Health Care Org. and MGMT Quiz #2
When you think about technology in health care, what is the innovation or outcome you get more excited or hopeful about?
When I think about technology in health care, I get excited about the outcomes that it could potentially produce. I think it can, and that we should, find ways to reduce costs using technology instead of increasing costs because it is possible and that is one outcome I get excited about. I also get excited thinking about how many lives can be saved and affected by using technology in the right ways. There are already so many new devices and advances in technology, it will be crazy to see what they come up with in the next decade or so, because we already know SO much about technology and about health care in general and what it can do to change the way health care is delivered as well as how much it improves the quality of people's lives and experiences within health care. Technology is a very powerful and innovative thing, and when used in the correct ways, it could really change the way our health care system works, and that makes me both hopeful and excited to see what the future of technology in health care has to offer.
Health Administration
Your role in the system: Trends and Expectations
Clinical Trial
a carefully designed research study in which human subjects participate under controlled observations
Residency
graduate medical education in a specialty that takes the form of a paid on-the-job training, usually in a hospital
REVIEW FIGURE 6.1 ON PAGE 137
illustrates the relationships between financing, insurance, access, payment, and total expenditures
Financing
refers to any mechanism that gives people the ability to pay for health care services - for most people, financing is necessary to access health care - free clinics, community health center, hospital emergency departments are how people with little or no means of finance get access to health care -- these are not available in all geographic settings though - before ACA 13.4% or 42.0 million people were uninsured -- 16.4 million have gained insurance since - complexity of financing is one of the primary characteristics of medical care delivery in US - most health insurance is privately financed - some people are eligible for tax-supported public health insurance (medicaid and medicare; veterans affairs (VA); military health system) - under the ACA the public sector's role in providing health insurance has increased but by no means fills the gaps enabling all Americans to have health insurance - burden of health care expenditures will probably shift to taxpayers - financing includes the various methods of paying providers for the health care they deliver - two functions encompassed in financing: 1) purchase of health insurance 2) payment for the services delivered to insured patients - (CMS) = centers for medicare and medicaid services - the actual payments to providers of care are handled in numerous ways - most cases --> patients directly pay a relatively small portion of the total cost of the services they receive - various private and public insurance plans pay the bulk of the cost of health care and they use several different types of payment mechanisms - the financing of health care through the various private and public sources ultimately aggregates into national health expenditures, which comprise the total amount of money a nation spends on health care delivery and other health-related activities - private employers and the govt. are the primary finances of health care in the US - from an economic perspective, one could argue that Americans, through employment and taxes, finance their own health care and subsidize health care for those who cannot afford it - general taxes = for medicaid - tax deducted from paycheck = for medicare
How are services paid?
- "bundled payments" combine physician and hospital payments for a specific episode of illness - Resource-based relative value scale - Medicare physician services - DRGs APCs RUGs/ prospective payment - Medicare facilities - Medicaid = per diem for facilities (also prospective) - Private insurers offer negotiated rates -- TCOC (also called cared shared savings contract) --- ACO like mechanism but for private insurance --- Total cost of care contract -- ACO --- How to build Medicare My Notes: Opposite of fee for service Different payers use slightly different mechanisms and call them different names Medicare part B = physicians Medicare part A = hospital
Delivering Value
- "what is appropriate?" rather than, "what is possible?" - VALUE: improved benefits at lower costs and health risks-- is becoming important to those who finance health care, including private employers, govt., and managed care organizations - value can be increased by improving quality, reducing costs, or doing both - problem is that insured patients often want to use all available medical resources, regardless of how little health benefit is received in relation to their cost - physicians often find themselves in situations where they are required to withhold treatment because of its cost-inefficiency
Advanced-Practice Nurses
- (APN) is a general name for nurses who have education and clinical experience beyond that required of an RN - direct caregivers - perform other professional activities such as collaborating and consulting with other health care professionals, educating patients and other nurse, collecting data for clinical research project, and participating in the development and implementation of totally quality management programs, critical pathways, case management, and standards of care - 251,000 in the US - Four areas of specialization 1) Clinical nurse specialists (CNS) 2) Certified registered nurse anesthetists (CRNAs) 3) Nurse practitioner (NPs) -- considered non-physician practitioners 4) Certified nurse-midwives (CNMs) -- considered non-physician practitioners - main difference between CNSs and NPs is that CNSs work in hospitals, NPs mainly work in primary care settings - CNSs can specialize in specific fields such as oncology, neonatal care, cardiac care, or psychiatric care
NonPhysician Practitioners
- (NPP) aka nonphysician clinician and midlevel provider and physician extenders - they can substitute for physicians - refers to clinical professionals who practice in many of the areas in which physicians practice but who do not have an MD or a DO degree - receive less advanced training than physicians but more than RNs - do not engage in entire range of primary care or deal with complex cases requiring the expertise of physician - often work close with physicians - typically include physician assistants (PA) - NPs work predominately in primary care - PAs are evenly divided between primary care and specialty care - The American Academy of Physician Assistants defines PAs as "part of the healthcare team who work in a dependent relationship with a supervising physician to provide comprehensive care" - they are licensed to perform medical procedures only under the supervision of a physician - major services provided are evaluation, monitoring, diagnostics, therapeutics, counseling, and referral - PA programs award bachelor's degrees, certificate, associates degrees, or meters degrees - in most states they have the authority to prescribe medications - The American Nurse Association defines NPs as individuals who have completed a program of study leading to competence as RNs in an expanded role - they constitute the largest group of NPPs and have experienced the most growth - NPs training may be a certificate program (at least 9 months of duration) or a master's degree program (2 years of full-time study) - must complete clinical training - primary function is to promote wellness and good health through patient education - provide services in nursing homes - CNMs are RNs with additional training from a nurse-midwifery program in areas such as maternal and fetal procedures, maternal and child nursing, and patient assessment - they deliver babies, provide family planning education, and manage gynecologic and obstetric care - substitue for obstetricians/gynecologists in prenatal and postnatal care, but refer abnormal or high-risk patients to obstetricians or jointly mange the care of such patients - patients cared for by CNMs are less likely to have continuous electric monitoring, induced labor, or anesthesia
Uptake Pre-HITECH
- 2007-2008 Survey of 2758 physicians -- 4% had extensive EHR system, 71% of these integrated with a hospital system -- 13% had basic system -- 16% had purchased but not implemented -- 26% intended to purchase within 2 years - Hospitals -- 8.7% had either basic or extensive system in 2008, 11.9% in 2009 (2% could meet MU criteria) My Notes: Survey done just before HITECH 20% wasn't even on the radar
Meaningful Use
- 2009 American Recovery and Reinvestment Act -- $19B for HIT and EHR adoption -- Health Information Technology for Economic and Clinical Health (HITECH) Act offered payments for "meaningful use" of a "certified" EHR -- Up to $44,000 for physicians demonstrating meaningful use over a 5-year period of time (had to have started in 2012) $2M bonus for a hospital, plus Medicare add-ons My Notes: Had to have certain information capabilities related to storage and transfer and privacy of data = "certified" EHR
Imbalance and Maldistribution of Physicians
- 2013 = approximately 767,100 licensed physicians under the age of 75 in active practice -- women = 1/3 (31%) of the workforce -- physicians between ages 65 and 75 in the active workforce = 10% -- physicians between 55-64 = 26% of the active workforce, and many in this age group will retire within the next decade - 2012 = 260.5 active physicians per 100,000 population in the US -- physicians will the highest number of physicians per 100,000 population are concentrated in the Northeast --- Example: Massachusetts - Looming Shortages and the Affordable Care Act - Geographic Maldistribution - Specialty Maldistribution
Reimbursement Under Managed Care
- 3 approaches are used my MCOs - PPOs use a variation of fee-for-service method were the PPO establishes fee schedules base don discounts negotiated with providers participating in its network - HMOs sometimes have physician son their staff who are paid a salary -- Capitation: another mechanism used by HMOS: a provider is paid a set monthly fee per enrollee (sometimes referred to as per member per month--PMPM) regardless of whether an enrollee sees the provider -- capitation removes the incentive for provider-induced demand--it makes providers prudent and encourages them to provide only necessary services
Uninsured Pre-ACA
- 30% of all young adults are uninsured - 10% of children under age 18 (Some are eligible for Medicaid/CHIP, but don't understand the paperwork a lot of the time) - People who work - 9% of people in households earning over $75,000 - 21% of Blacks and 32% of Hispanics (Health disparity) - Undocumented immigrants - Varies by states (TX and NM more than 20%) - Total number = 41M My Notes: - #'s pre-ACA - MN had about 9% -- not it is about 4%
Public Insurance
- 34.3% were covered by public insurance - public financing supports categorical programs, each of which is designed to provide benefits to a certain category of people who meet the eligibility criteria to become beneficiaries - US does not have publicly financed health insurance specifically for the unemployed - even though public insurance is financed by the govt., services are purchased from provers in the private sector, for the most part - one exception - Department of Veterans Affairs (VA), which runs its own health care system to provide most of the services to its beneficiaries
Uptake 2013
- 78% of office-based physicians used any type of electronic health record (EHR) system - 48% of office-based physicians reported having a system that met the criteria for a basic system. -- Range = 21% in New Jersey to 83% in North Dakota. - 69% of office-based physicians reported that they do or intended to participate in "meaningful use" incentives. - 13% of all office-based physicians reported that they both intended to participate in meaningful use incentives and had EHR systems with the capabilities to support 14 of the Stage 2 Core Set objectives.
Post ACA
- 8M Medicaid - End of 2014 = 30M uninsured - Gaps remain -- People of color -- Living in South -- Rural --- Less insurance offered—less networks
Why Important?
- A tool for achieving: -- Quality --- Better quality - Cost - Access - PFCC -- More patient friendliness
The Affordable Care Act and Medical Technology
- ACA mainly affects devices and biologics - a 2.3% excise tax on the sale of certain medical devices by manufacturers and importers of these devices became effective on January 1, 2013 - these higher costs will be passed on to the purchasers, mainly hospitals and physicians, and will eventually filter down to consumers through higher health insurance premiums - the Biologics Price Competition and Innovation Act of 2009 (incorporated into the ACA) authorized the FDA to approve biosimilars under a process similar to the approval of generic drugs - because of their complexity, the term generic cannot apply to biologics; hence the term biosimiliar was created to apply to products that are highly similar to, or are interchangeable with, an already approved biological product - Biosimilar Fee Act of 2012, passed subsequent to the ACA, authorized the FDA to charge biopharmaceutical firms a user fee to pay for the review of applications for biosimilar products - it is believed that the intro of biosimilars will create competition and drive down the cost of biologics - first biosimilar product approved in US was Zarxio--biosimilar to Neupogen-- which can be prescribed for the treatment of cancers
Current "Hot Topics" in Health Care Finance
- ACOs change provider incentives -- ACA mandates to individual and insurance -- "More integration between payers and providers" - Activity-based accounting -- Price based on cost to deliver service, not what insurance will reimburse -- Vs. Chargemaster
Medicare
- AKA Title 18 of Social Security Act finances 3 categories 1) Persons 65 years and older 2) Disabled individuals of any age who are entitled to Social Security benefits 3) People of any age who have permanent kidney failure (end-stage renal disease) - federal program administered by CMS - 2014 --> had 53.3 million beneficiaries - initially created for the elderly - 17% of people under the age of 65 are now covered - program will continue to grow - of all govt. programs, medicare poses the single greatest future challenge to taxpayers as the growing number of beneficiaries is supported by fewer working adults - approximately 4 workers per beneficiary are expected to decrease to 2.3 workers by 2030 - deductibles, copayments, premiums, and non-covered services can leave Medicare beneficiaries with substantial out-of-pocket costs - non-covered: vision care, eyeglasses, dental care, hearing aids, and many long-term care services - even for covered services, medicare has relatively high-cost sharing requirements - average out-of-pocket spending per beneficiary in 2010 was $2,744 - to cover those expenses, most have some source of supplemental coverage such as an employe-sponsored plan for retirees (35%), Medicaid for low-income individuals (19%), or privately purchased supplemental insurance plan, down as Medigap (23%) - had Part A and Part B --> now has a 4-part structure
Bundled Payments
- AKA package pricing-- a number of related services are included in one price - research has shown these payments can align incentives for providers to work closely together across specialties and health care settings - medicare is undertaking thees payment initiatives that link payments for multiple services beneficiaries receive during an entire episode of care - optometrists sometimes advertise package prices that include charges for eye exams, frames for glasses, and corrective lenses
Ambulatory Payment Classifications
- APCs are associated with Medicare's Outpatient Prospective Payment System (OPPS) for services provided by hospital outpatient departments - divides all outpatient services into more than 300 procedural groups - reimbursement rates are associated with each APC group - the rates are adjusted for geographic differences in wages - APC reimbursement includes services such as anesthesia, certain drugs, supplies, and recovery room charges in a package price established by medicare - medicare implemented OPPS to pay for facility services--nursing, recovery care, anesthetics, drugs, and other supplies--in freestanding (non hospital) ambulatory surgery centers - most common procedures performed in these centers are cataract removed and lens replacement, upper gastrointestinal endoscopy, and colposcopy - physician services are reimbursed separately under the physician fee schedule baed on RBRVS
Financing
- Any mechanism that gives people the ability to pay for health care services - Complexity - Mix of public and private My Notes: (People Payer) Payer to Provider (drawing on board) (Payer Provider) = payment
Other Technological Innovations
- Apps to track health data - "The Patient Will See You Now" -- You + Technology = The Doctor of the Future - Virtuwell - Other? My Notes: - Just wanted to share since it's a great article on EHRs. One thing we didn't even really touch on today which the article presents well is this issue of interoperability. To what extent do health records talk to each other? People go to lots of places for care, sometimes in different organizations, systems, or even to an online provider like virtuwell. Does all that data get stored together? http://healthaffairs.org/blog/2016/09/29/by-the-numbers-our-progress-in-digitizing-health-care/
The Demand
- As demand for other providers grow, so will the need for management - Bureau of Labor and Statistics -- Good opportunity, especially with work experience and management skills -- Masters is standard, BA level for entry-level jobs -- Hours may be long and not traditional
Legislation to Regulate Biologics
- Biologics are derived from living organisms and include a wide range of products such as vaccines, blood and blood components, allergenics, somatic cells, gene therapy, tissues, and therapeutic proteins that are indicated for the prevention or treatment of a disease or health condition - biologics are isolated from a variety of natural sources--human, animal, or microorganism - most are complex mixtures that are not easily identified or characterized - FDA regulates the licensing of biologics under the Public Health Service Act of 1944 - similar to drugs, the safety and effectiveness of biologics are regulated according to the Food, Drug, and Cosmetic Act of 1938
Children's Health Insurance Program
- CHIP, title 21 of Social Security Act, enacted under the Balanced Budget Act of 1997 - when it was created nearly 1/4 of the children in low-income families were uninsured - offers additional federal matching funds to states to expand medicaid eligibility to enroll children up to 19 years of age who otherwise would not qualify for coverage because their families' incomes exceed the medicaid threshold levels - certain adults, such as, pregnant women, parents, and caretaker relatives, may also be covered under CHIP - most states provided CHIP coverage to children with family incomes at or above 250% of the FPL or about $60,625 (higher in Alaska and Hawaii), for a family of 4, if they are not covered under a private insurance plan - states can run CHIP privately under insurance plans or run in it in conjunction with the state's medicaid program - 2013, 5.8 million were enrolled
Billing and Coding
- CPT codes -- Current Procedural Terminology - describes the service that was rendered (usually by a physician or other HC professional) for billing purposes (with ICD-9 codes to describe why that service was provided) - HCPCS -- CMS codes for billing for other services, not supplied by a physician - There are more!
