URPN quizlet

Core Functions of Public Health

assesment policy development assurance

• Health Care in the United States

• A point of cultural pride • The nation's largest economic sector • A moral issue • A policy issue • A deeply personal matter • Forged by political choices

How Do We Incentivize Quality Care?

• Finance, policy, and other drivers influence provider behavior. • We must find ways to harness these drivers to maximize and align positive incentives to the provision of quality and to eliminate perverse incentives. • We lack strong evidence of when, how, how much, and why most potential incentives will be effective in achieving their intended outcomes while avoiding unintended ones (e.g., manipulating metrics to achieve expected results). • Six drivers: • Professionalism • Public reporting • Payment • National and regional quality improvement initiatives • Consumerism • Regulation • Professionalism • Conduct, aims or quality that characterizes members of a given profession • Build on current science and clinicians' desire to do well • A commitment to continuing medical education • Public Reporting • Creating and disseminating comparative public reports for consumers can be a driver for improving quality • Enables consumers to comparison shop for health care • Employers, health plans, and others who contract with providers of care can favor highscoring organizations when creating networks of care and can educate their employees or plan members about the quality differences • Enables health care providers to compare their performance with the performance of their peers • Not changing consumer behavior yet • Face future challenges: • Linking cost information to quality • Incorporating social media • Increasing the timeliness and clinical robustness of public reports • Payment • Fee-for-service; capitation • Pay-for-performance; value-based purchasing • Reasons why the tracking of the effects of incentive strategies is not easy include the following: • Incentive size • Incentive confusion and fatigue • No pure controls • Context and implementation • National and regional quality improvement initiatives • Some of the most dramatic improvements in quality have resulted from deliberate, well-organized, regional or cross-regional collaborative efforts. • Combination of identifying an important problem, engaging senior leadership, leveraging a facility with data, and using practical strategies for applying data have been successful • Partnerships for Patients • Institute for Healthcare Improvement (IHI) • Quality improvement organizations (QIOs) • Community quality collaboratives • Consumerism • Consumer incentive functions differently in the health care market for several reasons: • The purchaser of care is generally not the actual consumer of that care. • Consumers and patients often lack the information they need to act in their own interests. • Consumers often do not feel empowered to question their medical care team on recommended services or drugs in the way they would question other service providers (e.g., mechanic). • Lifestyle factors have a larger effect on health than medical care. • Good health is a more distal goal that often cannot compete with immediate gratification. • Regulation • Mainstays of the regulatory approach to health care quality have included the following: • Inspections of health care facilities through accreditation • Verifying the credentials and skills of clinicians (credentialing) • Not enough to guarantee provision of high-quality care

Multilevel Models for Population-Based Health Behavior Change

• Social ecological models -• Integrate behavioral science with clinical and public health approaches • Multilevel strategies - • Address all levels of influence for behavior change

Public Health Services

• State responsibilities • 10 essential services (Figure 6.2) • Public health emergencies • New training, competencies, & accreditation

• Shifting demographics in the United States

- Aging population - Increasing number of people of color - Growing number of people are living with chronic disease(s) - Increasing income gaps - Straining of social sector that provides support for vulnerable populations

• Groups may be vulnerable to health inequities because of the following:

- Race - Ethnicity - Income - Gender - Sexual orientation - Immigration status - Ability level - Other factors (e.g., less power, social status)

Health Systems in England, Canada, France and China (OECD)

-Movement away from family, philanthropy, religious institutions, employers & local governments • Increased role of national government • 1950s & 1960s: growth years of health sector • 1970s: rationalization & cost containment • 21st century: health insurance dominant source of funding & health care services largest category of social expenditures

State of care in the US

1. Complex and multifaceted system 2. Private and public institutions operate in cooperation with but remain independent 3. No central government agency to control the delivery, yet government is a major purchaser of healthcare 4. Heavily influence the legislation 5. Continuum of care and compasses Care from cradle to grave

defining characteristics of the us health care system

1. Disorganization and lack of coordination 2. many factors work independently -doctors, nurses, hospitals, nursing homes, pharmaceutical companies, rehabilitation, technicians, and medical device companies 3. haphazard evolution 4. shaped by economic incentives rather than a logical design - medical care system -> restore health (limit spred, help person cope, and get rid of symptoms) 5. maintain health- screening and prevention services and identify early illnesses -requires vibrant public health and social system that works to help prevent illnesses by preventing epidemics, food, water, and sanitation are safe and monitor environmental toxins -develop community based public awareness and education -eat healthy, excercise, and not engage in unhealthy behaviors like smoking, overdrinking, recreational drugs, prescription drugs 6. health is determined by economic and social aspects -discrimination, abuse and social respect -involvement guides collective action to encourage prohealth norms and practice population health -"health in all" approach to social policy 7. importance of organization in delivery care 8. role of professionals in running system 9. emergence of new medical technology -expensive ways to improve care 10. tension between free market and government control -shapes american culture -more diversity of opinion are goods are rights 11. dysfunctional payment system -free for service system -valued services

major issues and concerns

1. improving -quality -access and coverage- patient protection and ACA -44,000-98,000 die because of medical errors mental health, substance abuse, asthma, diabetes and recieve effective care 1/2 the time 2. slowing the growth of health care expenditures -price of service x volume / number of services -total expenditures are inc more rapidly than rest of economy by cost has inc in past 50 yrs - divise ways to moderate the inc of share of economy devoted to health sector 3. encourage healthy behavior -avoid disease/injury or prevent from getting worse -for most not a high priority - policy initiatives- soda tax, trans fat, cal and sodium on menus, and policies for smoking 4. improving public health system -state and local health dept monitor health of residents - provide wide range of preventative services, reg health care providers and buisnesses - funding can be improved - quality, cost and access are due to lack fo coordination at the community level - effected by lack of integration of electronic health record system and lack of cooperative relationships between providers who treat same patients 5. improved coordination, transparency, and accountability of medical care 6. addressing inequities in access and outcome -social and economic background -race and geographical locations

