Healthcare Management Final Review
Why is US Healthcare costs so expensive?- why are costs rising? what are the main factors? Which are most important? How can we control them (contain costs)?
-3rd Party Payment: Services are paid for by a third party instead of the consumer, so individual out-of-pocket expenses are lower than service costs. Patients are then insensitive to care costs. -Imperfect Market: Providers set the price for healthcare services and the delivery system is not the regulated single-payer or free market model, utilization of services can go unchecked and prices can be charged higher than the actual economic cost of production -Growth of technology: New/advanced tech leads to advanced screening and imaging which is costly, also expensive to research and develop -Increase in elderly/chronic conditions populations: The life expectancy in the U.S. is increasing, the elderly population is expensive due to chronic conditions -Medical model of health delivery: Emphasis on intervention and not prevention leads to high treatment costs -Multi-payer system and admin costs: Administrative costs account for 25% of healthcare costs and the multi-payer system is expensive -Defensive medicine: Fear of legal risks leads to unnecessary testing and costs -Waste and abuse: Fraud, false bills, unnecessary care or bundling -Practice variations: Geographic differences, increased costs without better care
28. What are the ethical issues involved with end of life care? With technology?
-Broken communication: Family/loved ones may be unable to describe what their loved ones want -Patient autonomy may be compromised -Symptom management may be poor -Shared decision-making: More than one party being involved in the decision-making of EOL care (such as significant others going against patient wishes) -Living Will: Communicates a patient's wishes regarding medical treatment when they cannot make decisions due to terminal illness or incapacitation, however it is general and does not cover all situations -Medical Power of Attorney: A written legal document in which the patient appoints another individual to act as the patient's agent for healthcare decision-making if the patient is unable or unwilling to make decisions. The appointed person may not act in the same manner the patient would have acted had they remained competent. -Technology can increase life expectancy but what if the patient does not want it?
4. Why should the United States control the rising costs of health care? Why is US healthcare so expensive?
-Costs were so high that medical bankruptcies affected 2 million people, and these costs threatened to consume the entire federal budget. Costs are high due to expensive life-prolonging care that is given even when prognoses' are poor, the rise of malpractice lawsuits and defensive medicine, and the lack of price transparency.
19. Name the four basic functional components of the U.S. health care delivery system. Which role does each play in the delivery of health care?
-Financing: To obtain health insurance or health care services. Health insurance is typically employment-based (private) and employers purchase through an MCO or insurance company they choose. -Insurance: Protects the insured against financial catastrophe by providing expensive healthcare services when needed. Insurance determines the package of health services for the individual, and the MCO or insurance company also functions as a claims processor and manages the disbursement of funds to the health care providers -Delivery: Provision of health care services by various providers -Payment: Reimbursement to providers for services delivered. The insurer determines how much is paid for a certain service, funds for actual disbursement come from the premiums paid to the MCO or insurance company.
What are the features of US Healthcare Policy? Are they good or bad? How? How do we need to change them?
-Government as Subsidiary to the Private Sector: America does not trust the government, and health care is not a right/primary government responsibility; the private sector plays a dominant role in U.S. healthcare. The role of the government in healthcare is growing to address problems for the underprivileged, but it leads to the growth of healthcare expenditures, government left to fill gap of uninsured -Fragmented, incremental, piecemeal reform: Refers to the lack of coordination between the checks and balances system/federal/local/state governments. This leads to healthcare financing being complex and covered by different groups, ranging from employers to the government (Poor are covered through Medicaid, and special populations (Vets, armed forces) are covered by gov). Incremental and piecemeal policies refer to the compromises made to accommodate certain groups, such as children, the disabled, and the elderly/poor. -Pluralistic and interest group politics: Policy outcomes are influenced by the demands of interest groups, and compromises are made to satisfy those demands. Physicians, providers/hospitals, nursing homes, and pharmaceutical companies are different interest groups with different goals. Additionally, each branch/level of government in the U.S. can also influence health policy. Innovative/non-incremental policies are resisted as threats, interest groups are the most effective policy demanders, resist major changes, combine and concentrate resources/alliances (AMA, AARP, AHA), employers are concerned about employee benefits and costs, small business oppose mandates to coverage, and consumer groups are too diverse and lack resources to organize/advocate -Decentralized role of the States: Individual states play a significant role in development and implementation of policy, as it is more personal and respo