Leadership
- Can be part of management ("directing") - Creative problem-solving - Motivating employees (followership) - Managers and leaders not always the same people - Leadership can occur at any level
Current "Hot Topics" in Health Care Finance
- Changes in financial incentives to reward efficient use of resources. - Incentivize consumer decisions based on the value of a service -- Insurance products that offer discounts to consumers when they use more efficient providers
Health Administration
- Clinical office -- Front office -- Back office - Hospital -- Billing -- Patient accounts -- Prior authorization -- Contracts -- Compliance -- Quality -- Population care management -- Clinic management -- Food service management
Practical Tips
- Complexity is huge -- You can expect OTJ learning - Big data knowledge will be critical -- ReMAP for health care -- Unstructured data - Consider a Masters degree - someday
Costs
- Cost a barrier to adoption - Meaningful use supposed to offset some of it. - The average physician will lose $43,743 over five years after adopting electronic health records. -- Survey of 49 community practices in a large EHR pilot in Massachusetts projected that only 27% would achieve a positive ROI in 5 years -- 14% percent would be in the black assuming they received the $44,000 federal meaningful-use incentive.
Leadership
- Creative problem-solving -- Primary care shortages --- New ways to envision (e.g. rather than address supply, address demand) -- Use big data knowledge to improve care - Motivating employees -- Diverse backgrounds - education and pay -- Professional association and autonomy --- We'll discuss more later this week! -- Team-based care
Looming Shortages and the Affordable Care Act
- Demand for physicians continues to grow faster than supply -> projected shortfall of between 46,100 and 90,400 physicians by 2025 - Primary care shortfalls will range between 12,500 and 31,100 by 2025 - Specialty shortfalls will range between 28,200 and 63,700 - Expanded medical coverage under the ACA will likely increase demand by about 16,000 to 17,000 physicians (2.0%) over and above the increased demand resulting from changing demographics - To better plan for future workforce needs, it is critical to study some of the patterns of change: 1) how physician retirement patterns might change over time based on economic factors, work satisfaction, trends in health and mortality, cultural norms regarding retirement 2) whether young physicians will continue to have similar work-life balance expectations as older cohorts 3) how clinician staffing patterns, including those of advanced-practice clinicians, are likely to evolve over time 4) the effects of different payment methods, which are changing under ACA 5) the potential impact of emerging care delivery models, such as ACOs emphasized under the ACA - The ACA includes some provisions to address the looming shortages -- Seeks to modify federal Medicare payments for medical residency training and to authorize additional funding for medical residency training programs -- Seeks to expand the nonphysical workforce of clinicians with advanced training --- Example: the ACA includes provisions to expand the number of primary care providers under the National Health Service Corps to work in geographic areas where shortages exist -- ACA included establishment of the National Health Care Workforce Commission --> tasked with developing national health care workforce strategy -- Also established the National Center for Health Workforce Analysis to develop information describing and analyzing the health care workforce and related issues, oversee the health care workforce development grant program, develop performance measures, and establish a national Internet registry of grants awarded (to date, $12 million have been spent)
Paying for care
- Doctors account for more than 20% of all health care spending - Their decisions affect much other spending - Move towards paying for services as a set of physician + facility
Personal Skills for Good Communication
- Emotional intelligence components (Goleman) -- Self-awareness -- Self-regulation -- Internal motivation -- Empathy --- Feel with—experience same emotions, putting yourself in their shoes -- Social skills/awareness Skills related to each component My Notes: - Components all relate to each other and build off one another
Demand (BLS)
- Employment = 293,490 (2012) - Mean annual wage = $98,460 - Demand increasing (18% over the 2010-2020 time period)
More Types of Insurance
- FFS- Fee-For-Service -- Person pays provider, and insurance reimburses person -- Deductibles to meet -- This is different between financing and payment -- Go to doctor, get the bill, bring it to insurance and get reimbursed - Prepayment -- Person pays fixed amount (per time period) in exchange for services.—kind of like a premium -- May be a co-pay or deductible or both—sometimes all services are covered My Notes: Some very very rich people skip the payer part and pay a fixed amount per year to have a doctor at their disposal
Financing Type Incentivizes Different Things for Different Stakeholders
- Financing - health insurance -- Moral hazard --- More utilization—if everything is free all the time --- Require some small level of copayment, premium is what they said would help a little bit but then some people will just not go in (can cause problems) -- Provider-induced demand --- Recommend more procedures and treatments that are necessarily needed -- Demand-side rationing - Access and Payment to Providers -- Demand-side rationing --- We do a lot of this in the US --- Tell consumers to be better consumers or do things differently—raise prices, wellness plans - Supplier-side rationing --- Restrict # of providers in a given area --- Trying to create narrow networks My Notes: Adverse selection: highest risk people purchase most (this is what happens when people wait until they are sick to buy health insurance)—see a little bit of this with exchanges -- costs go up because of adverse selection -- what happens then is the people who are lowest risk and healthy question why they should even buy health insurance Different approaches to balance what consumers need and want to pay with what doctors can provide and what insurance companies can pay demand and supply side rationing - Think about what each stakeholder would think about in these cases (consumer vs suppliers)
Types of Private Insurance
- Group insurance - Self-insurance - Individual private insurance
High-Deductible Health Plans
- HDHPs have grown in popularity because of their low premium costs - generally, plans that carry at least $1,000 deductible for single coverage or $2,000 for family coverage are considered HDHPs - two types of HDHP arrangements are available both of which are link a savings account to a high-deductible insurance - the savings account gives consumers greater control over how to use the funds - savings are also used for relatively small and routine health care expenses - These plans are referred to as consumer-driven health plans - HDHPs minimize moral hazard and make consumers responsible users of health care resources - a study showed strong evidence that consumer-directed health plans reduced health care spending and could lead to significant cost savings for health care system First Type: - HDHP/HRA (health reimbursement arrangement) - HRA is funded by the employer; employees are prohibited from contributing to it - the funds are used to reimburse the insured for qualified medical expenses (which include payment of HDHP premiums and premiums for long-term care insurance) - employees do not pay taxes on the payment made to them from HRAs - although participants are not required to have an HDHP, the arrangement commonly includes both - when coupled with HDHP, the employee first pays for health care from the HRA and then pays for care on an out-of-pocket basis until the health plan deductible is met - subsequently, HDHP kicks in - unused HRA funds can generally be carried forward to the next year Second Type: - HDHP/HSA (health savings account) - meets federal standards - federal regulations require caps on the yearly amounts contributed to an HSA ($3,350) for single coverage and ($6,650) for family coverage - those older than 55 can contribute an additional $1,000 - employers may contribute but are not required - funds belong to account holder and can accumulate without limit - minimum annual deductible $1,300 (single) and $2,600 (family) - out-of-pocket expenses for deductibles and copayments were capped at $6,450 and $12,900 single and family - HSAs have significant tax advantages--contributions are tax deductible, withdrawals used to pay for medical expenses are exempt from federal income taxes, and account earnings are tax exempt
Health Insurance Portability and Accountability Act
- HIPPA of 1966 restricted the legal use of personal medical information for three main purposes to alleviate concerns about confidentiality of patient information: -- health care delivery to the patient, operation of the health are organization, and reimbursement - HIPPA legislation mandated strict controls on the stranger of personally identifiable health data between two entities, provisions for disclosure of protected information, and criminal penalties for violation - also established certain patient right, such as the right of patients to inspect and have copies of their protected health information, to request corrections to the records, and to restrict the use of the information - HITECH law strengthened the civil and criminal enforcement of HIPPA by including increased penalties for violations
Health Information Technology for Economic and Clinical Health Act
- HITECH Act of 2009 provides financial incentives to providers for adopting meaningful use of EHR technology - Meaningful use refers to specific criteria in quality, safety, efficiency, etc., that providers are required to meet
Assessment of Medical Technology
- Health Technology Assessment (HTA): refers to the evaluation of medical ethnology to determine its efficacy, safety, and cost-effectiveness - also informs various stakeholders about ethical, legal, and social implications of medical technologies - their objective is to establish the appropriateness of medical technology for wide spread use - HTA becomes essential because many technologies have not produced health benefits; some may even be harmful - Hence, HTA should govern decisions to adopt and disseminate new technology - efficacy and safety are basic starting points in evaluation the overall usefulness of medical technology - cost-effectiveness goes a step further in evaluation the safety and efficacy of a technology in relation to its cost--efficacy and safety are evaluated through clinical trials - cost-effectiveness is determined by using economic models the compare benefits of a treatment to its costs
Team-Based Care
- Health care professionals are always licensed - What does that license do? -- Licensing is done by the state, which allows you to practice--it is separate from education and training --- CEU (continuing education unit) = other --- CME (continuing medical education) = docs
More Types of Insurance
- High-deductible health plan (HDHP) or consumer driven (Newer Rand study & cost-savings) -- HAS- health savings account --- Must have HDHP --- Generally employee funded, employer can fund --- Tax advantages/fewer restrictions --- Only if the employee does a high deductible health plan—otherwise you have to do HRA -- HRA- health reimbursement account -- Not required to have HDHP -- Employer funded, tax free -- Reimbursement for qualified medical expenses
Health Administration
- Home health/SNF/Hospice - Public health department management - Research - Policy -- Medicare and Medicaid -- ACA - Informatics (EHRs) - Non-profit administration - Marketing - What else????
Hospital Insurance (Part A)
- Hospital insurance portion of medicare-- financed by special payroll taxes paid equally by employers and employees - taxes are paid by all working individuals, including those who are self-employed - all earning are subject tot medicare tax - designed to cover hospitalization, short-term convalescence and rehabilitation in a skilled nursing facility (SNF), and home health care - for terminally ill, medicare pays for care provided by a medicare-certified hospice - see figure 6.3 on page 149 - Part A benefits are rather complex - Benefit Period: hospital and nursing home stays, the timing of benefits is determined by (benefit period) -- it beings on the day a beneficiary is hospitalized and ends when they have not been in the hospital or an SNF for 60 consecutive days -- if after 60 days they are back, the benefit period restarts -- # of benefit periods one can have is unlimited (Acute Care) - services received during a hospital day are fully paid for the first 60- days after a deductible of $1,260 (2015) - deductible applies each benefit period - if a stay goes beyond 60 days, a copayment of $315 per day (2015) and must be paid from days 61-90 - benefit period has max of 90 days coverage - beyond 90 days, there is lifetime reserve of 60 additional hospital inpatient days to which a higher copayment applies ($630) per day (2015) - psychiatric hospital stays are limited to 190 days in the beneficiary's lifetime (Post Acute Care) - medicare pays for up to 100 days in Medicare-certified SNF subsequent to inpatient hospitalization for at least 3 consecutive days, not including day of discharge - admission to SNF must occur within 30 days of hospital discharge and it must be related to the same condition for which the beneficiary was hospitalized - all covered services are fully paid for in the first 20 days in the SNF - beyond that, copayment of $157.5 per day in 2015 must be paid for days 21-100 (Home Health) - medicare pays for home health care when a person is homebound and requires intermittent or part-time skilled nursing care or rehabilitation therapy determined necessary by a physician - services must be obtained form a medicare-certified home health agency - durable medical equipment (DME), such as wheelchairs, hospital beds, walkers, and medical supplies, are also covered - home health visits do not have a deductible, but a 20% coinsurance applies to DME (Hospice) - for terminally ill patients, Medicare pays for care provided by a medicare-certified hospice - a small copayment applies for prescription drugs for these patients
Billing and Coding
- ICD codes -- ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings. -- These classifications are developed, monitored and copyrighted by the World Health Organization (WHO). -- Designed so any provider could know dx -- ICD-10
Other Barriers and Discussion
- Implementing MU challenges - Time - physicians spend approx. 48 minutes a day on EHR work - Training - Discussion with patient involves computer - Privacy and data breaches - Other?
Government Intentions
- Improve care coordination - Reduce healthcare disparities -- Differences in disease rates in populations - Engage patients and their families - Improve population and public health - Ensure adequate privacy and security -- Part of this required using platforms that had that capability
What is it?