Financing

1.General revenue through fiscal tax system 2. Compulsory payroll tax (Social Security) 3. Voluntary premiums to private insurers 4. Individual out-of-pocket payments most developed one or two distinct models NHI systems use governments to organize social insurance programs • NHS systems rely on income taxes and general revenues • China and the U.S. rely on subnational and local governments to finance health care

Health Insurance Reform: A Brief Political History

1940s & 1950s • President Truman called for universal coverage • President Eisenhower instituted a tax deduction to employers offering health insurance -tax expenditure 1965 • Medicare & Medicaid passed under Johnson -thought as socialized health insurance 1993 • President Clinton designed and began the Children's Health Insurance Program (CHIP) 2009 • President Obama submitted "Obamacare" 2016 • President Trump "dismantled" components of ACA 2018 • Congressional Budget Office predicted rising numbers of uninsured people

States Expanding/Not Expanding Medicaid, as of June 2018

33 expanded 18 not expanded

key stake holders part 2

4. Insurers Dash mediate among payers, providers and consumers. Take some financial risk if payments exceed the premium set to employees they will lose money. Insurers leave employers to bare risk and is mediator. Negotiate insight rules governing eligibility for reimbursement and payment rates. Face pressure from other stakeholders and are moving toward capitated payment systems which are payments of a premium for a person or family regardless of use of current benefits per year. 5. Policy makers Dash appointed public officials and elected politicians. Don't act as a single stakeholder group and often have conflicting agendas. Different views about how healthcare system should work and the governments role in healthcare. Share consensus on wanting slower inflation rates, state of the art medical care and prevention measures and high-quality care in a better patient experience

Payment Sources for U.S. Health Care

75% insurance 11% out of pocket 2% government health activities 8% 3rd party programs 5% investment

Prudent layperson standard

A condition with acute symptoms of sufficient severity such that a prudent layperson, who possesses the average knowledge of health and medicine, could reasonably Expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ part

Overview of a Complex Infrastructure (cont'd)

ACA • New focus on prevention • Initially unprecedented single investment • Since inception, federal funding has declined • State funding level • Too soon to predict long-term trend for government funded public health Divided responsibilities and issue-specific organizations • Factors leading to complexity of public health • Decentralization of government (states' authority) • Problem-specific focus of laws, policies, & organizations • Heavy reliance on nongovernmental organizations • Broad definition of health goals & debates over how to achieve them

Health System Performance pt.2

Access to services across income groups • Concerns about government run systems and ration care • Limited access to specialists Cost • Concerns about population aging • Price, volume and technology diffusion influence costs • How much is too much?

Leading Determinants of Health: Weighting the Different Domains (cont'd)

Annual national County Health Rankings report • Ranks overall health of every county within each of the 50 states • Reports the contribution of multiple determinants of health on each county's overall health using a population health framework • Health outcomes are viewed as the result of a combined set of factors; factors are also affected by conditions, policies, and programs in their communities. • Rankings demonstrated dramatic variation between one county and another in health outcomes and in health determinants. • Bottom-line message: where people live matters to their health

NHS and NHI Systems Compared with the United States

Based on actuarial principles • Private insurance premiums based on estimated risks • Not an NHS or NHI system Patchwork of public & private insurance with large gaps of coverage - • Social insurance for older adults (Medicare) • Social welfare for low-income people (Medicaid) • Subsidized employer-based private insurance • Elements of socialized medicine (VHA)

Health System Models I:•NHS Systems

Based on the UK model devised by Lord Beveridge (wrote NHS after WWII) • Found in UK, Sweden, Norway, Finland, Denmark, Portugal, Spain, Italy & Greece • Most financing from general revenue taxes • Some private funding (especially in Italy & Spain) • Public & government managed

Changing Health Behavior

Brief history of behavior change interventions • 1970s and 1980s: efforts relied primarily on public education campaigns and individually oriented health education interventions • By 2000, recognized that physician advice could be a catalyst for health behavior change • Social learning theory remains the dominant model for effective cognitive behavioral health behavior change interventions. • Stages-of-change model • Precontemplation • Contemplation • Preparation • Action • Maintenance • Relapse

Behavioral Risk Factors: Overview & National Goals (cont'd) 7: Tabacco

Causes more preventable deaths and diseases than any other behavioral risk factor • Accounts for $170 billion in annual health care costs • Single most modifiable cause of poor pregnancy outcomes • Quitting can produce significant improvements in health and less use of health care services • Adult smoking has decreased; highest rates among members of low-income populations • Vaping and e-cigarette use is a concern, particularly among youth