6. What is the difference between HMOs PPOs and other MCOs?
-HMO: Health Maintenance Organization. They have their own set of healthcare providers with a specific set payment. HMOs require appointments and PCP referrals but cost less than PPOs. -PPOs: Preferred Provider Organization. They have a network of providers to use at a certain rate, allowing you to receive care in our out of your network, providing flexibility. PPOs use discounted fee arrangements of 25-35% instead of capitation. ACOs: Accountable Care Organizations. Integrated groups of providers who are willing to take responsibility for a defined population. Meant for the Medicare populations, came about with ACA. POS plans: Point of Service. Combines features of HMOs with choice of PPO. Allows provider choice but retains tight utilization. Free choice of providers is selling point. Enrollment is declining due to high out of pocket costs
2. What is the difference between licensure, certification, and accreditation?
-Hospital licensure: Regulatory requirements to operate a hospital overseen by the state government to emphasize building safety and sanitation policies. Emphasis on the quality of the space of practice (safety and building codes, etc). -Certification: The adherence of certain conditions that allow for a hospital to participate in Medicare and Medicaid programs (government). Unlike licensure, certification is not required and also focuses on the quality of care. -Accreditation: Private campaign to assure healthcare facilities meet basic standards. Although it is not required, accredited facilities are eligible for Medicare reimbursement, encouraging accreditation instead of going through the certification process. Accreditation is done by the Joint Commission and American Osteopathic Association, with the former setting standards for long-term care facilities, psychiatric facilities, substance abuse programs, and other none-hospital practices.
35. What is Quality? How is it measured? What metrics are used? How does transparency and public reporting affect/improve care?
-IOM Quality Definition: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge -Measured from unacceptable to excellent -Micro: Focus on services at delivery point, looks at performance of an individual or organization, medical errors, quality of life -Macro: Population viewpoint, system performance, cost of care, access
41. What are future challenges for healthcare? How do we put it all together?
-Innovate payment systems incentives new approaches -Value-based shared savings payments: Based on achievement of health goals, chronic condition management, preventative care, preventing hospitalization, reaching population health targets -Provider-led organizations will become risk-bearing entities -Workforce challenges: Shortages, burnouts, not working at the top of the license, geriatrics. lack of unified licensure across states -Elderly care and chronic conditions -Global challenges such as bioterrorism and armed conflicts -Controversial technology frontiers -No universal coverage -Medicaid has more barriers than employer-based insurance -Shortage of healthcare workers especially rurally -Insurance premiums are not moderated by the ACA, increasing deductibles and co-pays -Reform is held up in politics -National debt is rising -More utilization management and reimbursement limiting needed
16. From the standpoint of health insurance, what were the main accomplishments of the Affordable Care Act?
-Insured more people by expanding eligibility
Integrated Care Model
-Integrated Care Model: Formed in response to managed care. Integration of several organizations under the same ownership or contractual relationships. Provides a variety of healthcare services to a large community, including acute care hospitals, ambulatory care, physician group practices, LTC, and Home Health. Leading to better quality/lower utilization/cost savings. Pressure to reduce costs hard on small providers.
38. Why does Philadelphia County score so poorly in the County health rankings? What can we do about it? Who is responsible?
-Lack of preventative care: Unhealthy food options lead to high obesity rates, and lack of education can lead to sexual/general health, low-income can lead to lack of insurance/access to care/transportation to care/hesitancy to seek care, lack of exercise -Drug epidemic (opioids) -Social factors (racism) -Focus on preventative care as mentioned above and more accessible care in terms of cost and accounting for transportation
40. What are leading health indicators? Why are they important? How are they used?- WHO rankings. Healthy People Initiatives.
-Leading Health Indicators: Factors that impact major causes of death and diseases -Helps organizations, communities, and states across the nation focus resources and efforts to improve health Examples: -Access to health services -Clinical Preventive services -Environmental Quality -Injury and Violence Maternal Infant and Child Health -Mental Health -Nutrition, Physical Activity, and Obesity -Oral Health -Reproductive and Sexual Health -Social Determinants -Substance Abuse -Tobacco
11. What are the main differences between Medicare and Medicaid? What do you think of Medicare for All?
-Medicare: Federally INSURANCE funded by a trust fund from payroll taxes, 65+ or certain disabled people/end stage renal disease, not based on income, part of the cost is paid through monthly premiums for medical and drug coverage, deductibles, and coinsurance, divided into four parts (A, B, C, D) Medicare is for an individual -Medicaid: Federally and state funded (Federal, State, Local taxes) ASSISTANCE (therefore each state has its own regulations they must follow as well as the federal rules), based on low income, can cover nursing home care and personal services (dental and vision), don't typically pay anything for services other than a small co-pay, participants receive regular dental and vision exams, Medicaid can cover a whole family Both benefit people with disabilities, prescription drug coverage, outpatient and inpatient hospital care
21. What are the main characteristics of the US Healthcare System? How do they differ from other Countries who have Universal Healthcare? Which main roles does the government play in the U.S. health services system?