- Information Technology -- Clinical information systems -- Administrative information systems -- Decision support systems -- Patient-enabled applications - EHRs (or EMRs) operate across all 4 areas (she is going to use them interchangeably) -- Only part of medical and information technology -- EHRs - advantage is integration at patient level, more comprehensive, and government incentives My Notes: Information systems vs. Support systems -- housing information (data bases)— compared to ways in which we will use those data bases to make better clinical decisions Used by large organizations (EHRs)—Essentia EMRs are used by specialty clinics
Health Information Technology
- Information Technology (IT) has become an integral part of health care delivery - involves computer applications that transform massive amounts of data into useful information - is indispensable for managing the vast array of information that is used in patient care deliver, quality improvement, cost containment, billing and collections, and other aspects of operating health care organizations - most large health care organizations have information systems departments and managers who are charged with maintaining and improving the flow of information - IT applications are increasingly being used to link health care organizations to agencies outside those organizations -- for example, it is a common practice to electronically transmit billing information to payers
Health Administration
- Insurance -- Claims -- Customer service -- Contracts -- Benefits management -- Sales and marketing / client accounts -- Data analytics - Employer - HR Benefits - Pharmacy benefits management (PBM) - Worksite wellness management
Reimbursement Methods
- Insurance companies, MCOs, Blue Cross/Blue Shield, and the govt. (medicare and medicaid) are referred to as third-party payers, with the other two parties in the arrangement being the patient and the provider - Reimbursement: payment made by third-party payers to the providers of services
Major Issues in Management (BLS)
- Integration of HC delivery systems - Technological innovations - Increasingly complex regulatory environment - Changing job duties - Increased focus on preventive care - Improving efficiency - Improving quality
Big Data in Health Care
- Issues -- Volume - a lot of data (EHRs, machines, etc.) --- Heart-lung machines -- Velocity - data collected rapidly (blood pressure readings every 15 minutes) --- Real-time, rapid fire—hooked up to IV and blood pressure machine constantly providing data -- Variety - many sources Different machines, EHR -- Veracity - needing to be accurate Analyzing data
Intro to Health Insurance
- Joining with others to pool resources to protect against losses - Two key concepts: -- Risk is unpredictable for the individual -- Risk predictable for a group -- Risk is transferred from the individual to the group -- Sharing of costs of any covered loss incurred by group members My Notes: - Conditions under which insurance can work
Employer Characteristics Associated with Health Insurance Offer Rates
- Large employers versus small employers - Greater number of high-wage earners vs. low-wage earners - Full-time vs. part-time workers - Unionized vs. non-runionized employers - Smaller % of young workers vs. older workers
More Types of Insurance
- Managed Care- integration of the payer and provider -- HMO- health maintenance organization -- PPO- preferred provider organization POS- point of service -little bit of a mix between the two ^ -- Characterized by contracts with networks of providers or full integration between payer and provider My Notes: Most type of care today is managed care The more integration between the payer and provider the more narrow the network -HMO HMO now a days have relaxed a little bit but still push that integration PPO is a little more flexible -- can go to specialist outside of network and pay more
EHRs
- Many platforms exist -- Epic --- Scheduling and business functions—housing patient information -- Meditech (largest market share) -- Aetna My Notes: Biggest capturer of data on that patient level Many different platforms Interconnected information not just storing the information
Policy Limitations on Cost-Sharing
- Maximum out-of-pocket expenditures for individual -- Cap on out of pocket spending - Lifetime limits in benefits -- Eliminated under ACA -- Mandate on insurers
Efficacy
- May be defined simply as the health benefit to be derived from the use of technology, or how effective a given technology is in diagnosing or treating a condition -- if a product or service actually produces some health benefits, it can be considered effective - decisions about efficacy require that the right questions be asked (is current diagnosis satisfactory) - apart from evaluating the effects on morality and morbidity, issues related to quality of life are important
Standardized Practice Protocols
- Medical Practice Guidelines (or clinical practice guidelines) are systematically developed protocols to assist practitioners in delivering appropriate health care for specific clinical circumstances - HTA plays a significant role in the development of clinical protocols - unlike some other countries, however, cost-effectiveness has not taken central stage in health care deliver in the US - rising health care costs and excessive spending remain a top concern
What is it?
- Medical technology -- MRI, CT and other diagnostic equipment -- Treatment equipment (heart and lung machine) --- surgeries -- Technical procedures and devices (knee replacement) -- Biologics --- Somewhat different category --- Not in same class is drugs
Public Insurance
- Medicare Parts - Who and what it is paying for - ACA changes
Meaningful Use
- Money from Medicaid too - Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years - Stages 1-3, attest to meeting objectives/measures
Generalists and Specialists
- Most DOs are generalists - Most MDs are specialists
Types of Health Care Teams
- Most are clinical microsystems teams -- Less stable than ongoing teams - Some are rapidly formed -- Crash cart -- Dynamic and highly unstable - Goal is high reliability High reliability = improved patient outcomes (HCM 4570, Quality Improvement) My Notes: - High reliability generally results in better patient outcomes * - Not responsibility of just one person—the team
Cost-Effectiveness
- OR cost-efficiency; goes a step beyond the determination of efficacy and safety by weighing benefits against costs - at first, benefits usually outweigh; over time, additional treatments begin to lower the benefits in relation to rising costs - at some point along a time line, continued medical interventions yield benefits that are roughly equal to the additional costs - optimal cost-effectiveness is achieved when additional benefits equal the additional cost of treatment - beyond the optimal point, additional interventions either deliver no further benefits or the cost of providing additional care beings to exceed the benefits -- in such cases, additional care becomes wasteful - potential risk can also be incorporated as a type of cost - experts believe that much of the medical care delivered in the US is wasteful because after a certain point, additional care adds little or no health benefits while costs continue to accumulate - HTA will play a considerable role in future health care planning, policy, financing, and delivery - establishing the cost-effectiveness of various treatments (called comparative effectiveness study) can potentially relive physicians and insurers of the responsibility of making certain treatment decision that might otherwise become controversial and lead to conflict and legal battles
Other Doctoral-Level Health Professionals
- Optometrists -- provide vision care -- examinations, diagnosis, correction of vision problems -- licensed to practice --- including possession of a doctor of optometry (OD) --- completion of a written and clinical state board examination - Psychologists (most common of these four) -- provide mental health care to patients -- licensed or certified --- doctor of philosophy (PhD) or doctor of psychology (PsyD) --- minimum of 5 years postdoctoral experience --- completion of an examination administered by the American Board of Examiners in professional psychology -- can specially in several areas: clinical, counseling, developmental, educational, engineering, personnel, experimental, industrial, psychometric, rehabilitation, school, and social domains - Podiatrists -- treat patients with diseases or deformities of the feet -- with surgical operations, prescribing medications and corrective devices, and administering physiotherapy -- must be licensed --- completion and accredited program that awards a doctor of pediatric medicine (DPM) degree --- completion of a national examination administered by the National Board of Podiatry - Chiropractors -- provide treatment to patients through chiropractic (Greek for "done by hand") manipulation, physiotherapy, and dietary counseling -- help patients with neurologic, muscular, and vascular disturbances -- chiropractic care is based on the belief that the body is a self-healing organism --> they don't prescribe drugs or perform surgery -- licensed to practice --- completion of a 4-year accredited program that awards a doctor of chiropractic (DC) degree --- examination by the state chiropractic board
Home Health Resource Groups
- PPS for home health care pays a fixed, predetermined rate for each 60-day episode of care, regardless of the specific services delivered - all services provided by a home health agency are burdened under one payment made on a per-patient basis - an assessment instrument called the Outcomes and Assessment Information Set (OASIS) is used to rate each patients functional status and clinical severity level - the assessment measure translate into points; the points are based on the patients specific HHRG category - the HHRG classification uses 153 distinct groups in which patients can be classified according to clinical severity, functional status, and the need for rehabilitation therapies s
PMPM
- Per member per month costs -- Can be broken down into care, pharmacy, etc. - Standardized measure -- A way to compare across payors or assess if reaching targets for expenditures My Notes: Thinking about cost in terms of cost per member per month on average
Focus on Communications
- Personal Skills - Techniques used to standardize practice -- SBAR approaches - Have to be a good team member
Five Management Functions
- Planning - Organizing - Commanding/ communicating/ directing - Coordinating - Controlling
Insurance Terms - Cost-Sharing
- Premiums - regular payments - Copayments - at time of service -- Usually a fixed amount - Deductibles - required levels of payment to be met before insurer pays (annual) -- Separate deductibles by service type - Coinsurance - Insured persons pay a portion of all care, while insurer is responsible for the rest (e.g. 20%, 80%)—usually as premium goes up, coinsurance goes down--this kicks in after you pay the deductible - Stop-loss or maximum out-of-pocket liability My Notes: Know all these for sure
Differences Between Primary and Specialty Care
- Primary care can be distinguished from specialty care by the time, focus, and scope of services provided to patients - 5 main areas of distinction are: 1) Primary care is first-contact care and is regarded as the portal of entry to the health care system--specialty care, when needed, generally follows primary care 2) In managed care and integrated delivery environments, primary care physicians serve as gatekeepers--an important role in controlling costs, utilizations rates, and the rational allocation of resources -- in the gate keeping model, specialty care requires referral form a primary care physician 3) Primary care is longitudinal because primary care provers follow a patient through the course of treatment and coordinate various activities, including diagnosis, treatment, referral, consultation, monitory, and follow-up -- specialty care is episodic meaning it is more focused and intense 4) Primary care focuses on the person as a whole--a person may have multiple health issues (AKA comorbidity) -- primary care seeks to balance the patient's multiple health issues, including referrals to specialists when needed -- specialty care is limited in its scope to episodes of illness, specific organs systems, or the disease process -- specialty care is associated with secondary and tertiary levels of service 5) The difference in scope has to do with how primary and specialty care providers are trained -- primary care medical students spend a significant amount of time in ambulatory settings, familiarizing themselves with a variety of patient conditions and problems -- subspecialty care students spend a significant amount of time in inpatient hospitals, where they are exposed to state-of-the-art medical technology to diagnose and treat diseases and perform surgeries
Total Cost of Care contract example
- Provider group still gets FFS payments from payor/insurance plan - sometimes at a lower rate - A/HCO negotiates a cost target with payor - based on the total cost of care for the applicable population for the contract year -- If actual costs are less than cost target - payor shares savings with A/HCO -- If actual costs are more than cost target - A/HCO pays losses to payor
Other Professionals
- Public health - Administration -- Variety of different settings -- Variety of different job titles
Types of Insurance
- Publicly funded -- Medicare (for those who are 65 and over or who have serious disabilities) -- Medicaid (for low-income Americans) -- Other government provided programs --- Ex. VA or IHS - Privately funded -- 55% of all employers offer, but varies a lot - Uninsured
Cost-sharing Incentives/Disincentives
- Rand study - cost-sharing had an impact on lowering utilization w/o negative health consequences -- Point at which more cost deters access and utilization -- (explains under moral hazard in previous slide)
Safety
- Refers to protection against unnecessary harm from the use of technology - benefits of any intervention must outweighs any negative consequences - after safety has been experimentally determined, the outcomes from the wider use of a certain technology are closely monitored over time to identify any problems
Ways to characterize
- Role in the health care system - Scope of work - Numbers and other relevant demographics - Education required - Licensing and professional standards? Yes? No? Variation? - Who pays (insurance) for what services? - What they get paid My Notes: By the next quiz, be able to discuss different types of providers in light of this framework ***** There are several slides related to the demand for and job titles of various health care managers. That material is not something you will be tested on; however, it might give you some ideas for potential internship sites, job titles you want to learn more about on your own. *****
TCOC Contracts
- Services included in TCOC contracts -- Emergency department -- Inpatient and oupatient care -- Labs and x-ray -- Advanced imaging - 78% of private payer ACO contracts include pharmacy -- Pharmacy can be up to 30% of total cost of care --- Especially with Medicaid ACO Contracts
SLIDE 8 ON PAYMENT POWERPOINT
- Similar insurance; not receiving same quality of care; - Spending money to avoid flu shots? - One explanation is Mix of physician work force—spending high in areas with more specialists and fewer generalists, where you get fewer flu shots, mammograms, diabetic care; lack of coordination of care raises expenses and potentially crowds out low intensity high value care - Coordination problem - Quality ranking vs annual - Medicare spending of a beneficiary - Relationship between price and quality
SBAR
- Situation - Background - Assessment - Recommendation - Videos Bad Good Differences?
Stages (Meaningful Use)
- Stage 1 (Through 2014) -- Data capture and sharing --- Capturing smoking status - Stage 2 (Modified 2015-2017) -- Advance clinical processes --- How do we use EHR to better our practice --- Who might have gaps in service --- Download info from EHR and figure out women who are over 40 who need a mammograms - Stage 3 (2018 and beyond) -- Improved outcomes Note: timelines keep changing!