Social, Economic, and Political Forces Are Transforming Public Health

Challenges • Shrinking government • Wide swings in federal support Opportunities • Public Health Institutes • New role for health care sector • New resources for assessment • Effective communication & advocacy • Putting the public back in public health • Building & maintaining trust • More effective voices • The case for multi-sector collaboration • Real estate developers, city planners, public health practitioners, & advocates • Collaborative leadership

Health Systems in England, Canada, France and China: pt exception to OECD China

China (exception): increased privatization • 1949-1980: financed largely by government • 1978: called for market reforms, government reduced its share, slashed subsidies to public hospitals • 1990: Increased investment in public health • 2009: continuing to expand role of government with new public insurance schemes and public health regulations OECD face common challenges with distinct approaches. compare based on actions on problems such as provider payment, coordination of care, workforce and IT, and health system performance

community health

Community benefit, focuses on collaboration among a wide range of organizations to address issues that Impact a community accelerated in the 1990s focuses on employment, crime, housing, transportation, food and medical care

Four categories of hospitals

Community, special, rehab and chronic disease, psychiatric Federal and state regulated, license to operate, accredited, federal certification for reimbursement of Medicaid and Medicare, positions granted privileges to practice. Non-federal, short-term general, and other special hospitals are accessible to general public

Special hospital

Diagnosis and treatment for specified medical treatment both the surgical floor. Provide necessary services

Psychiatric hospital

Diagnostic and treatment for a patient with psychiatric illnesses. Short term, outpatient. Temporary or permanent care for those who need routine care, treatment, or controlled environment.

Palliative care

Discomfort, symptoms, and stress of serious illness. Providing relief from pain, fatigue, nausea, shortness of breath, and loss of appetite, or sleep.

Health Workforce Education

Education and training requirements vary • Little or no formal training, on-the-job training -• Personal care aides, medical secretaries • Some formal postsecondary education -• Surgical technicians, licensed practical/vocational nurses, emergency medical technicians • Associate degree/Bachelor degree -• Dental hygienists, respiratory therapists, clinical laboratory technicians, radiology technician, registered nurses • Postgraduate (typically at the doctoral level) - • Medicine, pharmacy, physical therapy, optometry • Interprofessional education • Traditionally focused on single professions • Opportunities are rare for professionals to learn together in the classroom or through clinical experience. • Interprofessional education (IPE) and subsequent interprofessional practice can improve the ability of health care professionals to provide high-quality patient-centered care. • The Interprofessional Education Collaborative has made specific recommendations regarding the competencies required for successful interprofessional collaborative practice under four domains: 1) Values and ethics for interprofessional practice, 2) Roles and responsibilities for collaborative practice, 3) Interprofessional communication, and 4) Interprofessional teamwork and team-based care. • Innovative models for health workforce education • Traditional: didactic instruction in classroom and clinical skills in health care delivery settings • Simulation-based clinical education • Used without risk to patients • Associated with high satisfaction and confidence • Increasing role in supporting IPE • Technological development • Flipped classroom and blended classroom approaches (combination of in-person and online learning) • Online, web-based formats, video-conferencing increasingly used for post licensure education and continuing education • Increasing educational expectations • Push to increase educational standards among some professions (e.g., pharmacists, nurse practitioners, certified registered nurse anesthetists, physical therapists) • Not all agree about higher standards. • Supporters focus on the additional time required to develop skills in patient care management as well as development and execution of quality improvement programs. • Opponents argue there is no evidence that higher educational requirements lead to better patient care and that higher levels of education increase costs for students and the health care system.

hospice care

End of life care when a person is expected to live six months or less. Team of health core professionals and volunteers in the house, hospice center, hospital or skilled nursing facility

Provider Payment- england

England • Two-thirds GPs work as independent contractors • 75% capitation, 20% fee-for-service • 2012: GPs in charge of clinical commissioning groups, control 70% budget • Now a Payment by Results system based on average cost of procedure

Looking Abroad to Promote Self-Examination at Home

Examining other systems provides the "gift of perspective" • Policy learning: a process of self-examination, the experience of other countries is largely valuable insofar as it prompts a process of critical introspection by enlarging our sense of what is possible and adding to our repertoire of possible policy tools. • For policy learning is not about the transfer of ideas or techniques, but about their adaptation to local circumstances. • Comparison to China & other OECD (organization for economic cooperation and development) nations • NHS countries: United Kingdom • NHI countries: Canada & France • BRIC nations: Brazil, Russia, India, & China

End of life care

Final days or hours of an individual's life. Physical, mental, and emotional comfort in social support of people living with a terminal of the illness. For advance, progressive, and incurable diseases

Prevention

Focus of health promotion and prevention services

The Medical Model

Focuses on individuals • Explores pathophysiology • Reductionist model --• Searches for molecular and physiological mechanisms that explain how specific factors produce illness or act as markers of incipient disease • Attempts to find the "silver bullet" that will stop or reverse those mechanisms and thus cure or prevent progression of the current medical problem • Frames risk factors as working through disease-specific pathways • Analyzes risk factors as if they were independent in statistical modeling • Considers how biological systems within the individual interact