-No central agency unlike most other nations with Universal Healthcare -Technology-driven system focusing on acute care -High cost, unequal access, average quality -Delivery of health care under imperfect market conditions (only partially free market) Government as a subsidiary of the private sector -Fusion or market and social justice -Multiple players and balance of power Quest for integration and accountability -Access to health care services selectively based on insurance coverage -Legal risks influencing practice behaviors -Insurers from a third party act as intermediaries between the financing and delivery functions
37. What are some of the ways we can improve quality and cost effectiveness?
-Peer reviews and peer review organizations (PROs) determine whether utilization/care was reasonable, necessary, good quality, appropriately provided -PROs can deny payment if care does not meet their standards -PROs are also now called Quality Improvement Organizations (QIOs) -Physician Quality Reporting System (PQRS) encourages reporting Medicare quality -National Committee for Quality Assurance (NCQA) -Healthcare Effectiveness Data and Information Set (HEDIS)
29. What are the alternatives to using the Emergency room? Why is this important?
-Primary care providers -Walk in clinics -Urgent care clinics -Convenience clinics -Telehealth -Important because the ER can get expensive
22. What are the pros and cons of Universal Health Care?
-Pros: No one dies due to being uninsured, nobody gets left out, no bills deductibles or premiums or copayments, patients, and physicians can focus more on treatment instead of payments and insurance, taxpayers save millions of dollars, simple and affordable, free choice of doctors and hospitals, no hospital bankruptcies, no excluding pre-existing conditions. -Cons: Long wait times, potential physician shortage since the prospect of making a lot of money is gone, limited choices between drug brands and treatment, diluted confidentiality system
What technology might be in the future? Costs?
-Raises consumer expectations/demand for use -Influences organizations and financing of services -Fuels cost escalation -Raises medical and ethical issues -Future issues include genetic mapping, personalized surgery and pharmacogenomics, drug design, non-invasive surgery, vaccines and xeno-transplant (from animals)
Describe the critical policy issues related to quality of care.
-Six areas for quality improvement: Safety, effectiveness, patient-centeredness, timeliness, efficiency, equity -Quality needs to be researched, measure the outcomes of interventions and appropriateness of medical procedures -Malpractice reform
26. What are some of the trends and directions of healthcare delivery?
-Social and Demographic: The U.S. is ethnically diverse, as well as older. Cultural aspects and lifestyle differences will require a change in the future of healthcare delivery. -Political: Politics are very polarizing over healthcare-related issues, and depending on which party has legislative majority, healthcare services may be accessible/inaccessible or costly/less expensive. -Economic: Economic growth, employment, household incomes, and the national debt determine the availability of healthcare services, costs, and affordability. -Technological: Technology is advancing healthcare, making treatment more accessible and effective. However, there are concerns about the high cost of research and development, as well as the implementation of these technologies. -Informational: IT is being used in healthcare delivery in a variety of ways and is continuing to evolve and be used. Although Americans are distrustful of smart cards due to potentially compromising information, it may become acceptable in the U.S. -Ecological: Global forces such as new diseases, disasters, and bioterrorism can majorly impact public health. The CDC will continue to evolve as new challenges emerge. -Global: As the economies of the world become more intertwined, this may lead to more affordable medication and medical equipment due to manufacturing and universal healthcare is emerging as a global trend in developing nations. -Anthro Cultural: Although society tends to focus on treatment-based care, population-level preventative interventions improve health and are being prioritized more.
42. How might the COVID pandemic change medicine for the future?
-Telemedicine/telehealth -Vaccinations become more polarizing (?) -More public health awareness
3. What is national healthcare spending? How does this vary between countries? What is remarkable about US healthcare spending? Do we get the value for our spend? What areas are we worse and what areas are we better?
-The United States spent $3.6 trillion on healthcare, which equals 17.7% of GDP (gross domestic product). In terms of Per Capita costs, it's $9,300. -The government finances 45% of our National Health Expenditure. -Despite our high costs, we lack equal access and have average (even poor) outcomes compared to other countries. We are good at specialty care, technology, and research
32. What is primary care? Why is it important? How does it relate to access, quality, and cost? What are the outcomes of primary care shortages?