ACOs and Medical Homes
- Structural ways of arranging care in teams Medical homes (or Patient-centered medical home) - State of MN certification allows you to bill Medicaid for care coordination - Private contracts also using in MN - AHRQ also certifies - The picture comes from a nursing home - Certification state - National level certification too -- A lot take this route -- Can bill and pay for care coordination and other team services My Notes: Arranging people in teams
Diffusion and Utilization of Medical Technology
- Technology Diffusion: the development and dissemination of technology -- determines which new technology will be developed, when it will be made available for use, and where it can be accessed -- high-tech procedures are more readily available in the US than they are in most other countries, and little is done to limit the expansion of new medical technology--we also have more high-tech equipment available --> American hospitals perform far greater number of catheterizations, angioplasties, and heart bypass surgeries than other countries -- to control medical costs, most nations have tried to limit--mainly through central planning (supply-side rationing)--the diffusion and utilization of high-tech procedures -- consequently, nations that employ central planning generally have waiting lines for specialized services (8.7 weeks for an MRI scan in Canada)--rationing of medical technology through central planning curtails costs, but also restricts access to care -- Sending on R&D drives innovation--which results in the development of new technology--and once it has been developed its use is almost ensured -- in 2012, US spent 119.3 billion dollars on biomedical R&D-59% was spent by private sector, 41% spent by government -- through NIH National Institute of Health is the largest source of funding biomedical research--has a budget of over 30 billion dollars, 90% of which is used to support both intramural and extramural biomedical research -- R&D spending in the US exceeds the in any other country --- but, if spending, even at reduced levels, is used more efficiently and productively than before, there should be little reason for concern - Major reasons that US leads all other nations in the development and use of technology: 1) cultural beliefs and values 2) medical training and practice 3) insurance coverage 4) competition among providers - see exhibit 5.2 on page 116 (mechanisms to control the growth of technology) *** important I think -- ^^ implementing those measures, would go against the fundamental beliefs and values of Americans and would generate much controversy
Telemedicine and Remote Monitoring
- Telemedicine, or distant medicine, employs telecommunications technology for medical diagnosis and patient care when the provider and client are separated by distance -- also enables a generalist to consult a specialist when a patient's illness and diagnosis are complex -- areas of specialized medical services in telemedicine include tele radiology, telepathology, and telesurgery -- adoption of this has been slow -- some main barriers have been licensure of physicians and other providers across state borders, concerns about legal liability, and lack of reimbursement for services provided via telemedicine -- cost-effectiveness of most telemedicine applications remains unsubstantiated -- diagnostic and consultative tele radiology is almost universally reimburse and has proven to be cost-effective, though - Remote in-home patient monitoring programs that monitor vital signs, blood pressure, and blood glucose levels are proving to be cost-effective -- remote monitoring of cardiac implantable electronic devices, such as pacemakers and cardioverter defibrillators, has shown a high level of patient acceptance and satisfaction -- may also reduce hospital utilization - Tele-ICU is a relatively new development -- links intensivists and other critical care professionals to a system network that enables remote monitoring of ICUs -- provides real-time patient assessment capabilities and communication with bedside teams through ongoing virtual rounds -- these programs have shown lower patient mortality, short lengths of stay, and increased patient safety
Research Technology
- The Agency for Healthcare Research and Quality (AHRQ), a division of the Department of Health and Human Services, is the lead federal agency charged with supporting research to improve the quality of health care, reduce health care costs, an improve access to essential services - the agency's reports on technology assessment are made available to medical practitioners, consumers, and other health care purchasers - federal govt. is also a major provider of financial support to private and public institutions for biomedical research - AHRQ and the NIH support both basic and applied biomedical research in the US
Government Roles
- The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records: -- Incentives: to providers who use IT -- Strict and open standards: To ensure users and sellers of EHRs work towards the same goal -- Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards
Empathy
- The ability to understand and share the feelings of another (Dictionary) - The ability to understand the emotional makeup of other people. A skill in treating people according to their emotional reactions. (Goleman) - Distinct from sympathy - Empathetic listening very important - "Homework practice"
Current "Hot Topics" in Health Care Finance
- The best way to contain health care costs is to help people live healthier lives and avoid chronic diseases.
Costs
- The biggest difference in which practices achieved a + vs. - return stemmed from: -- EHRs used to increase revenue by seeing more patients or through improved billing. -- Reduction of paper --- 45% still kept paper back up (YIKES!!) - Practices with over 6 physicians saw greater + impact -- Because upfront cost of training and implementation per physician—way more in if you had more doctors
Legislation to Regulate Drugs
- The regulatory functions of the FDA have involved over time - Under the Food and Drugs Act of 1906, the Bureau of Chemistry (predecessor of the FDA) was authorized to take action only after drugs had been marketed to consumers--it was assumed that the manufacturer would conduct safety tests before marketing the product--if innocent consumers were harmed, only then could the FDA take action - Drug law was strengthened by the passage of the Federal Food, Drug, and Cosmetic Act of 1938 in resource to the Elixir Sulfanilamide disaster (100 deaths) due to poisoning - under the revised law, drug manufacturers were required to provide scientific evidence about the safety of new products before putting them on the market - drug approval system was further transformed by 1962 drug amendments (Kefauver-Harris Amendment) to the Federal Food, Drug, and Cosmetic Act--remains in place today for most new drugs--law was tightened after the thalidomide tragedy (sleeping pill but was marketed to help with morning sickness for pregnant women --> deformed infants were the results) - Legislation then established a premarket approval system, giving the FDA authority to review the safety as well as the effectiveness of a new drug before it could be marketed - now FDA could prevent harm before it occurred -- this new rules, however, was criticized for slowing down the introduction of new drugs, and consequently, denying patients the early benefit of the latest treatments - late 1980's FDA received pressure from those wanting rapid access to new drugs for treatment of HIV infection--which called for a revision of the drug review process - Orphan Drug Act of 1983 and other amendments were passed to provide incentives, such as grand funding, for pharmaceutical firms to develop new drugs for rare diseases and conditions - as a result, new drug therapies, called ORPHAN DRUGS, have become available for conditions that affect fewer than 200,000 people in the US - 1992, congress passed the Prescription Drug User Fee Act--which authorized the FDA to collect fees from pharmaceutical companies to review their drug applications--these fees have allowed the FDA to make new drugs available more quickly by shortening the time it takes for approvals to be issued - on the flip side, there has been an increasing trend in the number of prescription and over-the-counter drug recalls - there is clearly a tradeoff between accelerating the review process and potential safety risks - 1997, congress passed the Food and Drug Administration Modernization Act -- this law provides for increased patient access to experimental drugs and medical devises -- also permits fast-track approvals when the potential benefits of new drugs for serious or life-threatening conditions are considered significantly greater then those currently available for therapies - FDA's drug approval process remains far from perfect, however - the agency does not carry out its own testing of new drugs, but instead evaluate drug studies conducted by pharmaceutical companies - many times drug recalls are issued by the manufacturer or the FDA years after a drug has been on the market and further research has shown the drugs to be ineffective and/or unsafe EXHIBIT 5.3 (SUMMARY OF FDA LEGISLATION)***
Main Components of Meaningful Use
- The use of a certified EHR in a meaningful manner, such as e-prescribing (taking level of uncertainty away from prescribing). - The use of certified EHR technology for electronic exchange of health information to improve quality. - The use of certified EHR technology to submit clinical quality and other measures. - Providers need to show they're using EHRs in ways that can be measured in quality and quantity. My Notes: Attesting = referring to meaningful use documenting meaningful use to the government
Financing System
- Third party payer system -- We pool our risk of incurring high costs through insurance - Variability in need/use -- 20% of Americans use 80% of health care dollars - Enrollee or beneficiary My Notes: Pay in—once you get sick you don't end up paying as much Member is used as well as enrollee or beneficiary
Medicaid
- Title 19 of Social Security Act - for the indigent - each state has its own criteria for determining eligibility - federal law specifies coverage for low-income elderly, the blind, disabled receiving Supplement Security Income (SSI), and some pregnant women--also instrumental insurance to children of low-income families - most states at their discretion have defined other medically need categories--most importantly are these individuals who are institutionalized in nursing or psychiatric facilities and individuals who are receiving community-based services but would otherwise be eligible for medicaid if institutionalized - all have to qualify abased on assets and income, which must be below the threshold levels established by each state - medicaid is a MEANS-TESTED PROGRAM - it is jointly financed by federal and state goats. - federal govt. provides matching funds to the states based on per capita income in each state - weather states have a smaller share of their costs reimbursed by the federal govt. - for a state to receive federal matching funds, the state must provide some specific health services - REVIEW PAGE 154
"Shared-savings" contracts
- Total cost of care contracts - Upside -- Savings for efficient care, if meets metrics -- No penalties, but if cost is more than contract, the health system loses money - Downside -- Risk on both sides -- Penalty for additional money if don't meet metrics My Notes: - Risk on both sides - If you don't meet quality criteria and metrics, you have to pay a penalty compared to if you do—you get rewarded
How are doctors paid?
- Traditionally, fee-for-service for doctors services - Now, shift towards more fixed rates from public and private insurers (some FFS-like) - System gets paid for the total package of services/service (combining doc and other services) - Shift reflects a larger shift towards more management of care - Prospective payment vs. retrospective My Notes: - Costs are increasing faster than inflation - Trend toward more prospective payments
Good Communication Practice for Administrators
- Use consistent channels - Use checklists or critical language -- Tool to review a critical service -- Stops errors -- Allows those of less status in health care to speak out Conflict resolution (DOWN ARROW) SBAR approach
Demand for Health Care
- What does the book say? - Demographic trends - Health trends - What else?
Primary Care Technician
- What from class/the book did you see evidence of? - Discussion -- Creative idea? -- Feasible?
Self-Insurance
- a large employer often has as workforce that is big enough and sufficiently well diversified in terms of risk to warrant offering its own insurance - rather than pay insurers a dividend to bear the risk, large employers can simply assume the risk by budgeting funds to pay medical claims incurred by their employees - Self-Insurance: gives employees a better control over the health plan - can protect themselves against any potential risk of high losses by purchasing reinsurance from a private insurance company - 61% of workers in 2014 were self-insured
Prescription Drug Coverage (Part D)
- added to existing medicare program under medicare prescription drug, improvement, and modernization act of 2003--fully implemented in 2006 - available to anyone, regardless of income, who has A and B coverage - offered through two types 1) Standalone Prescription Drug Plans -- offer only drug coverage and that want to stay in the original fee-for-service program 2) Medicare Advantage Prescription Drug Plans -- available to those who want to obtain all health care services through MCOs participating in Part C - like part B, Part D is voluntary because it requires payment of a monthly premium -- $33 per month which is adjusted upward according to income and type of plan selected by the beneficiary -- after annual deductible = $320, benefits are paid according to three layers of personal out-of-pocket spending on prescription drugs SEE TABLE 6.1 PAGE 152 1) Deductible Initial Coverage 2) Coverage gap or "Doughnut Hold" 3) Catastrophic Coverage--after the coverage gap ends Read more on page 152 (table)
National Health Expenditures
- aka national health spending and national health care costs - are an estimate of the amount spent for all health services and supplies and health-related research and construction activities in the US annually - it is common to compare the total health care expenditures to the total economic consumption - GDP measures the total value of goods and services produced and consumed in a country - GPD in 2013 was $16.8 trillion--hence, 17.4% of the total economic output in the US was consumed by health care - another way to look at it is in terms of the average per capita spending, which controls the changes in the size of the population - in 2013, the average per capita spending for health care amounted to $9,255 for each American - Table 6.4 on page 161 - figure 6.5 on page 162-163 - 85% was spent on personal health services and products - 15% was spent on public health services (research, investment, etc.) - Consumer Price Index: measures inflation in general economy - health care cost inflation is a concern for almost all developed nations, too
Individual Private Insurance
- although employer-sponsored group plans and govt. programs are the most popular; individually purchased (non group) private health insurance is an important source of coverage for many Americans - the family farmer, the early retiree, the employee of a business that does not offer health insurance, and the self-employed make up the bulk of the people who rely on private nonemployer-related health insurance - growth in this sector is due to ACA
Impact on Quality of Care
- americans generally equate high-technology medicine to high-quality care, but such an association is not always accurate - quality is enhanced only when new procedures can prevent or delay the onset of serious disease, provide better diagnosis, make quicker and more complete cures possible, increase safety of medical treatment, minimize undesirable side effects, promote faster recover from surgery, increase life expectancy, and add to quality of life - technology can provide remedies where none existed before--also improved remedies that are more effective, less invasive, or safer - outcomes in such cases can include increased longevity and decreased morbidity, both of which are indicators of quality health care - EXHIBIT 5.4 ON PAGE 123 (criteria for quality of care) * - numerous examples illustrate the role of technology in enhancing the quality of care -- example: tiny cardiac pacemakers and implantable cardioverter defibrillators can be placed in the human body to prevent sudden cardiac death - but, some degree of caution must prevail - past experience shows that greater proliferation of technology does not necessarily lead to higher quality of care - unless the effect of each individual technology is appropriately assessed, some innovations may actually be wasteful, and others may possibly be harmful
Managed Care Plans
- are offered mainly by health maintenance organizations (HMOs) and preferred provider organizations (PPOs) - are a type of health insurance because they assume risk in exchange for an insurance premium - unlike traditional insurance companies, MCOs assume the responsibility for obtaining health care services for their enrolled by contracting with a network of providers - MCOs also use a variety of mechanism to monitor utilization and a variety of methods to reimburse providers for the services rendered
Fee for Service
- based on the assumption that services are provided in a set of identifiable and individually district units of services - each service is separately billed - providers would balance bill--ask the patients to pay the difference between the actual charges and the payments received from insurers - initially providers favored this, but then didn't due to rising costs - less common now - x-ray bill, recovery room charges
Cultural Beliefs and Values
- beliefs and values have been instrumental in determining the nature of health care delivery in the US - capitalism and limitations on government intervention promote innovation - economic and political environment in which innovation thrives creates opportunities for scientists and manufacturers to develop new technology - Americans have high expectations of finding cures through science and technology, and they equate use of advanced medical technology with high-quality care - Consequently, Americans indicate overwhelmingly that advanced tests, drugs, medical equipment, ad procedures are critical for improving the quality of health care - TECHNOLOGICAL IMPERATIVE: -- the desire to have state-of-the-art technology available, accompanied by the desire to use it despite its costs
Benefits of Technology Assessment
- benefits: -- establishing the safety and efficacy of new technology is essential to prevent potential harm to patients -- improved quality of care -- better quality of life -- better access -- better control of costs - delivering value - cost containment - standardized practice protocols
Group Insurance