Coordination of Care pt.2

France • Inadequate communication • No formal institutional relationships • Poor hospital discharge planning and lack of coordination China • Before 1978 rural areas had "barefoot doctors" • Since 1978 lack of doctors in rural areas • Reduced subsidies to state-owned hospitals • 2009 health insurance coverage brought people back under financial protection • Still disparities across regions and medical sectors • Absent coordination

Provider Payment-France

France • Negotiated fee schedule + extra billing • Vary by subspecialty • Extra-bill charges set with "tact and measure" • Public hospital physicians paid on part-time or full-time salary • Private for-profit hospital physicians bill based on negotiated fees • 1984: reimbursements were retrospective, cost-based, per diems • 1990s: reimbursements per diem adjusted for case mis • 2004: adjustments made to create level playing field • 2012: aligned to national activity-based payment tariffs = growth P

The Politics of Providing Equitable Health Services

Free health care - no cost to the patient • Health disparities - coverage aid care varies widely • States are expanding Medicaid

Public health

Function of federal, state, and local public health departments to address concerns of the public at large Epidemic, environmental hazards and healthy living

Who Pays? The Politics of Medicare, Medicaid, and Much More

Government is the largest source of health insurance in the U.S. 41% • Medicare - federal government program • Medicaid - joint federal and state Private health insurance plans 34% Individual payers- higher prices because no negotiating leverage Private charities

The Medical Model (cont'd)

Health care is generally reactive. -- • Responds to abnormality, disease, or injury --• Characterized as a "sickness care system" • Health care has traditionally been delivered (and reimbursed) in acute episodes ---. • Less value placed on, and less reimbursement provided for, efforts to promote health or to prevent illness and injury • Americans' chances for living long and healthy lives are not improving, despite ever-greater U.S. spending on health care. US health disadvantage- highest spending on health but prob of survival to 80 is lower than that to other developed countries

Population Health

Health care is one of many factors that contribute to physical and mental health of a population • Other determinants responsible for health or disease of population include the following: • Education and income • Genetics • Behaviors • Environmental exposures • Influences outside the health care system greatly affect which groups of people are more likely to become ill, to be injured or to die early • These influences also help determine people's health care outcomes once they become sick, injured or disabled

Health Data Needs and IT Use Cases

Health care providers • Use EHRs to record, manage and share patient information • EHRs can: • Contain electronic information about a patient's medical history, diagnosis and related data • Archive and share this information digitally at various points of care • Offer access portals to clinical decision support (CDS) tools • Automate and streamline providers' workflow • Increase organization and accuracy of patient information • Support analyses based on aggregated patient data • Support key market changes in payer requirements and consumer expectations • Make possible a range of public health, health services and medical research Health care providers (cont'd) • Clinical decision support • Patient alerts (i.e. conditions, prescriptions, treatment) • Computerized physician order entry (CPOE) (i.e. medications, lab tests, imaging) • Electronic prescriptions • Electronic clinical quality measures (eCQMs) calculated directly from patient HER data • Health information exchange (HIE) • Supports the secure electronic exchange of patient data among authorized providers and patients • Directed exchange: point-to-point sending of health data from one user to a trusted and authorized end recipient to support referrals and care coordination • Query-based exchange: supports unplanned care episodes and refers to providers exchanging information based on a request for patient data from existing data sources • Consumer mediated exchange: allows patients to access and share electronic records from and with their care providers Consumers and individuals • Individuals have the right to review and obtain a copy their protected health information (PHI) as granted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) • Patient portals • Offer people direct access to their PHI • Allow streamlined communications between physicians and patients • Consumer-directed exchange: patients can request health data in a format to be shared with third-party or other entities • Consumer decision support tools • Help consumers compare products and providers Health insurers • Use HIT for the following: • Receive and process claims • Evaluate quality of care provided • Manage care for patients covered under their plans • Administrative claims • Important source of data to evaluate patterns of care utilization and quality of care • Analyses used to do the following: • Manage preferred provider networks and incentivize improvements through valuebased payment arrangements • Support evidence-based management in provider operations (e.g., evaluation of workforce productivity) Governmental public health entities • Use data to support 10 essential public health services • Data used by state and local health departments to more effectively serve as chief health strategists for their communities • Better integration and data-sharing can help to address social determinants of health (e.g., income, education) • Shared data can support targeted public health interventions Researchers • Large-scale aggregation and analysis helps to answer questions about the effectiveness, safety, and real-world outcomes of many therapies • Patient-Centered Outcomes Research Institute (PCORI) • Supports research networks • Enables complex analyses and queries across distributed virtual datasets

Health status is affected by

Health policy, individual behavior, social determinants, physical determinants, biology and genetics, and availability of health services Major focus of the ACA, most health plans cover a set of preventative services at no cost to the beneficiary, a new reimbursement mechanisms incentivize provider organizations to keep patients healthy

population health

Health status indicators for a defined group of people in the world is to improve the health and reduce inequities.

Levels of Care: Secondary

I need attention and treatment in order to cure or control of the fax. Would you examinations and task. Education and institutional practices

Defining Quality

IOM's 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 Six dimensions of quality • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

Levels of emergency care

Immediate less than one minute, emergent 1 to 14 minutes, urgent 15 to 60 minutes, semi urgent 61 to 120 minutes, non-urgent 121 to 24 hours

Rehabilitation organizations

Impatient; freestanding with hospital, unit in acute care hospital, in transitional care. outpatient; for those who can't handle intensive rehab. We have agencies, we have clinics, public health agencies We have a Jaycees organizations with integrated program is through specialized team. We have clinics or outpatient by doctors.