-The entry point of healthcare that follows the timeline of an initial evaluation, prevention, diagnosis, treatment, consultation, and follow-up. -Focuses on the whole patient, ambulatory training -Integrated, allows access to treating more people, treating multiple problems simultaneously (comorbidity), and also controlling costs and resource utilization. -Primary care shortages are due to the near 50/50 amount of specialists to PCPs. This leads to increased costs and decreased quality. There is also a shortage of PCPs in rural areas, leading to more need for government assistance, longer wait times, accessibility struggles, long-distance travel, and limited resources
Describe the critical policy issues related to cost of care
-The government's main weapon of cost control has been cutting payments to providers -PPS has achieved success in reducing inpatient costs, but outpatient costs climb -Prescription drug spending is rapidly rising
36. What is the triple aim? How are we trying to address these goals?
-Three aims towards improving care: experience of care, the health of the population, and reducing per capita cost. -This balance accounts for keeping everyone satisfied, care on the individual level (patient and provider) being a positive experience, and encouraging people to seek care when needed. Population health means more healthy people, and reducing per capita costs means less for people to pay. -Care coordination, patient engagement, transparency, accountability, and aligning the economic incentives to provide the best care at the best price
Traditional Care Model:
-Traditional Care Model: Uncoordinated between inpatient, outpatient, primary care, and specialty care. Also has different quality metrics, different pay for performance programs, and different payer rules
17. Discuss the main cultural beliefs and values in American society that have influenced health care delivery, including how they have shaped the health care delivery system. What is market justice? Social justice? Where does the US system stand in regards to these? Why? Do you think this will change over time? What are the effects of politics, special interest groups, leadership?
-US traditional beliefs: conservative, market justice -Market Justice: Treats healthcare like a good in a free economy; only obtainable if you have the money for it, meaning those who struggle financially struggle to receive healthcare. Market justice does not consider economic factors on health, putting society at risk. -Social Justice: Treats healthcare as a social responsibility: Everyone should have access to healthcare, as it is not a regular good and service, best when a central agency is responsible for production and distribution, need-based instead of cost-based
What is VBP? What is the 3rd leading cause of death and what does quality improvement have to do with that?
-Value-Based Performance: The idea that value is made up of quality measures, patient experience, and cost of care. Providers have a portion of their work paid for based on the patient outcomes, and patients are encouraged to rate their experience, which is given to the government. Cost of care includes reducing additional costs while keeping treatment effective. -Medical error is the third leading cause of death
What is the future of healthcare? In what ways can we overcome the costs and fragmentation in order to communicate, coordinate, and improve access/quality/cost-effectiveness?
-We will have ACOs, bundled payments, core measures, HCAPS, VBP, but what else? -Need to focus on the Triple Aim -Infant mortality, high obesity, uninsured and underinsured are struggling (50 million), elderly population is growing, Medicare/Medicaid will probably get cut -FFS should go towards prevention, waste reduction, decreasing costly admissions, and coordinating care -Stakeholders should work together: Share medical records, evidence-based/continued/patient-centered care -Patients and families should have a relationship -End of life decisions
Types of HMOs
1. Staff model- employs its own salaried docs. Limited choice of providers. Greater control over practice patterns 2. Group model- HMO contracts with a multispecialty group and separately with hospitals. Docs are employed by the practice, not the HMO. Practice is paid by capitation 3. Network model- HMO contracts with more than one group practice. Able to offer more choice. Dilution of utilization control 4. IPA (Independent Practice Association)- the IPA establishes contracts with docs. Serves as intermediary. If MCO loses the contract, it loses many participating docs
Why do we need to reform healthcare?
1.) Costs are skyrocketing, by 2030 payroll taxes will only cover 38% of Medicare costs, the rest will contribute to the federal budget deficit 2.) Healthcare reform will improve US care quality (we have the worst healthcare in the developed world due to chronic diseases) 3.) Reform covers the 25% of Americans with little/no health insurance, 100k people die per year due to lack of insurance, half of bankruptcies results from high medical costs 4.) Reform is needed to decrease Fraud costs (60-200 billion dollars annually)
What is the ACA? Why did these develop? What were their goals? Were they effective?
ACA: Affordable Care Act, signed into law March, 2010. Every citizen was required or face an income tax penalty (eliminated by the Tax Cuts and Jobs Act). Everyone could choose how to get coverage (Through employer, Medicare/Medicaid, private). Those without could purchase it from a health insurance exchange for a possibly subsidy. Purpose: To lower federal gov. spending on healthcare, reduce the number of hospital (ER) visits if everyone had insurance. ACA added $940 billion to the federal budget in the first ten years, but Medicaid eligibility expanded to 133% of the federal poverty level and subsides for those with income up to 400% the FPL
ACO
Accountable Care Organizations. Integrated groups of providers who are willing to take responsibility for a defined population. Meant for the Medicare populations, came about with ACA. POS plans: Point of Service. Combines features of HMOs with choice of PPO. Allows provider choice but retains tight utilization. Free choice of providers is selling point. Enrollment is declining due to high out of pocket costs
33. What is burnout and how can it be avoided or treated?
Burnout is the comprehensive feeling of tiredness due to excessive workload and administrative burden, as well as the inability to find meaning and purpose in work. Healthcare professionals such as nurses and physicians report 35-54% burnout, which could be caused by the growing patient population. Unwell providers may lead to less coordinated and effective care, as well as proving damaging to the provider's well being. Utilizing NPPs may address burnout to ease the weight of nurses and PCPs.
