costs burden on U.S. companies hinder their ability to compete globally. • Employers have so far responded by shifting costs to their employees. • A national debt crisis threatens Medicare and Medicaid. • Deficits will be a burden on future generations. • Higher taxes • Government does not cut expenses, the politicians in the U.S. may be left with no choice except to take drastic "austerity measures" a term used to describe spending cuts.
• Both AHRQ and NIH provide financial support to private and public institutions for biomedical research.
• The AHRQ also supports research on quality, cost, and access.
Technology-Driven and Focuses on Acute Care
• The US invests in research and innovations in new medical technology. • Growth in science and technology helps create demand for new services, despite of the factors contribute to increase of demand for expensive technology care. (i.e. patients often assume the lastest innovations represents the best care and many want to try the latest gadgets. Even if having the modern equipment there is pressure to recoup their investments made in technology.
Evidence-Based Health Care
• The Use of clinical practice guidelines is not widespread in the community. • Reasons for resistance from physicians to use EBH is because they feel that it is too simple or too complicated • Promote "Cookbook care" • Lack creditable authors or evidence • are biased • Decreased flexibility • Reduced autonomy • Does not apply to practice population
Social Determinants of Health
• The framework includes: • Demographics, personal behaviors, and community-level inequalities and their defining influence on health. • Personal demographics directly contribute to vulnerability levels. (e.g., race/ethnicity or age) • Socioeconomic status is defined by education, employment or income, both individual and community level socioeconomic status have independent effects on health • Personal behaviors: smoking or exercise • Social and income differences are contributions to health disparities (i.e. discrimination the difference in one's action towards another individual or group based on their personal characteristics.)
Consumer Groups
• The interests of consumers are not uniform. • Consumers do not have enough financial means to organize and advocate for their own best interests.
• Safe Medical Devices Act of 1990
• The law requires reporting of all injuries and deaths resulting from medical devices. • Research on Technology
Medical Care Determinants
• The medical care system focuses primarily on treating illness or poor health. Preventative Care is an exception because problems with access and quality of care exists • This framework includes: - A broad spectrum of medical care services and interventions to improve health, - Some services through preventive and primary care contribute to general health status others are more influential in end-of-life mortality • (specialty and long-term care) Patients will likely come across issues such as poor continuity of care and insufficient coordination of care for multiple needs.
Fragmented, Incremental, and Piecemeal Reform
• The poor are covered through Medicaid via federal, state, and local revenues. • Special populations, such as Veterans, Native Americans, and the armed forces, have coverage provided directly by the federal government.
Market Justice
• The production of health care is determined by now much the consumers are willing and able to buy at the market price. • It follows that in a free market system individual without enough income or uninsured will face financial barrier. • Those who are not able to pay have barriers to health care. - The prices and ability to pay the types of services people consumes. These limitations on obtaining health care are referred to as Demand side Rationing or price rationing. • Focuses on individual rather than a collective responsibility for health.
• Pharmacists
• The role of pharmacists has expanded from The preparation and dispensing of prescriptions to include: Drug product education. Serving as experts on specific drugs, drug interaction, and generic drug substitution.
Patients are responsible for
• Their own health to the extent of influencing it. • Being judicious in the use of resources.
• Social Justice"The Good Society"
• Theory is at odds with capitalism and market justice. • The fair distribution of health care is society's responsibility. - Goal can be achieved by letting the government take over the production and distribution of health care. - Should be collectively financed and available to every citizen regardless their ability to pay - Public health also has social justice orientation over the production and distribution function. an inability to obtain medical services because of financial barrier resources is considered unjust.
Costs of Care • Areas where primary care is stronger, as measured by PCP to population ratio is higher:
• There are much lower total health care costs than in areas where there are fewer physicians.
• Utilization of Medical Technology
• To control medical cost, other nations limit the availability and use of technology through supply-side rationing. • Implementing these measures would be contrary to the fundamental beliefs and values of Americans. • The US spends more on medical R&D than any other country in the world.