Opportunities in the ACA to Meet Health Care Needs of Vulnerable Populations

Increased insurance coverage for individuals • Improving access to community health centers • Advancing payment and delivery reform • Limitations of the ACA - Refusal of many states to expand Medicaid - Specifically excludes undocumented immigrants and their families - These limitations will place a significant burden on safety-net hospitals that provide care. - Falls short of making necessary investments in the social service sector • Challenges of health care reform and threats to the ACA - Debate over the following: • Health care right versus privilege • Which individuals should be eligible for care • How health care can be improved - Presidential executive orders have altered aspects of the ACA

A Framework for Understanding Vulnerability

Individual Risk Factors • Demographics • Age • Gender • Race/Ethnicity • Socioeconomic Status • Health Status • Health Insurance • Belief systems/health behaviors Environmental (or Ecological) Risk Factors • Geography • Rural vs. urban • Socioeconomics of community • Neighborhood income level • Unemployment rate • Resource Inequalities • Social capital (or social cohesion) of neighborhood

How Personal Health Decisions Become Public: The Case of Obesity

Individual freedoms • Alcohol • Tobacco • Obesity -Taxes on sugar-sweetened beverages and junk foods - Calorie labels on restaurant menus - Encouragement to reduce sugar, salt and/or fat content - Nutritional quality of school lunches

Best practices

Innovative approaches to improving healthcare delivery. Intermountain healthcare; technology and innovation to provide increased quality care at a decrease cost. Cleveland clinic; provide employees access to World class healthcare at reasonable prices

Hospitals

Institutions engage in providing, by or under supervision of physicians, to inpatient, diagnostic and a therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick person; or rehab services for injured, disabled, or sick people.

Other healthcare delivery organizations

Integrated delivery system; collaborative network of providers who go together to provide a continuum of care to a particular patient population. Presented; link organizations that provide same level of care. Example multi specialty group practice. Vertical; different levels of care samples; preventative, primary, secondary, tertiary and long-term care Emergency medical services, home healthcare organization; public, nonprofit or proprietary, hospice and palliative care organizations, pharmacies, pharmaceutical companies come in the pool device manufacturers, and telemedicine and retail clinics

Traditional Approaches to Health Workforce Planning

Limited centralized health care system • Limited engagement in national health workforce planning efforts • Planning left primarily to private sector and local government agencies • Traditional supply-and-demand approach • Compares number of working health professionals with estimates of demand for health workers • Demand projections may not align with budgetary realities and demand seen in the labor market • Shortcomings of workforce planning • Tied to current care delivery models • Treats each health professional independently

Comparing The Medical and Population Health Models: Tobacco

Medical • Focus on individuals who smoke or chew • Behavioral change: --- • Cessation counseling ---• Nicotine replacement Pop Health • Explores influence of: --• Tobacco production --• Advertising --• Distribution --• Patterns of use by groups • Interventions --- • Smoke-free laws --- • Tobacco taxes --- • Regulation of advertising ---• Targeting specific group

Comparing The Medical and Population Health Models: Obesity

Medical • Family history • Diet & activity history • Lab tests to rule out: --• Hormonal causes --• Other physiological causes ---• Diabetes • Referral to nutritionist • Diet & exercise prescription • Bariatric surgery *doesn't ask why Pop Health • Focus on obesity epidemic • Race, income as risk factors • Reasons for noncompliance • Multiple factors --- • Zoning law changes ---• Menu labeling ---- • Challenging food industry ----• Education

The Influence of Social Determinants on Health Behavior and Outcomes

Medical model ---• Well accepted and respected by health care providers and researchers --- • Widely viewed as grounded in "hard science" and reflecting "truth" about causes of disease • Population health model --• Less widely perceived as scientifically rigorous --• Many are not aware of the magnitude and rigor of scientific evidence underlying findings or of the effectiveness of associated population-level interventions.

The Population Health Model (cont'd)

Multiple determinants of health describes determinants that arise from five domains: 1) Social and economic environment (e.g., income, education, employment, social support, culture) 2) Physical environment (e.g., urban design, housing, availability of healthy foods, air and water safety, exposure to environmental toxins) 3) Genetics and epigenetics (study of gene-environment interactions) 4) Medical care, including prevention, treatment, and disease management 5) Health-related behaviors (e.g., smoking, exercise, diet) • Reverse causality

Health Care Infrastructure and Spending: Many Dollars, to What Effect? pt.2

Patient Outcomes and Beyond: Evaluating American Health Care -U.S. performs poorly compared to peer nations in other 9 categories • Access • Care process • Administrative efficiency • Equity -Financing contributes to poor outcomes

Understanding Factors and Systems

People affected by inequities are everywhere. • Difference between inequalities and inequities • Health equity seeks to address systemic barriers. • U.S. has a long history of oppression, discrimination, social exclusion, and marginalization. • Many U.S. policies, systems, and institutions continue to oppress the following: - People of color; - People who are poor; - People living with physical disabilities; - People with mental health issues; - People practicing nondominant faiths; and - People who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) • Vulnerability influenced by factors that include the following: - Disease status (e.g., chronic conditions, mental illness) - Demographics (e.g., socioeconomic status, racial/ethnic background, immigration or refugee status) - Age group (e.g., children, elderly) - Ability to access care (e.g., uninsured, those who live in a remote rural area, those who lack a regular source of care)