- can be obtained through an organization such as an employer, a union, or a professional organization - anticipates that a substantial number of people in the group will participate in purchasing insurance through its sponsor - risk and often cost of insurance are shared by member of the group - health insurance plans have commonly combined major-medical coverage with all-inclusive comprehensive coverage that includes basic and routine physician office visits and diagnostic services
Impact of Medical Technology
- effects of advances in scientific knowledge and medical technology have been far-reaching and pervasive - effects often overlap, making it difficult to pinpoint the precise impact of technology on the delivery of health care - impact on quality of care - impact on quality of life - impact on health care costs - impact on access - impact on the structure and processes of health care delivery - impact on global medical practice - impact on bioethics
Value of NPP Services
- efforts to formally establish the roles of NPs, PAs, and CNMs as nonphysician health care providers began in the late 1960's when it was widely recognized that they could improve access to primary care, especially in rural and medically underserved areas - helps alleviate some geographic maldistribution of physicians problems - NPPs can provide high-quality and cost-effective medical care - compared to physicians, NPPs spend more time with patients and establish better rapport with them - they have been noted to have better communication and interviewing skills than physicians - patients are more satisfied with NPs than with physicians because they are more likely to do comprehensive examinations - CNMs are effective in providing access to obstetric and prenatal services in rural and poor communities - among the issues that remain to be solved before NPPs can be used to their full potential are legal restrictions on practice, reimbursement policies, and relationships with physicians - NPPs face financial barriers related to reimbursement - reimbursement for their services is generally indirect; that is, payments are made to they physician with whom they practice
Health Services Administrators
- employed at top, middle and entry levels of various types of organizations that deliver health services - top: provide leadership for an organizations long-term success -- responsible for operational, clinical, and financial outcomes of the entire organization - middle: may have leadership roles in major service centers such as outpatient, surgical services, nursing services, or may be departmental managers in charge of single departs such as diagnostics, dietary, rehabilitation, social services, environmental services, or medical records -- they often have direct responsibility for implementing changes, enhancing efficiency, and developing new procedures with respect to changes in the health care delivery system - entry: may function as assistant to midlevel managers and may supervise a small number of operatives -- main function may be to oversee and assist with operations critical to the efficient operation of a department unit
Health Care Financing and its Effects
- financing of private and public health insurance enables access to health care - payment to providers - moral hazard (consumer behavior that leads to a higher utilization of health care services when the services are covered by insurance) - provider-induced demand (the providers' ability to create demand) -- these services often create little or no additional health benefits - technology and services with liberal reimbursement proliferate - total health care expenditures are greater than if the same services were to be paid by the patients
Conclusion
- financing plays a critical role in health care delivery - for consumers, it pays for insurance coverage, which enables them to obtain health care services - for providers, it reimburses them for the services they need to deliver - ACA has been instrumental in expanding health care insurance coverage; but serious gaps still remain - for most services, the methods of reimbursement were changed from retrospective to prospective mechanisms after it became widely known that cost-based methods and fee-for-service reimbursement contained perverse incentives for providers to increase the cost of health care delivery - prospective payment methods, now widely used, and capitation, used by health maintenance organizations, contain incentives for the delivery of cost-effect health care - comprehensive health insurance also contained perverse incentives for consumers to use more health care than needed, a phenomenon known as moral hazard - deductibles and copy were instituted after payers realized that these methods of cost sharing reduced the excessive use of health care - current emphasis is on creating value-based payment models - govt. incurs a sizable proportion of total health care expenditures, estimated to be 43% of all health care spending in the US - hence, at least from a financing standpoint, the US has a quasi-national health care system
Insurance Coverage
- generosity of insurance coverage stimulates technological change - financing of health care through insurance, private or public, largely insulates both patients and providers from personal accountability for the utilization of medical services - because out-of-pocket costs are of limited cancer, patients expect their physicians to provide all that medical technology has to offer - knowing that services demanded by their patients are largely covered by insurance, providers vernally show little hesitation in delivering the series - other developed countries offer universal health insurance, but they use supply-side rationing to limit the overutlization of technology
Impact on Access
- geographic access to health care can be improved for many people by providing mobile equipment or by using new communications technologies that allow remote access to centralized equipment and specialized personnel - mobile equipment can be transported to rural and remote sites, making it accessible to those populations - mobile cardiac catheterization laboratories, for example, can make the bents of high technology available in rural settings
Effects of Health Care Financing and Insurance
- health care financing produces some undesirable effects - health insurance enables people to pay for health care, but also desensitizes both consumers and providers to the price of those services - First, it creates excessive demand from consumers who want to use their health insurance benefits -- consumes are driven to utilize more health care services than they would if they had to pay the entire price out of their own pockets - Second, financing exerts powerful influences on supply-side factors, such as how much health care is delivered -- financing indirectly affects the growth of medical technology - both moral hazard and provider-induced demand waste health care resources and add to the rising cost of health care - to counter these affects, countries with national health insurance implement supply-side rationing (focuses on restricting the availably of expensive medical technology and specialty care) - without a centrally managed health are system, the US cannot ration health care directly - indirect type of rationing (demand-side rationing) -- utilization of services is curtailed to some extent because not all Americans have health insurance coverage, despite the ACA - if health insurance is extended to everyone,m without other restrictions, total health care expenditures will rise at a much faster rate than they do now
Chapter 4 Conclusion
- health services professionals in the US constitute the larges proportion of the labor force - growth and development of these professions are influenced by demographic trends, advances in research and technology, disease and illness trends, and the changing environment of health care financing and del ivy - physicians play leading role in delivery of healthcare services - maldistribution of physicians - shortage of physicians due to ACA (more people are getting insured which means they are going to get access to healthcare meaning we need more physicians)
Resource-Based Relative Vale Scale
- implemented by medicare - RBRVS - reimburses physicians according to a relative value assigned to each physician service - relative values are based on the time, skill, and intensity it takes to provide a service, and the actual reimbursement is derived using a complex formula - each year, medicare publishes the Medicare Fee Schedule, which gives the reimbursement amount for each of the services and procedures identified by a current procedural terminology (CPT) code - amounts are adjusted for the geographic area in which the practice is located
Medicare Advantage (Part C)
- in reality is not a program that offers specifically define medical services - the program was formerly called Medicare+Choice--took effect on January 1, 1998 and was mandated by the Balanced Budget Act of 1997 -- the law expanded the role of private managed care health plans such as HMO and PPO plans - to participate in part C, a beneficiary must be enrolled in Part A and Part B, pay part B premiums, and an additional premium to the MCO (some plans have no premiums) - beneficiaries ego have the choice to remain in the original medicare fee-for-service program - by enrolling in part C, a beneficiary receives all the benefits of Part A, Part B, Part D services through an MCO - medicare pays a set capitalized amount of money each month to the participating managed care plans on behalf of each beneficiary - in turn, the plan manages Medicare benefits for its members - to attract medicare enrollees, MCOs may offer extra benefits, such as basic dental and vision benefits, which may lower the beneficiaries out-of-pocket costs - all Part C also eliminates the need for Medigap coverage - in 2014, 30% of beneficiaries were enrolled in Part C
Basic Insurance Concepts
- insurance is a mechanism for protection against risk - Risk: refers to the possibility of a substantial financial loss from some event - insurance, in a general sense, is primary designed to protect people against that risk (expensive treatments, cancer, surgery--that would be way to expensive to pay out of pocket) - health care providers are also subject to substantial risk when they are required to treat the sick and injured who cannot pay - Insured: an individual who is protected by insurance against the possible risk of financial loss -- referred too as enrollee or member, too (in a private health insurance plan) -- referred to as beneficiary (in public health insurance plan) - Insurer or Underwriter: the insuring agency that assumes risk - Underwriting: a systematic technique for evaluation, selecting (or rejecting), classifying, and rating risks - Four fundamental principles underlie the concept of insurance 1) Risk is unpredictable for the individual insured 2) Risk can be predicted with a reasonable degree of accuracy for a group or population 3) Insurance provides a mechanism for transferring or shifting risk from the individual to the group through the pooling of resources 4) Actual losses are shared on some equitable basis by all members of the insured group - based on underwriting, the insurer determines a fair price to insure against specified risks - Premium: the amount charged for insurance coverage (usually paid each month) - including both the employer's and employee's share, the average monthly cost of health insurance premiums in 2014 was $502 for a single plan and $1,403 for a family plan
Cost Sharing
- insurance requires some type of cost sharing so that the insured assumes at least part of the risk - purpose of cost sharing is to reduce the misuse of insurance benefits - with few exceptions, all health insurance plans must provide certain recommended preventative services and immunizations without cost sharing, mandated by ACA - 3 main types of cost sharing 1) Premium Cost Sharing 2) Deductibles (amount the insured must first pay before any benefits by the plan are payable) -- usually paid annually -- these vary greatly by the type of plan -- a plan may also have separate deductibles for hospitalization and outpatient surgery 3) Copayments (amount that the insured has to pay out of pocket each time health services are received after the deductible amount has been paid) -- form of dollar amount -- (cost sharing in the form of % = coinsurance) --> a plan with an 80:20 coinsurance pays 80% of all covered medical expenses after the deductible requirements has been met; the insured pays remaining 20% -- most plans include a stop-loss provision --which is the maximum out-of-pocket liability an insured would incur in a given year (purpose is to limit the total out-of-pocket cost for the insured) -- in case of a catastrophic illness or injury, the copayment amount can add up to a substantial sum -- once the stop-loss ratio has been met, the plan pays 100% of any additional expenses -- ACA mandates health plans (with some exceptions) to limit the stop loss to no more than $6,350 for single plans and to no more than $12,700 for family plans - in employer-sponsored health insurance, the employee is vernally required to share in the total cost of the premium -- of the premium costs given previously, insured workers on average paid 18% of the cost for single (individual) plans and 29% of the cost for family plans - in addition to paying as share of the cost of premiums through payroll deductions, insured individuals also pay a portion of the actual cost of medical services out of their own pockets -- these out-of-pocket expenses take the form of deductibles and copayments and are incurred only if an when medical care is used - previously, $1 to $2 million lifetime limits on benefits were common -- under ACA, the lifetime limits are prohibited for all health plans sold or renewed on or after September 23, 2010 - the rationale for cost sharing is to control the utilization of health care services - because insurance creates moral hazard by insulting the insured form the cost of health care, making the insured pay part of the cost promotes more responsible behavior in health care utilization - a study showed that cost sharing had a material impact on lowering utilization without any significant negative health consequences
Nanomedicine
- is an emerging area of medical technology that requires manipulation of materials at the atomic and molecular level - scientists are working on the use of nano materials for accurate diagnosis and treatment of diseases, such as cancer
Allied Health Professionals
- is someone who has received a certificate; associates, bachelors, or masters degree; doctoral-level preparation; or post baccalaureate training in a science rated to health care and has responsibility for the delivery of health or related services - these services may include those associated with the identification, evaluate, and prevention of disease and disorders; dietary and nutritional services; rehabilitation; or health systems management - they differ from those who have received (MD or DO), dentistry, optometry, podiatry, chiropractic, or pharmacy; a graduate degree in health administration; a degree clinical psychology; or a degree equivalent to one of these - time constraints due to more patients and lack of physicians, created a need to train other professionals who could serve as substitutes for physicians and nurses - they receive specialized training - this gave physicians and nurses the extra time they needed to keep them abreast of the latest advances in their disciplines - constitutes 60% of the U.S health care work force - Allied health professional can be divided into two broad categories 1) technicians and/or assistants 2) therapists and/or technologists
Nurses
- largest group of health care professionals - are the major caregivers of sick and injured patients, addressing their physical, mental, and emotional needs - licensed to practice -- graduation from an approved nursing program -- successful completion of a national examination - Two levels of nurses 1) Registered nurses (RNs) -- associates degree (ADN), a diploma program, or a bachelor of science in nursing (BSN) degree -- ADN takes about 2-3 yrs and are offered at community and junior colleges -- Diploma = 2-3 years and offered by hospitals -- BSN = 4-5 years and offered by colleges and universities 2) Licensed practical nurses (LPNs)--called licensed vocational nurses (LVNs) in some states -- must complete a state-approved program in practical nursing -- take a national written examination -- most programs last about a year which includes classroom study and supervised clinical practice - RNs supervise LPNs - patient-to-nurse staffing rations have increased, and caregiving has become more intensive - alternative settings has created new opportune for nursing employment - supportive roles for RNs are growing - shows current national shortfall of nurses, and is projected to increase - sluggish wages, low levels of job satisfaction, and inadequate career mobility pose some major impediments to attracting and retaining nurses - many U.S. hospitals turn to developing countries for their nursing supply and this is likely to continue
Dentists
- major providers of dental care - main role is to diagnose and treat problems related to the teeth, gums, and tissues of the mouth - must be licensed to practice - ^ includes: -- graduation from an accredited dental school that awards a doctor of dental surgery (DDS) or doctor of dental medicine (DMD) -- successful completion of both written and practical exams - 8 specialty areas are recognized by the American Dental Association: 1) orthodontics (teeth straightening) 2) oral and maxillofacial surgery (operating on the mouth and jaws) 3) pediatric dentistry (dental care for children) 4) periodontics (treating gums) 5) prosthodontics (making artificial teeth or dentures) 6) endodontics (root canal therapy) 7) public health dentistry (community dental health) 8) oral pathology (diseases of the mouth) - growth of dental specialties is influenced by technological advances like implant dentistry, laser-guided surfer, orthognathic surgery for the restoration of facial form and function, new metal combinations for use in prosthetic devices, new bone graft materials in tissue-guided regeneration techniques, and new materials and instruments - many dentists are involved in the prevention of dental decay and gum disease - dental offices generally employ dental hygienists and assistants to perform many of the preventative and routine care services - dentists also spot symptoms that require treatment by a physician - most dentists practice in private offices, either alone or in groups - dental offices are operated as private businesses and dentists often perform business tasks such as staffing, financing, purchasing, leasing, and work scheduling - some work within dental clinics in private companies, retail stores, franchised dental outlets, or managed care organizations - group dental practices have slowly grown - federal government employs dentist, mainly in the hospitals and clinics of the Department of Veterans Affairs and the U.S. Public Health Service - emergence of employer-sponsored dental insurance caused an increase demand for dental care because it enabled a greater segment of the population to afford it - demand for dentists will continue to increase in populations having high dental needs -- increased due to greater public awareness of how important dental care to general health status is -- fairly widespread appeal of cosmetic and aesthetic dentistry -- inclusion of dental care as part of many publicly funded programs (Head Start, Medicaid, community and migrant health centers, maternal and infant care) - specialties for dentists (table on page 91)