Integrated delivery systems
• To counteract managed care's power. • Hospitals expanded services in other areas. • Large integrated health care organizations can provide a full array of health care services. • Physicians have consolidated into larger group practices and hospital partnerships. • Information revolution
Focusing on Determinants
• To improve the nation's health and resolve disparities among its vulnerable populations, • A framework embodying the social and medical determinants because it is the combination of these factors that ultimately shapes health and well-being.
• Both MDs and DOs use
• Traditionally-accepted methods of treatment, • Including drugs and surgery. • Osteopathic medicine, practiced by DOs, emphasizes the musculoskeletal system, such as correction of joint tissues.
High-Deductible Health Plans (HDHPs)
• Two main types: · HDHP/HRA · HDHP is combined with a health reimbursement arrangement. · Employer-financed account. · Tax exempt payments made for qualified medical expenses.
Public Health Service
• Typically provided by • Local health departments. Services include: • Well-baby care, • Venereal disease clinics, • Family planning services, • Screening and treatment for tuberculosis, • Ambulatory mental health
Medical Training
• Until about 1870, medical training was largely received through an individual apprenticeship with a practicing physician rather than through a university. • two-year Doctor of Medicine degree. • There were only about 42 such schools in 1850. • To train a larger number of students than was possible through apprenticeship, • Mainly out of economic necessity, American physicians began opening medical schools.
Capitation
• Used by HMOs. • Per member per month (PMPM) fee to cover all needed services. • Prudent delivery of services. • Minimize provider-induced demand.
Prospective reimbursement
• Uses certain pre-established criteria to determine in advance the amount of reimbursement.
Secondary care
• Usually short-term • Sporadic consultation from a specialist • Includes hospitalization • Routine surgery • Rehabilitation
Premium cost sharing
• Utilized by private insurance; deducted from payroll, insured pays for a portion of cost of medical services out of their own pocket -
The key characteristic of market justice and their implications are
• Views health care is good for the economy • Free market conditions of health services delivery • Markets are more efficient in allocating health care resources fairly • Production and distribution of health car are determined by market-based demand • Medical care distribution is based on people's ability to pay. • Access to medical care is viewed as an economic reward of personal effort and achievement.
Types of Outpatient Care Settings and Methods of Delivery
• Visits are short in duration. • Solo practices merged into groups due to: • Uncertainties of the health care delivery system, • Competition from large health organizations, • High cost of establishing a new practice, • Complexity of billings and collections • Increased external controls over private practice. • Functions particularly in inner-city areas • the community's safety net, providing primary care to the indigent and uninsured. • A key source of profits for hospitals.
Free-standing Facilities
• Walk-in Clinics • Ambulatory care from basic primary to urgent care • Nonroutine, episodic basis
Medicare Part A
• Was designed to use Social Security funds to finance hospital care.
Medicare Part B
• covers physicians' services through government-subsidized insurance. • The elderly would pay part of the premiums.
Evidence-Based Health Care's full potential has not yet been realized but ongoing work is seeking to:
• improve and implement practice guidelines and their adherence: • Practitioners, payers and policy makers need to become Stakeholder • Use of computer-based models will help incorporate EBM into medical decision making • Robust research designs; using Evidence Based Medicine as their backbone • Practice guidelines according to new evidence • Future practice guidelines must Incorporate economic analysis. Mounting health care expenses will pressure the society to make rational choices on certain types of services • Incorporate financial incentives in reimbursement • EBM will eventually have physicians do and will incorporate all caregivers. For examples, it will infuse the practice of nursing, pharmacology, and other disciplines, allied with the practice of medicine • EBM will become the standard that will govern the multidisciplinary process of health care delivery
Domains of Primary Care
• point of entry • coordination of care • essential care • integrated care • accountability
Market justice:
• proposes free economy can best achieve fair distribution of health care. • Medical services distributed on the basis of people's willingness and ability to pay. In other words, the people are entitled to purchse a share of goods and services that they value.