Long term care

Personal care needs on long-term basis. Most are not medical care, activities of daily living, in-home or community setting/institution

Multilevel Models for Population-Based Health Behavior Change (cont'd)

Population-based health promotion efforts • Use multiple approaches • Take account of special needs of target groups • Apply a long view of health outcomes • Involve sectors of society that have not traditionally been associated with health promotion efforts (e.g., law, business, education, social services, media) Examples from tobacco control • Smoking bans and restrictions • Tax and price increases • Mass media campaigns • Telephone quitline and mobile phone-based support • Health care system interventions Examples from childhood obesity prevention • Downstream • Increase social supports for physical activity and exercise • Provider reminder systems and provider education • Midstream • Increase time students spend in moderate or vigorous physical activity at school physical education classes. • "Point of decision" prompts on elevators and escalators to use stairs • Upstream • Create or increase access to safe places for physical activity • Informational outreach about benefits of physical activity

Clinical integration

Position hospital moment; employment relations with economic integration. Physician employment bottle; tie compensation to increase quality and productivity.

Causes of Obesity Epidemic Identified by the Population Model

Prevalence of fast food in low-income areas • Presence of vending machines in schools • Subsidized school lunches high in calories, fat • Decrease in physical education & recess • Less walking or bicycling to school • No safe places to play or walk near home • Lack of grocery stores with healthy options • Marketing obesogenic foods to children

Levels of Care: Primary

Preventing or reducing the probability of the currencies of a disease in the future.Services provided through public and private; Public health department, physician offices, places of employment, and houses of worship. They educate on risk factors, immunization of child diseases, smoking cessation luis, weight loss, prenatal and baby care, increase workplace safety, and promotion of Handwashing for flu

Workforce and Information Technology

Primary care vs. specialty care balance • U.S.: 10% of physicians are generalists • Most OECD systems: 31% are generalists • Effective system of primary care leads to improved coordination and continuity of care Workforce shortage/surpluses • U.S., France, & China: shortage of clinicians • U.K.: surplus Push for electronic medical records & IT • May or may not improve quality & cut costs

Provisions of Health Services

Public • National (VHA) • Subnational (state mental hospitals) • Local (municipal hospitals) • Private not-for-profit • Quasi-public organizations (hospital trusts) • Private for-profit • MCOs

Public Health Requires a Collective Response from Society

Public health focuses on: • Entire populations, not individuals • Incidence, prevalence & distribution of health problems • Action at community, state, or collective level • Determined by behavioral, community, environmental and societal level forces Historical effectiveness of collection action • Utilitarian (greatest good for greatest number) • Human rights & social justice • Concerns of opponents of public health focus: - • Loss of individual liberty -• Abuse of power -• Improper role of government • Inadequacy of private & nonprofit orgs - • Market failures

Health System Performance pt.3

Quality • 2002 Health Care Quality Indicators project • Five areas for monitoring quality: - Cardiac care - Diabetes mellitus - Mental health - Patient safety - Primary care and prevention/health promotion • Access, cost, quality called "three-legged stool"

Rehabilitation

Restored to original state of health. Keep, we gain, or improve skills and function for daily living. Lost because of illness or injury. PT, OT, speech Language pathologist, and Psychiatric rehabilitation. Inpatient and outpatient facilities

The Population Health Model

Seeks to explain and intervene in the causes of the systematic differences in health between different groups • Analyzes patterns or distribution of health between different groups of people in order to identify and understand factors leading to differences in outcomes -• Factors described as "upstream" causes (influence health through a series of pathways that may not be immediately visible) - • Term determinants of health is used rather than factor or cause

Emergency care

Setting, serious illness or injury. Sometimes for non-emergency care by under or uninsured people. Medical emergency is defined by what is known as the prudently layperson standard

Acute care

Short term, intense medical care providing diagnosis and treatment For communicable or non-communicable diseases, illnesses or injuries. Primary, specialty, Sherry, I want to marry. As outpatient or inpatient. Emergency services provided given time sensitive nature of the need for diagnosis and treatment. The care, trauma, prehospital emergency, acute care surgery, critical care, urgent care, and short-term inpatient stabilization

Provider Payment-US

Significantly higher prices for medical care • Price most important factor in explaining spending • Does not operate within a budget • Does not negotiate prices with providers

Coordination of Care pt.1

Size and delivery system examples • France --• 3.3 doctors/1,000 population --• 4.1 hospital beds/1,000 population England • >1 million workers, >2,500 hospitals • Managerial challenge due to fewer health care resources • More aggressive in being efficient • Barriers as a tripartite structure with strong local control Canada • Specialists paid FFS, work in community & hospitals • Hospitals: private, non-profit, publicly financed • Patients referred to local hospitals with extended wait times

The Influence of Social Determinants on Health Behavior and Outcomes (cont'd)

Socioeconomic status & morbidity/mortality • Education • Income • Occupational status or grade (Whitehall Study) --• Measured in gradients or dose-response effects based on model • Many studies on stress • Neighborhood effects Predictive factors of life expectancy • Income (most predictive) • Degree of education (most predictive) • Race & racial discrimination • Gender non hispanic whites have a higher health status then anyone else inc level of education, inc health status