18. Why does cost containment remain an elusive goal in U.S. health services delivery?
Cost containment is unsuccessful due to cost shifting: make up for lost revenue by increasing volume, charging higher prices in areas free of control (insured patients) Providers charge insured patients more than uninsured patients for the same treatment to offset the loss of revenue that stems from Medicare/Medicaid
What is cost-sharing? Different types? Pros and Cons?
Cost-Sharing: Payment that a patient needs to make for their care, decreasing moral hazard and sharing the cost between the patient and insurer. Three types. -Deductibles: Amount the patient needs to pay upfront before their insurance kicks in to pay. These can be small or large -Co-pays: Usually a small flat fee that the patient pays before receiving any service -Co-Insurance: A percentage of the bill -Pros: Patients have more to lose so hopefully they don't seek unnecessary care (decreasing moral hazard) -Cons: Patients may not be able to afford cost-sharing so they skip or delay needed care, leading to poor health outcomes.
Describe the critical policy issues related to access to care, cost of care, and quality of care.
Critical Policy Issues: Access. 1.) All Americans have a right to the same level of care or 2.) All citizens have a right to some minimum level of care. -Providers (access to all types of providers including/especially primary care since we have an increase in specialists) -We have no integrated system -The elderly (spending should be restrained to keep the program viable, the program is not adequately focused on chronic condition management, the program does not cover long-term nursing home care). -Minorities: Minorities are more likely to struggle to access healthcare services, but no minority population (other than Native Americans) has a program specifically for their needs. -Rural areas, low income, persons with HIV/AIDS
How has technology changed healthcare and its delivery? Its role in ACOs, IDSs, and Medical Homes? Telehealth? Robotics?
Delivery: -Geographic access is improved with mobile equipment/communication allowing remote access to centralized equipment and specialists -Hospitals->medical centers -Development of outpatient services -Technology available in patient homes -Raises ethical questions (gene mapping, STEM cell research, genetic cloning, life support technologies) -ACO/IDSs: Accountable Care Orgs and Integrated Delivery Systems will coordinate your care with the help of the electronic health record (less repeated tests) -Medical Homes: Allows for more accessible services with shorter waiting times, 24/7 electronic or telephone access, as well as alternative communication methods through HIT, uses data from HIT to assist patients and families in informed decision making
20. Why is it that, despite public and private health insurance programs, some U.S. citizens are without health care coverage?
Despite policy efforts, insurance and coverage is still costly
24. What are the social determinants (disparities) of care? Why are they important? What issues do they cause relating to access, quality, and cost? How can we address them? Who is responsible to do so?
Disparities in care relate to unequal care/access for multiple underlying reasons. They include the Social Determinants of health- broad social, economic, cultural, health, and environmental factors affecting healthcare. They include living and working conditions, social/family, and community networks, and individual behaviors and risk factors. Examples include income and education, homelessness, ethnicity, geographic location, etc...These are important as they affect a person's access to care and their physical and mental health and well-being. It relates to the individual but also to society. It can affect the ability of a person to be healthy enough to earn a living, and effects employers and society. If we follow a Social justice viewpoint, everyone is responsible to help everyone/society. We need all stakeholders to be aligned to help overcome these disparities. We need to address root causes of chronic diseases, have preventative strategies and environmental approaches, have collaboration between healthcare systems/public health/communities; to provide housing and transportation solutions, to decrease bad behaviors and support good ones (nutrient and physical activity). We need patient engagement in self-care. Improved communication; coordinated care efforts. Improve quality, use technology wisely- redesign clinical practice. Use data better, share best practices. Align incentives and goals.
27. Explain the trend in movement from FFS and acute hospital care to Value Based Payments and ambulatory services. The effect of the PPS and Managed Care. The Triple Aim. The development of ACOs, IDS, and new models involving bundled payments, metrics, and Pay for Performance.