Impact on the Global Medical Practice
- many nations wait for US to develop new medical technologies that can then be introduced into their health care systems in a more controlled and manageable fashion - European and other economies get a free ride on US biomedical R&D and obtain nearly all the benefits of US medical technology at much lower health care costs - on the other hand, research partnerships overseas are extending the boundaries of knowledge about disease and strategies for diagnosis, treatment, and prevention - such collaborations will take added significance as global health will increasingly have repercussions for health of Americans - the home turf will no longer remain the domain of biomedical research and technological innovation
Legislation to Regulate Devices
- medical devises inclue general-purpose lab equipments, reagents, and test kits or diagnostic ultrasound equipment, x-ray machines, and other imaging technology - can be super simple or very complex - FDA was first given jurisdiction over medical devices under the Federal Food, Drug, and Cosmetic Act of 1938 - initially was confined to the sale of products that were believed to be unsafe or that made misleading claims of effectiveness - 1970's, several deaths and miscarriages were attributed to the Dalkon Shield, which had been marketed as safe and effective contraceptive device - The Medical Devices Amendments of 1976 extended the FDA's authority to include premarket review of medical devices divided into three classes: -- Class I: Devices that pose the lowest risk and are generally simple in design --- these devices are subject to general controls regarding misbranding--that is, fraudulent claims regarding their therapeutic effects --- examples: enema kits & elastic bandages -- Class II: devices subject to requirements for labeling, performance standards, and postmarked surveillance --- examples: powered wheelchairs & some pregnancy test kits -- Class III: devices that come under the most stringent requirements of premarket approval regarding safety and effectiveness --- devices in this class support life, prevent health impairment, or present a potential risk of illness or injury --- examples: implantable pacemakers and breast implants - The Safe Medical Devices Act of 1990 has particular relevance for health care providers, who are required by law to report to the manufacturer, and in some cases to the FDA as well, all injuries and deaths caused by medical devices -- requirements under this act serve as an early warning system for any serious device-elated problems that could potentially become widespread
Impact on the Structure and Processes of Health Care Delivery
- medical technology has transformed large urban hospitals into medical centers where the latest diagnostic and therapeutic remedies are offered, but technology also takes modern medicine to outpatient services and patients' own homes - this trend has led to reduced costs where similar technology was previously only available in hospitals - numerous diagnostic procedures, including some of the latest imaging procedures, are perfumed in outpatient settings - without technological innovations, extensive adaptions of modern treatments in outpatient and home care would not be possible
Conclusion
- medical technology includes: drugs, devices, procedures, facilities, information systems, and organizational systems - technology is one of the primary factors in the growth of health care expenditures in the US - FDA regulates the introduction of new drugs, devices, and biologics based on their efficacy and safety, but without evaluating their cost-effectiveness - most medical care in the US is wasteful, but at this point, no one is quite sure how to contain Americans' insatiable demand for the almost indiscriminate use of technology
Resource Utilization Groups
- medicare pays SNFs on the basis of RUGs, but the method differs from the way in with DRG-based payments are used for hospitals - whereas a fixed amount of reimbursement is associated with each DRG, RUG categories are used for determine an SNF's overall severity of health conditions requiring medical and nursing intervention - Case Mix: the aggregate of clinical severity in a facility - it is determined by first evaluation each patient's medical and nursing care needs - based on that evaluation, each patient is classified into 1 of 66 RUGS (according to RUG-IV classifications) - the case-mix composite of an institution is then used to determine a fixed per diem amount--an all-inclusive bundled rate-- associated with that case mix - the higher the case mix score, the higher the reimbursement - adjustments to the PPS rate are made for differences in wages prevailing in different geographic areas and for facility location in urban as opposed to rural areas
Specialists
- physicians in a non-primary care specialities dealing with particular diseases or organ systems - commonly requires additional years of advanced residency training followed by several years of practice in the specialty - specialty board exam is often required - Common medical specialties include: -- anesthesiology -- cardiology -- dermatology -- specialized internal medicine -- neurology -- obstetrics -- gynecology -- ophthalmology -- pathology -- pediatrics -- psychiatry -- radiology -- surgery - These specialties can be divided into six major functional groups: 1) the subspecialties of internal medicine 2) a brand group of medical specialties 3) obstetrics and gynecology 4) surgery of all types 5) hospital-based radiology, anesthesiology, and pathology 6) psychiatry
Geographic Maldistribution
- physicians often choose to concentrate in metropolitan and suburban areas rather than in rural and inner-city areas because they offer greater prospects for better living standards, professional interaction, access to modern facilities and technology, and professional growth -- most of the well-insured live in metropolitan area - demand for physicians' services is primary determined by the population's health care needs - the actual delivery of services is based on people's ability to pay for them, mainly through health insurance - this leaves rural areas and inner cities with provider shortages
Generalist/Primary Care Physicians
- physicians trained in family medicine/general practice, general internal medicine, and general pediatrics - for the most part, they provide preventative services (health examinations, immunizations, mammograms, Pap smears) and treat frequently occurring and less severe problems
Physicians
- play a central role by evaluating a patient's health condition, diagnosing abnormalities, and prescribing treatment - some engage in medical education and research to find new and better ways to control and cure health problems - they are required to be licensed before they can practice medicine - license requirements include: -- graduation from an accredited medical school and that awards a doctor of medicine (MD) or doctor of osteopathic medicine (DO) -- successful completion of a license exam administered by either the National Board of Medical Examiners or the National Board of Osteopathic Medical Examiners -- completion of a supervised internship/residency program -- most serve 1 year rotating internship after graduation before entering residency, which may last 2-6 years - number of active physicians has steadily increased in the US - of the 192 medical schools in the US, 163 teach allopathic medicine and award the MD degree, and 29 teach osteopathic medicine and award the DO degree
Private Insurance
- private insurance includes many different types of health plan providers, such as commercial insurance companies (Metropolitan Life, Prudential), Blue Cross/Blue Shield, self-insured employers, and managed care organizations (MCOs) - nonprofit blue cross and blue shield association function much like private health insurance companies - generally available in individual or family plans - daily plan covers the spouse and children of the subscriber in addition to the subscriber - in contrast, govt. programs such as Medicare and Medicaid do not offer family plans; each individual is an independent beneficiary - 5 Main Types of Private Insurance are Available: 1) Group Insurance 2) Self-Insurance 3) Individual Private Insurance 4) Managed Care Plans 5) High-Deductible Plans (HDHPs) - see figure 6.2 on page 142 - employment-based health insurance offers rates--percentages of employers who offer insurance--vary quire significantly according to employer characteristics (6.2) - 55% of employers in US offered health insurance benefits but this was before ACA mandated for employers to provide health insurance - 98% of large employers (200 or more workers) offered health insurance to at least some of their workers; but only 54% of small employers (3 to 199) did so - high cost of health insurance is the main reason small employers five for not offering it - offer rate is lower among employers that employ a large % of low-wage earners - only 24% of employers offered health insurance to part-time workers - large employers are more likely than small to offer health insurance benefits to part-time workers - health insurance offer rates are higher among workplaces that are unionized - offer rates are lower among employers that employ a large percentage of young workers aged 26 years and younger - among employers that offer health insurance benefits, 53% also offer a separate dental plan
The Affordable Care Act and Private Insurance
- private insurance remains backbone for obtaining coverage under the ACA - that coverage is obtained through one's employer or through govt.-run exchanges (called health insurance marketplaces) in which private insurers participate - The insurance expansion is addressed through the following main mandates (read fully on page 146) 1) Legal residents of the US were mandated to have what is refereed to as minimum essential coverage --if don't, you get penalized through income tax called sharing responsibility payment -- minimal exceptions (religious, 8% of income, etc.) 2) To purchase health insurance through government-run exchanges, subsidies are made available to people with incomes between 100% and 400% of FPL 3) The exchanges offer 4 types of standardized plans (bronze, silver, gold, platinum) tiered according to premium cost and cost sharing -- bronze = least expensive (covers approximately 60% of a person's health care costs 4) In an ACA provision that was delayed and changed by the Obama administration from implementation in 2014, employers with 100 or more full-time-equivalent workers must cover at least 70% of their full-time workers (30 hours or more per week) -- 95% by 2016 -- heavy fines to those who do not comply -- employers with less than 50 workers are exempt from this mandate 5) ACA made it illegal to deny health insurance to people with preexisting medical conditions and had required children and young adults under the age of 26 to be covered under their parent's health insurance plans
Some major chances triggered by technology
- raised consumer expectations about what may be possible leading to greater demand for utilization of the latest and best that technology can offer - influences organization and financing of medical services-special services that previously could be offered only in hospitals are now available in outpatient and community settings - influenced the scope and content of medical training and shaped the practice of medicine, fueling a trend toward specialization in medici at the expense of public health, preventative medicine, and primary care - as a whole, technology has contributed to health care cost escalation--for both consumer and provide, the cost of excessive treatment has generally been of little concern as long as a third party--either an insurance plan or the government--pays for it - raised complex moral and ethical dilemmas in medical research and decision making--life support decisions - economic globalization has also enveloped biomedical knowledge and technology--particularly true for the developed and developing nations where leading physicians have access to the same scientific knowledge through medical journals and the Internet--most drugs and medical devices available in the US are also available in many other parts of the world
Technologists and Therapists
- receive more advanced training - educated in how to evaluate patients, diagnose problems, develop treatment plans, evaluate the appropriateness and potential side effects of therapy treatments and teach procedural skills to technicians - physical therapists (provide care for patients with movement dysfunction) - occupational therapists (help people of all ages improve their ability to perform tasks in their daily living an work environments) --rehabilitate individuals who have conditions that are mentally, physically, developmentally, emotional disabling - Dietician's, or nutritionists and dietetic, ensure that institutional foods and diets are prepared in accordance with acceptable national standards - dispensing opticians - speech-language pathologists - audiologists - social workers
Electronic Health Records (EHRs)
- replace traditional paper medical records - use of these in the US is well under way, but little progress had been made in the development of information-sharing networks - make it possible to access individual records online from many separate, interoperable automated systems within an electronic network - INTEROPERABILITY = the ability to share and access patient information by various users - some evidence that EHR use produces improved patient care by enabling physicians to have timely access to patient records, altering them to a potential for medical errors, and making critical lab values available when needed - downside--there is some indication that use of EHRs may be time consuming, resulting in decreased productivity--US also has far to go in achieving interoperability because a significant number of physicians who us EHR still do not get all the needed information electronically - According to the Institute of Medicine (2003), a fully developed EHR system includes four key components: 1) Collection and storage of health information on individual patients over time, where health information is defined as information pertaining to the health of an individual or health care provided to an individual 2) Immediate electronic access to individual and population level information by authorized users 3) provision of knowledge and decision support that enhances the quality, safely, and efficiency of patient care (health informatics) 4) support of efficient processes for health care delivery
Cost Containment
- simply pointing to technology as the culprit for cost escalations and putting arbitrary restraints on technology development and dissemination would be a misdirected strategy - technology has the potential to enhance health benefits but also reduce costs - a greater emphasis should be placed on developing technology specifically for reducing costs
Medical Training and Practice
- specialty care over primary care and preventative services is emphasized in the US medical culture - emphasis is reflected on training of physicians - medical graduates consistently choose specialty rather primary care practice - oversupply of specialists has had important consequences for the development and use of new technology because primary care physicians use less technology than specialists, even for similar medical conditions
Supplementary Medical Insurance (Part B)
- supplementary medical insurance (SMI) - voluntary program - financed partly by general tax revenues and partly by required premium contributions from beneficiaries - almost all persons entitled to hospital insurance also choose to enroll in SMI because they cannot get similar coverage at that price from private insurers - coverage includes physician, ambulance, outpatient, rehabilitation, annual wellness exam, medically needed preventative services; hospital outpatient services such as outpatient surgery, diagnostic tests, radiology, pathology, emergency department visits, renal dialysis, prostheses, medical equipment and supplies - also covers limited home health services that are not associated with a hospital stay or SNF stay - premiums are income based - standard premium was 104.9 per month in 2015 - for beneficiaries earning more $85,000 and filing individual tax returns (or earning more than $170,000 and filing joint tax returns), premiums range between $146.9 and $333.7 depending on income - Part B also carries an annual deductible, $147, and an 80:0 coinsurance that applies to most services
Impact on Bioethics
- technological change is raising serious ethical and moral issues - gene mapping of humans, genetic cloning, stem cell research, genetic engineering, genetic testing, etc., may hold potential benefits, but they also present serious ethical dilemmas - example: research on embryonic stem cells may lead one day to the discovery of treatments and cures for diseases and other long-term degenerative illnesses (such as parkinson's disease, spinal cord injury, etc)--but the use of human embryos for research is highly controversial - life support technology also raises serious ethical issues in medical decision, including whether life support should continue when a patient may simply list in a permanent vegetative state or whether life support should be discontinues, and if so, at what point
The Government's Role in Technology Diffusion
- technology diffusion has been accompanied by issues of cost, safety, benefit, and risk - federal legislation, in turn, as attempted to address these concerns - govt. plays a signifiant role in carrying out research and providing funding for research Regulation of: - drugs - devices - biologics -- The Food and Drug Administration (FDA) is an agency of the US Department of Health and Human Services that is responsible for ensuring that drugs and medical devises are safe and effective for their intended use -- FDA also controls access to drugs by deciding whether a certain drug will be avail be by prescription only or as an over-the-counter purchase
Competition Among Providers
- technology-based specialization has been used by the medical establishment as an enticement to attract insured patients by advertising the availability of the latest technology, which creates a perception of quality in the midst of consumers - state-of-the-art technology also plays a role in the ability of a hospital or clinic to recruit specialists - when hospitals develop new services and invest heavily in modernization programs, other hospitals in the area vernally are forced to do the same, for competitive reasons - results in tremendous amount of duplication of services and equipment and have further contributed to medical specialization
Impact on Health Care Costs