Physician organizations

Solo practices; 20% owned by physician. Single specialty group; most common 42%. Multi specialty group; 25%. Corporate medical; corporate practice medicine or professional service corporation; some are prohibited in certain states. Urgent care; growth area. Community health service; must be resident poor and uninsured. Ambulatory service center; surgical outpatient.

key stake holders influencing the health systems

Stakeholders - set of people who have a strong interest in how something in our society is done. 1. Consumer/individuals - should be at center, are often by standards in decisions affecting their own health and care; payment issues. Can be influential when many are dissatisfied. Example; 1990s insurers change the rules of early managed care payment systems. Individuals need to grasp role in making healthy choices and they want easy access to quality healthcare. 2. providers and healthcare professionals Dash work to advanced medical knowledge and practice, motivated by full of keeping people healthy, faces pressures to contain costs, except lower fees, provide higher quality at a greater value, and provide better patient experiences. They do this by creating larger practices. Want simple rules for healthcare provision and compensation 3. Employees - offer employee insurance as a benefit, view insurance as a cost of doing business. Affect on profitability concerns, want a decrease in healthcare expenditures, want to healthy, productive employees, and advocate for high-quality healthcare wellness and prevention programs

Governmental Agencies Have Legal Authority for Core Functions

State authority for public health • State law -• Fragmented -• Not current -• Neglect important safeguards -• Problems that cross state lines • State health departments Tribal public health • Sovereign nations • May provide public health services • Supercedes federal law Federal-state relations • Preempts state laws • Floor preemptions • Ceiling preemptions • Funding streams are categorical • Delegation of state authority to local health departments • Collaboration among federal, tribal, state and local health departments

What is health?

State of complete physical, mental, and social well-being. Not merely in the absence of disease or infirmity (who) includes all orders, institutions and resources that have a primary purpose of promoting, storing, and or maintaining health. Services include prevention, care, rehab, and how Tatian efforts oriented to either individuals or population

How Are We Doing?

Successes • Reduction in cardiovascular diseases • Improvement in HIV management • Reduction in % of Americans who smoke Need for Improvement • Care for chronic illnesses • Quality of care • Variations in clinical practice • Safety • External factors

Levels of care; tertiary

Targeted and individuals who already have symptoms of a disease in order to prevent damage from the disease, to slow down progression, to prevent complications as a result of the disease and ultimately restore good health. Education institutional practices. diabetic patients and , infection control in hospital

rehab and chronic disease

Therapeutic intervention to help patient speaking in functional ability to the highest possible level after injury or illness is that cause disability. 75% of patients require intensive rehab related to Straub, spinal cord, trauma, brain or other disease

Health system performance

Triple aim; improve patient experience, improve health of population, and decrease per capita cost of healthcare Five components; focus on individual families, redesign primary care services instructors, population health management, pass control platform, and system integration and execution. patient centered ness; respect your patience values, preferences in need. Coordination and integration of care, information, communication and education. This will comfort and emotional support. Involvement of family and friends Population health management; manage a network of providers, ensure efficient and effective cure, navigate position in specialty care, manage transitions of care, and provide care at home.

Health Policies and Returns on Investment

U.S. expenditures on health care: ---• Two thirds spent on treating preventable diseases ---• 5% spent on prevention of these diseases ----• 95% spent on direct medical care • Education vs. medical services • Health impact assessments • Community-level prevention initiatives • Community benefit spending by non-profit hospitals Opportunities that have resulted from the ACA include the following: --• Increased collaboration by many hospitals with public health and community partners --• "Health dividend" --- • Prevention and Public Health Fund ---• ACA, Medicaid waivers, and innovation grants • Health care sector is beginning to screen patients for social determinants of health (e.g., housing, transportation, food insecurity)

Health Care Infrastructure & Spending: Many Dollars, to What Effect?

U.S. most complicated health care system among advanced countries • Some nations manage health care through the government (Great Britain) • Others rely on the private market (Switzerland) • Still others mix government-run care for low-income residents with a private system (Singapore) • Fragmentation characterizes the U.S. system (US) Providing Health Care in the U.S. • Government-provided care -Veterans Health Administration • Private companies -70% nonprofit (universities, religious institutions, charities, or nonprofit networks) -30% for-profit -Drug industry almost entirely private • No national health planning, yet a leader in innovation • Health Care Spending in the U.S. -Hospital care (1/3 of spending) •Mix of tradition • Strategic decisions • Investor choices • Political compromises - Most per capita Bending the Cost Curve? Health Spending in Coming Years -Prescription drug increases • Drug company monopolies • CMS required to cover nearly all drugs • High costs of R&D and delays in FDA approval • Fragmentation of the industry -Higher costs for out-of-pocket care - Rising Medicare expenses -ACA premium hikes

Urgent care

Use for an illness, injury, or condition is serious but doesn't need emergency care. Ambulatory, provided by physicians or dance practice providers, walk in basis, and traditional setting or urgent care center

Other hospitals 209

VA, DOD for active duty, and Indian Health service

Health System Performance pt.1

WHO ranked health systems by five objectives • Maximizing population health (DALE) • Reducing inequalities in population health • Maximizing health system responsiveness • Reducing inequalities in responsiveness • Financing health equitability • Issues using DALE • U.S. has failed to invest in education, housing, employment, and social programs • U.S. is not performing well • Shift towards population health