Fee For Service: Charges set by providers, each service billed separately, providers could balance bill, leading to rising costs Value-Based Payments: Holds providers accountable for cost and quality Bundled Payments: Related services are bundled and billed at one price, attempt to align incentives and lead to collaboration, reduce the incentive for nonessential services Prospective Payment System: System in which reimbursements are based on diagnosis-related groups, shifting from a cost-plus payment system that leads to overstaying and overcharging to be in hospitals. Hospitals are reimbursed by the patient's diagnosis and staying longer will cost the hospital more, discouraging hospitals from keeping patients longer than they should and encouraging a quick turnaround time for recovery. Helps cost containment Integrated Delivery System: Network of organizations that provides/arranges to provide a continuum of services to a defined population. 6 Attributes: Efficient care coordination, disease management, case management strategies -> Lower inpatient costs, lower professional costs, reduced utilization of emergency department and urgent care sites
What is HIPAA? Why did these develop? What were their goals? Were they effective?
HIPAA: Health Insurance Portability and Accountability Act. HIPAA aims to protect patient health information. The three rules are: 1.) The Privacy Rule (standards to have privacy or disclose certain information), 2.) The Security Rule (protecting electronic health information), 3.) The Breach Notification Rule (the Department of Health and Human Services must be notified about security breaches). Very effective
12. What is health information technology? How is it used? Why is it important?
HIT includes: -Clinical information systems (supporting patient care delivery, electronic medical records) -Administrative support systems (financial and admin support such as payroll/billing/accounting) -Decision support systems, and internet/e-health (analytical and informational tools to support managerial and clinical decision-making). HIT is important to aid the increasing flow of info in healthcare, making decisions to improve healthcare delivery, and overall increase organizational efficiency while complying with various laws and regulations
1. What is healthcare policy? How is policy formulated? Why does it matter? What policies work or don't and why?
Healthcare policy is the combination of stated and unstated principles that characterize the distribution of resources, services, and political influences on the population. These policies are authoritative decisions made in the legislative, executive, or judicial branch of government with the intent of influencing or directing others. Policy fills in as guides for access, quality, and cost, influencing individuals and organizations. Policies are continuously modified, and the process is complex involving both public and private sectors. The Policy Cycle is the formation and implementation of health policy in five parts: 1.) Issue raising, 2.) Policy design, 3.) Building public support, 4.) Legislative decision making and policy support building, 5.) Legislative decision making and policy implementation.
9. How does a high deductible health plan work?
High-Deductible Health Plans and Savings Options: Savings option with a health insurance plan with a high deductible, and premiums are lower. Link a savings account to the insurance, combined with a health reimbursement arrangement. Includes an employer-financed account. Tax-exempt payments made for qualified medical expenses
How has technology changed movement to ambulatory care?
Less invasive procedures with faster recovery times (ambulatory services)
31. What is the role that LTC will need to play in the future and why?
Long-term care is care for chronic debility from acute and chronic illness. It can encompass a variety of different services and locations depending on need and resources. It can include medical, nursing, and rehabilitation care. Mental health services, social support. It can be formal or informal. Level of need can change over time. LTC has a spectrum- broadly it can be done at home, in the community, or in an institution. Cost in an institution is the highest, at home is the lowest. LTC has many concerns including access, cost, and quality. Regarding these, the aging of the baby boomers who likely have more chronic disease and need for LTC will put a strain on LTC resources as well as drive up costs. The increased volume of those needing LTC will exacerbate access, cost, and quality issues- and we are not prepared for it. We can't afford it under current status. Regarding the benefits of taking care of people at home- it is less expensive and preferred by most people. Usually, a family member or friend helps with the care in an environment more suited for the patient. Can have more dignity, privacy.
What is MACRA? Why did these develop? What were their goals? Were they effective?
MACRA: Medicare Access and CHIP Reauthorization ACT (2015). -Developed to create merit-based incentive payments for outpatient services or join an alternative payment model. -Merit-Based: Measures quality, resource use, clinical practice improvement, pay depends on their scores -Alternative payment method: Such as an ACO, the organization they join acquires that responsibility and has higher incentives The goal was to solve the sustainable growth rate problem, move towards value-based care. -MACRA is still a work in progress, physicians dislike it (they say it is hard to meet or report requirements)
7. Has the quality of health care declined as a result of managed care? Explain.
MCOs do not diminish quality (are equal whether there is an HMO) because financial pressures under capitation do not lead to significant physician behavior changes
5. How do MCOs control cost? To what extent has managed care been successful in containing health care costs? Why are they less effective than they could be?