- technoloical innovations have been the single most important factor in medical cot inflation--may have accounted for half of the total rise in health care spending in recent years - addition of new technology in health care usually increases both labor and capital costs (when its supposed to do the opposite) Cost increases associated with new medical technology: - Acquisition costs are often high because of R&D and precision manufacturing - Training or hiring of technicians with special skills - Facilities may require refurbishing or expansion to accommodate the new technology - Utilization when covered by insurance (moral hazard and provider-induced demand) - many new technologies increase costs, other actually reduce costs when they replace treatments that are more expensive - cost-effectiveness of individual technologies is also being evaluated Main areas in which use of technology has saved health care costs (Cost Saving Medical Technology): - Replacement of earlier, more expensive procedures - Minimally inverse procedures that eliminate the need for overnight hospital stays - Technologies that shorten hospital stays - Drugs that reduce inpatient psychiatric care - Technologies that enable services to be rendered in outpatient and home care settings instead of hospitals
Public Health Professionals
- the field of public health employs a diversity of health professionals - public health professionals focus on the community as a whole, rather than on treating the individual, and deal with issues such as access to health care, infectious diseases control, environmental health issues, and violence and injury issues - these include: -- physicians -- researchers -- administrators -- lawyers -- environmentalists -- social scientists - most have acquired a graduate degree from a school of public health (49 in the U.S.) - Five core disciplines in public health education -- biostatistics -- epidemiology -- health services administration -- health education/behavioral science -- environmental health
Specialty Maldistribution
- the number of primary care physicians increased by only 13%, # of specialists increased by 121% - supply of primary care physicians dropped between 1949 and 1970 and has slowly declined since then - the # of positions filled in family practice residency programs showed an increase during first few years of 1990s but has experienced a slow decline--similar trends with other ares in primary care training - declining interest in primary care among medical graduates - US = 38% generalists, 62% specialists - other industrialized countries typically have generalists accounting for over 50% of their physician workforce - Specialty maldistribution has ingrained in US health care delivery system for 3 main reasons: 1) medical technology 2) reimbursement methods and remuneration 3) specialty-orientated medical education - gap between primary and specialty physician workforces continues to expand - specialists are paid more - specialists have more predictable work hours and enjoy higher prestige among colleagues and the public at large - Many undesirable outcomes from the imbalance -- too many specialists = high volume of intensive, expensive, and invasive medical services and he rise of health care costs -- a greater supply of surgeons increases the demand for initial contacts and follow-up visits with surgeons (specialists) --> seeking care directly from specialists is often less effective than using primary care physicians who often provide early intervention before complications develop -- higher # of PCP (primary care physicians) = associated with lower overall mortality and lower death rates resulting from cardiovascular disease and cancer -- hence, the underserved populations suffer the most from shortages of primary care physicians
Pharmacists
- traditional role is to dispense medicines prescribed by physicians, dentists, and podiatrists - as well as to provide consultation on the proper selection of medicines - required license -- ^ PharmD degree requiring 6 years of postsecondary education -- graduation from an accredited pharmacy program -- successful completion of a supervised internship -- salary range is between $51,000 and $130,000 - most pharmacists are generalists, but some become specialists -- pharmacotherapists specially in drug therapy and work closely with physicians -- nutrition-support pharmacists determine and prepare drugs needed for nutritional therapy -- radio pharmacists (nuclear pharmacists) produce radioactive drugs used for patient diagnosis therapy - most hold salaried positions and working in community pharmacies that are independently owned or are part of a national drugstore, supermarket, or department store chain - are employed by hospitals, MCOs, home health agencies, clinics, government health services organizations, and pharmaceutical manufacturers - page 93 = sites of employment for pharmacists - role of pharmacists has expanded over last 2 decades from preparation and dispensing of prescriptions to include drug product education and serving as experts on specific drugs, drug interactions, and generic drug substitution - in about 1/2 of all states, pharmacists have the authority to initiate or modify drug treatments - pharmaceutical care: educating and counseling role of pharmacists
From Retrospective to Prospective Reimbursement
- traditionally medicare and medicaid established per diem (daily) rates for reimbursing hospitals, nursing hoes, and other patient facilities - they were bad don the actual costs the providers had incurred during the previous year--because they were set after evaluating the costs retrospectively, the method was referred to as retrospective reimbursement - how health was also reimbursed on the basis of cost - because retrospective method was based on costs that were directly related to length of stay, services rendered, and the cost of providing the services, providers had no incentive to control costs - services were rendered indiscriminately because health care institutions could increase their profits by increasing costs - because of this, it has largely been replaced by prospective methods of reimbursement - Prospective Reimbursement uses certain reestablished criteria to determine in advance the amount of reimbursement medicare has been using the prospective payment system (PPS) to reimburse inpatient hospital acute care services under Medicare Part A since 1983 - Four main prospective reimbursement methods currently in use are based on diagnosis-related groups (DRG), ambulatory payment classifications (APCs), resource utilization groups (RUGs), and home health resource groups (HHRGs)
Diagnosis-Related Groups
- used to pay for hospital in patient services - predetermined rate is set by DGRs - they prospectively set a bundled price according to the diagnosis at the time of admission - hospital receives the predetermined fixed rate for that particular DGR classification - primary factor governing the amount of reimbursement is the main clinical diagnosis, but additional factors can create differences in reimbursement for the same DRG -- such factors include differences in wage levels between geographic areas, an urban versus a real hospital location, whether the institution is a teaching hospital, and an adjustment related to treating a disproportionately large share of low-income patients - Medicare Severity Diagnosis-Related Groups (MS-DRGs) were implemented which include patient severity to better reflect use of hospital resources - this has forced hospitals to: -- control their costs -- keep costs below the fixed reimbursement amount -- minimize the length of inpatient stay - if there is a difference, the hospital gets to keep the remaining amount - but if they go over, they lose money - example on page 159 and very bottom of 158
Technicians and Assistants
- usually less than 2 years of post secondary education and are trained to perform procedures - require supervision from therapists or technologists to ensure that care plan evaluation occurs as part of the treatment process - this groups includes: -- physical therapy assistance -- certified occupational therapy assistants -- medical laboratory technicians -- radiological technicians -- respiratory therapy technicians
The Affordable Care Act and Payment Reform
- value-based payment providers is the next wave of change in the US health care delivery, required by ACA - these payment arrangements will be designed to incentivize and hold providers accountable for the total cot and quality of care for a population of patients - risk will increasingly shift to providers - one challenge-- is how value will be measured - also require changing the culture in which health care is practiced--how physicians practice medicine and what patients expect - experts agree that the current reimbursement system is not sustainable - the goals is to have 30% of medicare payments tied to quality or value by 2016, and 50% by 2018; using alternative payment models in which providers are held accountable for quality and cost - new model would include bundled payment as well as shared-savings and shared-risk arrangements
Work Settings and Practice Patterns
- variety of settings in which physicians work include hospitals, where they are employed as medical residents, staff physicians, or hospitalists - others work in the public sector--such as federal government agencies, public health clinics, community migrant health centers, schools, and prisons - most physicians are office-based practitioners in private clinics - in private practice, physicians are partners or salaried employees under contractual arrangements
Allopathic medicine
- views medical treatment as an active intervention to produce a counteracting reaction in an attempt to neutralize the effects of disease
Hospitalists
- whose specialty is organized around the site of care, the hospital - involved in inpatient medicine - their roles parallel those of primary care physicians in an outpatient setting, in that they manage the care of hospitalized patients - has long served a significant role in urban hospitals in Canada and the UK - came to significant extent in the past decade when managed care began to dominate the health care system--placing an emphasis on cost-efficiency - they seek to decrease overall cost and length of stay for patients, yet still maintain referring-physician satisfaction and the readmission rates of sub specialist colleagues - most train under various primary care concentrations such as general internal medicine, family practice, or general pediatrics
What does NPP stand for? Who are they? And, why are they important?
-NPP stands for Nonphysician Practitioners - These are clinical professionals who practice in many of the areas in which physicians practice but who do not have an MD or DO degree; PAs or physician assistants, NPs or nurse practitioners, and CNMs or certified nurse midwives. - They are important because they help alleviate some geographic maldistribution of physicians problems because they can substitute for physicians, they can provide high-quality and cost-effective medical care, they spend more time with patients compared to physicians and establish better compatibility with patients as well, they have been noted to have better communication and interviewing skills than physicians (these are important in community and migrant health centers in assessing patients who are predominantly of minority origin and often have little education), and patients tend to be more satisfied with them over physicians due to the fact that they are more likely to do comprehensive examinations.
Briefly describe two demographic trends that are increasing the demand for health care services.
1) One demographic trend that is increasing the demand for health care services is due to the aging of the baby boomer population that will continue to turn age 65 and older through 2029. Because of the baby boomers, we are going to need more health care services in nursing homes, long-term care facilities, in-home care, and many other services that require the attention and time of health care professionals. 2) A second demographic trend that will increase the demand for health services is increased life expectancies. Due to the increasing knowledge in what we know about health care, diseases, prevention, health determinants, and more; people's life expectancies are going to increase, and due to that we will need more health care services to compensate for the growing and increased longevity of the human population.
Briefly describe two ways in which physicians are maldistributed.
1) Physicians are geographically maldistributed because physicians have the tendency to concentrate in metropolitan and suburban areas over rural and inner-city areas due to what they offer. Such as, greater expectations for better living standards, professional interaction, access to modern facilities and technology, as well as professional growth. Most of the well-insured live in metropolitan areas and the demand for physicians is determined by the populations health care needs. And, the actual delivery of services is based on people's ability to pay for them through health insurance--all of this leaves rural areas and inner cities with provider shortages. 2) Physicians are also specialty maldistributed--meaning the percent increase in specialty physicians (121%) over general physicians (13%) is an astounding difference. There is a declining interest in primary care among medical students, which can be the results of a few things; such as, specialists are paid more, specialists have more predictable work hours, and they enjoy a higher prestige among colleagues and the public at large. The gap between primary and specialty physician workforces continue to expand; the US currently has 38% generalists and 62% specialists. This maldistribution of special physicians happened for three reasons: medical technology, reimbursement methods and remuneration, and specialty-oreitnated medical education.
List the 4 major categories of IT applications. How do "decision support systems" differ from "information systems"?
4 Major Categories of IT applications: 1) Clinical Information Systems 2) Administrative Information Systems 3) Decision Support Systems 4) Clinical Decisions Support Systems "Decision Support Systems" provide information and analytical tools to support managerial decision making--such as patient volume, project staffing requirements, evaluating financial performance, analyze utilization, conduct clinical research, and improve quality and productivity and CDSSs are interactive software systems designed to help clinicians with decision-making tasks such as recommendations for treatment; whereas "Information Systems" support patient care delivery such as EMR that provide reliable information necessary to guide clinical decision making, and they are also designed to help carryout financial and administrative support activities such as payroll. Support systems are more for evaluating managerial decisions, where as information systems are more for assisting support activities and that support patient care delivery. Her Notes: Information systems house information and support processes. Decision support systems are designed to make better use of the information.
Care Team Examples
ACOs and Medical Homes
Medical Home
An approach to the delivery of primary care that is: Patient-centered: - A partnership among practitioners, patients, and their families ensures that decisions respect patients' wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care. Comprehensive: - A team of care providers is wholly accountable for a patient's physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Coordinated: - Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports. Accessible: - Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations. Committed to quality and safety: - Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health. My Notes: - All members have to know what is going on—team meetings - If it is certified through the state/govt. they have to have proof that they have these different roles taking place within the team
START OF HER POWER POINTS
Chapters 4-6
Three ways of looking at it if you're a provider
Cost = what it costs to actually give care Charges = what you charge for that service Payment = what you get paid by insurance The tricky part is they are all different My Notes: - Don't have a good idea of what health care is actually going to cost—don't know the true cost physicians; how can put the price on cancer treatments (don't know how much you will need or what types, etc) - Charges may differ from cost—what they actually end up charging - Charges and payment will be different depending on what type of insurance you have - Discounts based on volume (how many people—the more, the better (likely a better discount)
Health care payment
Discussion
The Internet, E-Health, and E-therapy
E-Health - refers to "all forms of electronic health care delivered over the Internet, ranging from informational, educational, and commercial 'products' to direct services offered by professionals, non-professionals, businesses, or consumers themselves" -- the use of e-health has grown as many providers have created secure Internet portals to enable patients to access their EHRs; allow patient-provider e-mail messaging; use mobile apps for smartphones and tablets E-Therapy - has emerged as an alternative to face-to-face therapy for behavioral health support counseling -- also referred to as online therapy, e-counseling, teletherapy, or cyber counseling -- e-therapy refers to professional therapeutic interactions online between qualified mental health professionals and their clients -- growing evidence that it is effective for a variety of psychosocial problems -- main difference between e-health and e-therapy is that the former is a self-help approach for obtaining Web-based information; the latter involves interaction with a heath care professional - by accessing self-help information from the Internet, patients have become more active participants in their own health care - is does have the potential to create conflict between patients and their physicians - using the right source can provide valid and up-to-date information to both consumer and practitioners - the internet is not merely a source of info; it also offers new ways to create efficiency - in practice settings, the internet is being used to register patients, direct them to alternative care sites, transmit diagnostic results, and order pharmaceuticals and other products - by assessing patient information through the internet from their homes or hospital lounges, physicians can get a head start on their hospital rounds
What does the acronym EHR stand for? What is one? How close/far are we to interoperability?
EHR stands for Electronic Health Records -- They replace the traditional paper medical records; and make it possible to access individual records online from many, separate, interoperable automated systems within an electronic network The ability to share and access information by various users is what is meant by interoperability - We are not super close, actually we are still far from interoperability. Little progress has been made in the development of information-sharing networks. The U.S. has far to go because a significant number of physicians who use electronic health records still are unable to get all of the needed information electronically. Her Notes: With regard to interoperability, we still have a long way to go because 1) many physicians do not get all the information they need electronically, 2) people visit multiple providers across different systems, and 3) the platforms from different EHR companies still are not fantastic about communicating with each other (inadequate information-sharing networks). However, the situation is improving all the time.