Managed Care Organizations. -Deliver a large variety of healthcare services to a group of enrolled members through negotiated prices or payment with providers. -Gatekeep: PCP coordinates all services with an emphasis on preventative care -Utilization Review needed -Assume risk in exchange for a premium. -Assume responsibility for obtaining services by contracting with providers, and controlling costs since financial integration/insurance/delivery and payment functions within one organization. -Most dominant force in US healthcare delivery for their ability to control costs, but has received backlash -Have buying power by enrolling large segment of insured population
Medical Home
Medical Home: -Team-based primary care practices that provide the majority of patient health needs either directly or through provider coordination -Medicare/Insurers pay monthly care management fees or provide other resources to support enhanced care quality activities, streamlining care provision -Core attributes: Patient-centered, comprehensive, coordinated, accessible, committed to quality and patient safety
8. What is moral hazard? How does cost sharing effect moral hazard? What are the pros and cons (risks) of cost -sharing?- What was the goal versus the end result of cost-sharing?
Moral hazard is the situation when a person who has health insurance uses more services than needed because the insurance company pays the bill (the patient may have a copay or deductible as their out-of-pocket costs but is otherwise not responsible for the bill). This causes an increase in the use of services (utilization), which will drive up the cost of healthcare. The increased utilization due to moral hazard can be driven by the patient wanting/requesting more services than necessary, or by the provider who feels they can order as much as they want since the insurance company pays for it (not the patient) and by providing more services might get more income. Moral hazard in healthcare is when people who have insurance coverage use services more often than needed or they should just because they have insurance coverage. This drives up cost unnecessarily. This can lead to inefficient services, and expensive care can only be affordable with insurance. Increased costs and overutilization of services. Higher workload for providers but also raising costs of services. Provider induced demand -> waste of resources -> adds to rising costs
10. What is Medicare Part A? Which benefits does Part A cover? Which benefits are not covered? What is Medicare Part B? Which main benefits are covered under Part B? Which services are not covered?
Part A: Hospital Insurance: Everyone who contributed to Medicare through payroll taxes are entitled to hospital insurance (acute-care, psychiatric, inpatient rehabilitation, skilled nursing facility home health, and hospice care). Typically 90-100 day stay. Financed by a special pay roll tax- paid equally by employer and employee. Complex rules for deductible, co-pays, and co-insurance Part B: Supplementary Medical Insurance: Voluntary Medicare program financed by general tax revenues and a premium from beneficiaries. Premiums are income-based. Includes physician services, emergency services, outpatient surgery, diagnostic tests, dialysis, annual physical exam, and organ transplants. Carries an annual deductible and a 20% coinsurance.
34. What is P4P?
Pay for Performance: -Implemented program of paying for performance (positive outcomes of treatment) instead of how many patients are admitted (inpatient reporting). -U.S. Congress asking the IOM to consider the potential of P4P for Medicare. -The IOM found it to potentially decrease care access, increase healthcare disparities, and halt innovation. However, monitoring P4P could minimize these consequences and possibly control costs
P4P pros and cons? How does it relate to Value? How does it drive provider behavior? How is it being used in innovation (pilots)?
Pros: -Quality > quantity -Funds promotion of best practices -Public transparency of metrics leads to better quality/cost providers -Drives competition -Uses FFS while allowing time to adjust to Value-Based Payments -Reduces costs -Improved readmission rates and decreased preventable conditions Cons: -Reduces access for socioeconomically disadvantaged (providers do not want to treat them, do not perform well on metrics, struggle to pay for meds, follow-up barriers) -Reduces job satisfaction -Gaming of the system -Costly for administration -Confusing collection of metrics and requirements -Clinicians may skew treatment schemes towards P4P metrics and away from individual patient needs -Multiple providers lead to difficulties attributing outcomes
23. What are the pros and cons of the ACA? Provide an overview.
Pros: -Eliminating annual/lifetime limits, allowing coverage for pre-existing conditions, and preventing companies from dropping coverage for sick people while adding benefits (parents adding kids aged 26, must provide 10 essential health benefits) -Extends healthcare subsidies to help people afford coverage -Medicare/Medicaid are more affordable -Funds scholarships for providers, promotes background checks for nursing home staff, and reduces fraudulent doctor/vendor relationships -Promotes electronic health records -No more penalty for not having health insurance Cons: -Additional taxes on people making over $200k (increased Medicare taxes on higher income households) -Expensive: Added $940 billion to federal budget -Some people pay higher premiums
39. What is public health? Population health? Community health? How do they overlap? Differ?
Public Health: -The health of the community as a whole/factors that affect everyone -Hygiene, epidemiology, disease prevention -Subject to government regulation Population Health: -The health of a group of individuals, including the distribution of their outcomes -Based on socioeconomic factors, genetics, medical care, and environmental influences -Addresses morbidity and quality of life in specific populations -Clinical interventions Community Health: -Based on geographic location -Non-clinical interventions/social drivers -Access, transportation, food, behavioral health, emotional support, education
13. Provide a brief overview of how technology influences the quality of medical care and quality of life.
Quality: -Prevents/delays disease -Provides more accurate diagnosis -Provides quicker care -Increased treatment safety -Minimize side effects -Faster recovery from surgery/illness -Increased life expectancy
25. What external forces affect healthcare delivery? Describe the importance of these factors given that acute healthcare delivery only accounts for about 13-20% of overall healthcare outcomes (look at County Health Rankings model).
Social values and culture -Ethnic/cultural diversity, social cohesion Global influences -Immigration, trade and travel, terrorism, epidemics Population characteristics -Demographic trends and issues, health needs, social morbidity (AIDS, drugs, etc) Physical environment -Toxic waste, pollutants, chemicals, sanitation, ecological balance/global warming Technology Development -Biotech, information systems Economic conditions -General economy, competition Political climate -President/Congress, interest groups, laws and regulations
Donnabedian 3 Domains of Quality
Structure: -Stable characteristics of the providers of care, their tools, and the physical/organizational setting -Foundation and quality of healthcare, such as licensing and accreditation of the facility, caregiver qualifications, equipment, and distribution of hospital beds and physicians Process: -Specific way care is provided, such as correct tests or treatments, clinical practice guidelines, critical pathways, risk management -Delivery of healthcare, diagnosis and treatment, interpersonal aspects Outcomes: -Effects or final results from using structure and process, recovery and patient satisfaction, measures the effectiveness of the delivery system, should improve overall health status
How has technology changed healthcare and telehealth?
Telehealth: Broader than telemedicine, encompassing telemedicine (educational, research, and administrative uses), as well as clinical applications that involve a variety of caregivers. Caregivers range from physicians, nurses, and psychologists to pharmacists. Telemedicine: Distance medicine that uses communication technology for medical diagnosis and patient care. This is used when the patient and provider are separated by distance. Telemedicine can also apply to specialized services, such as teleradiology (radiographic images), telepathology (tissue-specimen studying via video-microscopy), telesurgery (robotics), and clinical consultation. Remote in-home monitoring of vitals, glucose, and blood pressure. High levels of patient satisfaction, may reduce hospitalizations Access: telehealth increases access for those living in prison, rural areas, or away from specialty care providers. However, those without access to a stable internet may face difficulties with telemedicine. Cost: Telehealth can be costly for providers due to the required technology needed. Reimbursement policies may also be uncertain as it is fairly new Quality: Quality of care is a concern, as some conditions or diseases may require taking physical samples or in-person examinations of a patient.
What does working to the top of your license mean?
To have less training, but do work that used to be done by someone who was more trained. In this case, NPs/PAs could do the work of physicians, and the work of NPs/PAs can be done by RNs, etc. -Decreases high levels of burnout, improves access to healthcare because patients would still be seen by professionals, no imbalance of responsibilities on physicians, and patient satisfaction would thus improve.
14. Why is there a geographic and specialty maldistribution of the physician labor force in the United States? How can we address physician shortages- geographically and by specialty? How does the ACA try to address these? What is the impact of the ACA on the workforce?
Workforce shortages for physicians include geographic and specialty maldistribution. -Rural areas lack primary care physicians and specialty physicians in comparison to urban areas. -Over half of physicians are specialty care providers (PCP shortage) -Federal programs aim to increase PCP services in rural areas by funding education, as well as the increasing number of international medical graduates practicing in the US. There is a nurse deficit projected to occur in 2030, so health services organizations are aiming to create incentive packages for new nurses, increase pay and benefits for current nurses, introduce more flexible work schedules, award tuition reimbursement for education, and on-site daycare. The ACA has expanded coverage which increases the need for medical professionals. The ACA component called the Advanced Nursing Education Expansion Program allocated $30 million to support academic training programs for NPs and certified nurse midwives.
Medical Home Strategy
•Patient-centered: supports patients in learning to manage their own care based on their preferences, and ensures that patients, families, and caregivers are fully included in the development of their care plans •Comprehensive: offers whole-person care from a team of providers that is accountable for the patient's physical and behavioral/mental health needs, including prevention and wellness, acute care, and chronic care •Coordinated: ensures that care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services, and long-term care supports •Accessible: delivers accessible services with shorter waiting times, enhanced in-person hours, 24/7 electronic or telephone access, and alternative methods of communication through health information technology (HIT) •Committed to Quality and Safety: demonstrates commitment to quality improvement and the use of data and health information technology (HIT) and other tools to assist patients and families in making informed decisions about their health