Chapter 6
Financing and Reimbursement Methods
Physicians practicing family medicine, internal medicine, pediatrics and primary care are termed:
Generalists
Role Plays
Goal: Practice SBAR approaches in groups MY Random Notes: New types of roles/jobs (kind of goes along with article) Care Coordinator: bachelors-masters/ coordinate care for chronic conditions could be in the psychology field, sociologists, etc. Practice Facilitator role: more concerned with quality metrics--measures for clinics that they have to meet that recognize good quality care Primary Care Technicians: kind of like medical assistants—and community health workers (CHW) who are lay people who are trained in providing resources and referral and information often to very specific communities- schools that are very under developed/funded get parents involved to help How do you feel about managing these personnel or getting care from them? -- If it was a basic service I wouldn't mind at all more serious I wouldn't feel that comfortable -- probably going to continue to go in this direction MUA = medical underserved area usually high need area driven by demographics of community HPSA = health professional shortage area don't have enough providers (primary care, dental*, *mental health care—particularly those that can serve low income people) -- two federal ___
Chapter 6
Health Care Financing Health Care Payment
Chapter 4
Health Care Providers and Professionals Intro: - U.S. health care industry is the largest employer in the nation - It employs at least 13% of the total labor force in the U.S. - The health care sector will continue to grow because of 1) growth in the overall population, mainly due to immigration 2) aging of the population, as the baby boomers continue to turn age 65 years and older through 2029 3) increased life expectancies - Health professionals are among the most well education and diverse of all labor groups - Health professionals work in a variety of health care settings - The majority are employed by hospitals, followed by nursing care facilities, and physicians' offices and clinics (page 82 table) - the demand for health service professionals closely follows demographic trends, advances in research and technology, disease and illness trends, and changes in insurance and the delivery of services - Advances in science = new methods of preventing, diagnosing, and treating illness - Need to update skills due to new and complex medical techniques and machines - Greater utilization of health care services = greater demand for health care professionals - Emphasis is placed on physicians in this chapter because they play a leading role in the delivery of health care - There is an imbalance between primary and specialty care services, the maldistribution of practitioners, and the looming personnel shortages
Relevance
Increased focus on providing care in teams, driven by: - The nature of disease (chronic) -- Not easily addressed in one visit—often have to refer to other health care professionals, or involve other healt care professionals a lot of the time - Complexity of cases / complexity of procedures -- Long-term cases--can be very complicated - Physician maldistribution -- Chapter 4 - Physician burnout -- Physicians are too over worked, too tired, too stressed - Medical home approaches and other organizational / payment approaches (Ch. 6) -- Favoring team treatment—ACO's (lump sum payment for a TEAM), measuring quality metrics "Work smarter, not harder" My Notes: - really, really important - Care is always provided in teams
The Current State
It is a very odd and complicated mix... One foot in the FFS world One foot in the ACO/TCC world My Notes: Payment is complex—especially for doctors/hco Various contracts may have similar or different quality metrics they need to meet
Government-determined criteria related to quality, safety, and efficiency that providers are required to meet in order to get money for adopting electronic health records are termed:
Meaningful Use
Principles of Team-Based Care
Measurable processes and outcomes: The team agrees on and implements reliable and timely feedback on successes and failures in both the functioning of the team and achievement of the team's goals. These are used to track and improve performance immediately and over time.
What is Medical Technology
Medical Technology refers to the practical application of scientific knowledge to improve people's health and to create efficiencies in the delivery of medical care - medical science has benefited from developments in other applied sciences such as chemistry, physics, engineering, and pharmacology -- for example, advances in organic chemistry made it possible to identify and extract the active ingredients found in atrial plants to produce drugs and anesthetics - Magnetic resonance imaging (MRI) --had its origin in basic research on the structure of the atom--later was transformed into a major diagnostic tool - nanomedicine - in its narrow sense, medical technology includes sophisticated machines, pharmaceuticals, and biological therapies - in broader sense, it also covers medical and surgical procedures used in rendering medical care, ultramodern facilities and settings of care deliver, health information systems, and management and operational systems that make health care delivery more efficient - see exhibit 5.1 on page 110 (examples of medical technology)
Briefly describe how Medicare pays for inpatient services. Is this prospective or retrospective?
Medicare pays for inpatient services through DRGs (diagnosis - related groups). Medicare sets a bundled price for a set of services associated with a particular diagnosis at the time of admission. Additional factors such as geography, urban/rural, type of hospital and population of those served by the hospital also factor in. DRGs are a form of prospective payment.
Consumer behavior that leads to higher utilization of health care services when such services are covered by insurance is called.
Moral hazard
Principles of Team-Based Care
Mutual trust: Team members earn each others' trust, creating strong norms of reciprocity and greater opportunities for shared achievement. Effective communication: The team prioritizes and continuously refines its communication skills. It has consistent channels for candid and complete communication, which are accessed and used by all team members across all settings. My Notes: Progress and outcomes that are measurable
This health care profession is the largest in terms of number of persons.
Nurses
Describe one difference and one similarity between devices and biologics.
One similarity between devices and biologics is that they both include a wide range of products. They also can both be considered to be very complex. At some point, they both had jurisdiction based on the Federal Food, Drug, and Cosmetic Act of 1938. They also both include reagents (complex mixtures). Lastly, they are both used to help treat or prevent a disease or health condition. One difference between devices and biologics is that biologics are derived from living organisms, such as blood components and gene therapy, whereas devices are not--such devices are x-ray machines, ultrasound equipment, pacemakers, etc. Biologics are isolated from a variety of natural resources--human, animal, or microorganism--devices are not.
Types of Health Care Teams
Ongoing -- usually fixed staff -- fairly conventional -- pretty stable team Microsystem -- a little less stable -- floor unit or surgical unit -- different people all the time performing the same set of tasks ** airplane flight team Microsystem: - Signifies, we have a team, somewhat stable, somewhat rotating in terms of person and function - Setting for professional formation, form themselves, some structure, some patterns of ordered relationships - Locus of control for much of the workforce, can be motivating and dissatisfying, basic building blocks - Units of clinical policy and practice - Leading, cutting edge, most innovative - Care is delivered largely through these microsystems - Us managers are most likely going to be a part of these teams PICTURE OF THIS ON SLIDE 4 IN TEAM-BASED CARE
Health Care Payment
Powerpoint (some notes in notebook from this powerpoint)
Define provider-induced demand and describe how fee-for-service reimbursement increases it.
Provider-Induced demand is the artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes. Fee-for-service reimbursement increases this demand because fee-for-service is based on the assumption that services are provided in a set of identifiable and individually distinct units of services--such as an examination, an x-ray, an admission kit--all which are paid for separately and not as a bundled package. The more you consume the more you pay, so the higher the providers income will be. Because a consumer is paying for each individual unit, the provider is going to try and use as many possible units--and unnecessary ones too-- to charge the consumer for, to increase their incomes--because the consumer will be paying for unnecessary/unneeded services.
Chapter 4
Providers and Professionals In US Health Care Last, I have posted on Moodle an article that I would like you to read for Monday - it's called "Primary Care Technicians" and I will use it as a platform for discussion. PCTs are a new, innovative and evolving component of a health care team, designed to alleviate some of these issues with physician maldistribution in a cost-effective manner.
Impact on Quality of Life
Quality of life indicates a patient's overall satisfaction with life during and after medical treatment - example: quality of life is enhanced when technology enables people to live normal lives despite disabling conditions affecting speech, hearing, vision, and movement - major technological advances have furnished the clinical ability to help patients cope with diabetes, heart disease, end-stage renal disease, and HIV/AIDS - HIV/AIDS has become a chronic condition disease instead of a death sentence - new categories of drugs are instrumental in relieving pan and suffering - minimally invasive surgical procedures, such as lithotripsy, which crushed kidney and bile stones by shock waves, have improved quality of life by reducing pain and suffering and allowing a quicker return to normal life
Personal skills chart and definitions
REVIEW SLIDE 14 ON TEAM-BASED CARE POWERPOINT (DEFINITIONS)
Percent Point Decrease in Uninsured, by Medicaid Expansion Status
REVIEW SLIDE 19 My Notes: First time around of the ACA - Most of newly insured are highest risk based on income -mostly eligible for medicaid
Where Does the Money Come From?
REVIEW SLIDE 3 My Notes: - Global level - Most is financed through public matters--not private
Per Capita Spending Among the Non-elderly
REVIEW SLIDE 4 My Notes: - non-elderly because most are covered by Medicare
National Health Expenditures By Type
REVIEW SLIDE 5 My Notes: Growing faster than inflation most of the time Hospital care is the biggest chunk Most is spent on care for people
Changes in NHE and GDP / HDHP or MSA Coverage
REVIEW SLIDES 23 AND 24
In one sentence, describe the main difference between financing and reimbursement? NOTE: I will only grade the first sentence.
Reimbursement is the payment made by third-party payers (govt., insurance companies) to the providers of services whereas financing is any mechanism that gives people the ability to pay for health care services.
Payment
Reimbursements made from payers (or "payors") to providers and health care organizations (hospitals, integrated systems)
Health care payment
Revenue cycle (how it works from HC Org. perspective) REVIEW SLIDE 18 ON HC PAYMENT PP My Notes: Starts with appointment scheduling Health care managers working at each stage of this cycle too
Providers
Role is to provide care - Doctors - Dentists - Pharmacists - Nurses - Mid-level professionals - Allied health professionals -- Social work, health education, therapists, technicians
What is the government's role in technology diffusion?
Select one: a. Regulate technology b. Incentivize the use of technology c. Research the use of technology d. All of the above Correct **** e. None of the above
Principles of Team-Based Care
Shared goals: The team—including the patient and, where appropriate, family members or other support persons—works to establish shared goals that reflect patient and family priorities, and can be clearly articulated, understood, and supported by all team members. Clear roles: There are clear expectations for each team member's functions, responsibilities, and accountabilities, which optimize the team's efficiency and often make it possible for the team to take advantage of division of labor, thereby accomplishing more than the sum of its parts.
Similarities and Differences Between MDs and DOs
Similarities: - both use traditionally accepted methods of treatment, including drugs and surgery Differences: - mainly differ in their philosophies and approaches to medical treatment - Osteopathic medicine, practiced by DOs emphasizes the musculoskeletal system of the body (the correction of joints or tissues) - in their treatment plans, DOs stress preventative medicine such as diet and environment factors that might influence natural resistance - they take a holistic approach to patient care - MDs are trained allopathic medicine - are particularly generalists - may use also preventative medicine along with allopathic treatments Approximately 1/3 of MDs and more than 1/2 of DOs are generalists
Major Categories
Specific IT system applications in health services delivery fall into four main areas: 1) Clinical Information Systems -- IT applications that support patient care delivery -- Electronic medica records, for example, can quickly provide reliable information necessary to guide clinical decision making and to produce timely reports on the quality of care delivered -- computerized physician-order entry enables physicians to transmit orders electronically from the patient's bedside -- telemedicine is baed on integrated applications of telecommunications and information technologies -- HEALTH INFORMATICS is the term now used for IT applications that are designed to improve clinical efficiency, accuracy, and reliability 2) Administrative Information Systems -- designed to assist in carrying out financial and administrative support activities such as payroll, patient accounting, staff scheduling, materials management, budgeting and cost control, and office automation 3) Decision Support Systems -- provide information and analytical tools to support managerial decision making -- such tools are used to forecast patient volume, project staffing requirements, evaluate financial performance, analyze utilization, conduct clinical research, and improve quality and productivity 4) Clinical Decision Support Systems (CDSSs) -- interactive software systems designed to help clinicians with decision-making tasks, such as determining a diagnosis or recommending a treatment for a patient -- is not yet widespread -- internet and e-health applications enable patients and practitioners to access information, facilitate interaction between consumers or between patient and providers, add certain conveniences for both physicians and patients, and enable the possibility of VIRTUAL VISITS online between a patient and physician
SLIDE 7 ON PAYMENT POWERPOINT
Steven Brill, A Bitter Pill in Time Magazine MRI scans, 28 million MRIs $8,000 in U.S. $280 France Increased 80% from 2004-2010 vs 12% when no financial incentive to order scans What actually gets paid
Chapter 5
Technology and Health Care
Chapter 5
Technology and Its Effects - technology has brought numerous benefits, but it comes with a price that society has to pay - new medical cures have increased longevity, and new drugs have helped stabilize chronic conditions and have given an improved quality of life to many - life expectancy has almost doubled from 1900 to 1965--and was a result of advances in social conditions--improved sanitation, nutrition, and living conditions--rather than advances in medical treatment - the continuing increase in longevity since then, however, has been largely attributed to advances in medical technology as well as better nutrition and living conditions - other countries have been able to place limits on the availably and use of costly technology through supply-side rationing - America, not so much--hence, the major predicament of extending health care to all Americans--basic health care for some and availability of technologically advanced services for others are impractical in the US
Health care payment
The Big Picture
Match the insurance term to its definition:
The amount charged for insurance coverage on a yearly or monthly basis. = Premium The amount the insured must first pay before any benefits are payable by the plan. = Deductible The amount the insured has to pay out of pocket when services are received. = CoPayment When cost sharing is in the form of a percent of covered medical services, versus a fixed amount. = CoInsurance Maximum amount an insured would pay out-of-pocket in a given year. = Stop-Loss Provision
Health care payment
The details
Affordable Care Act and Public Insurance
The main changes to the public insurance programs under the ACA are: (REVIEW PAGE 155 FOR FURTHER INFORMATION) 1) payment cuts to managed care plans participation gin medicare advantage between 2012-2017-- enrollment in medicare advantage was expected to decrease but they actually increased by 41% between 2010-2014 2) expansion of medicaid under the penalty of losing matching funds if a state would not expand its medicaid program was signifiant in the ACA --option to extend medicaid or not 3) for people whose incomes range between 139% and 200% of the FPL--who would not otherwise qualify for media--the ACA allows states to set up a separate Basic Health Program --where enrollees obtain health insurance through the state govt., not through the exchanges even though they qualify for exchange-offered insurance
Team-based care
The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable.
Team-based care definition
The provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, efficient, and equitable. (Institute for Healthcare Improvement) My Notes: - Patients are part of the team - Family care givers (should the patient choose) - In addition to the team, there may be community resources that are helpful - Shared goals - Safe, effective, patient-centered, timely, efficient, and equitable (asked to memorize these) part of the Institute for Healthcare Improvement