Types of prevention

clinical, healthcare provider Community base, non-healthcare provider Holistic; cultural, social, environmental changes Initiative that focuses on individual or population-based

Quaternary

expansion of tertiary; complex medical and surgical care for highly specialized and unusual cases. Experimental procedures or medication. Advanced trauma and organ transplants. Academic medical centers

• The Affordable Care Act (ACA) and American Recovery and Reinvestment Act of 2009 (ARRA)

have created greater momentum toward ensuring quality by doing the following: • Accelerating interest in linking payment for services to results • Creating multiple provisions that put providers on a path to high-quality, affordable care

tertiary

hospitalization for specialty care that requires specialized equipment and expertise. Involves more complex therapeutic intervention. Example; coronary bypass, neurosurgery, no neonatal ICU, burns, and severe injuries. Protection order with admitting privileges

Issues facing providers

increase pressure in screen from the government, private insurance organizations, &the public. Need to control cost for increasing access and adapting continuously to survive

Long term care organizations

independent living facilities; provide meals, transportation, housekeeping and social activities. Assisted living; provide meals, laundry on medication reminders.Help with some ADLs and I ADLs Skilled nursing facilities; 24 hour nursing care, room and board, and activities.

Health IT Interoperability

interoperability • Enables the secure exchange of electronic health information with, and use of electronic health information from, other health IT without special effort on the part of the user • Allows for complete access, exchange, and use of all electronically accessible health information for authorized use under applicable State or Federal law • Does not constitute information blocking

The importance of good health in american life

life liberty and the pursuit of happiness -2nd sentence of declaration of independence -good health is core need -essential to participate in social and political system history of research and investment in health -19th century- germ theory and sanitation -20th- rapid advances in technology today: health care -enterprise blend of altruistic and industry -20% of economy, 11% of jobs -spent through taxes, health insurance, and out of pocket expenses

Emergency medical treatment and labor act of 1968

must be screened in evaluated, provided the necessary stabilizing treatment, and admitted to the hospital when necessary; regardless of ability to pay

Subacute impatient

needed immediately after or instead of hospitalization for an acute illness, injury, or exacerbation of a disease process. One or more active medical conditions for one or more complex treatments. We had in convalescent services for those in need 10 to 100 days of treatment and is provided in settings except acute care beds.

Innovation models of care delivery

patient centered Medical homes. Health homes; ACA to Medicaid people with chronic illness. Accountable Care organization; cooperation between different organizations, group share responsibilities, costs to Medicare people. Community base solutions; having food, housing, crime and poverty.

Total Health Expenditures Per Capita (U.S. dollars), 2016-2017

review figure -determine what characteristics other countries have that we can learn from

Distribution of U.S. Health Care Spending 2018

review picture

-free for service system -valued services

rewards for providing more billable services rather than reward for being efficient in providing effective care -movement way from this long way to go to become economically logical, patient friendly, and focus on delivery of high quality services - not transparent for those who use health xare

Prehospital

stabilization of emergency service. Primary - physicians, PA, nurse practitioner and family, internal, pediatric, OB/GYN, etc. Secondary -Specialist in medicine; referral, acute and prevention chronic-Continue training/modeling; diabetes, hypertension and depression. 1/4 of Americans and 2/3 of other people have two chronic diseases. Considered primary or specialty. Chronic disease can cause acute diseases that can be worse. 66% cost are for chronic condition.

Evaluating Health Systems: Comparing 11 Wealthy Countries

view figure and compare with total health expenditures from previous figure to find themes

Community Hospital

volunteers; nonprofit. Investor owned; profit/proprietary. Public; state or local government. Could be participating in a network to

Behavioral Risk Factors: Overview & National Goals (cont'd) 7: Alcohol use and misuse

~5% of the U.S. adult population meets the criteria for alcoholism or alcohol dependence. • Alcohol misuse is most common in young adults, particularly among White and Native American men. • Low and moderate levels of alcohol use in adults have been linked to modest health benefits, such as a lowered risk for heart disease. • Estimated cost $249 billion • Alcohol retail density and alcohol-related advertising can vary by certain neighborhood sociodemographic characteristics. • Health benefits of treating alcohol dependence are well established

Public health lecture 7

• "What society does collectively to assure the conditions for people to be healthy" (IOM 2002) • Science, practice & art of protecting & improving health of populations • Historically focused on sanitation & environment • Later on communicable diseases, health behavior • Late 20th cent., last resort provider of indigent care

Initiatives to Address Expenditure/Value Tradeoffs

• 1980s • Employers shifted costs to employees (trend continues today) • Managed care organizations created (primary health insurance model today) • 2009 • Insurers began to experiment with new payment models. • Models began to address the need for value—providing incentives to improve outcomes at lower costs. • Value-based care model goals include the following: • Improve the patient experience (including quality and satisfaction) • Improve the health of populations • Reduce costs • Value-based payment models • Bundled payments • Providers receive a lump sum payment for each episode of care they provide to patients. • Providers can benefit when patients require little care. • Cost of care given can exceed the amount of the lump sum payment in complex cases or when complications arise. • Bundled payments for care improvement (BPCI) initiative • BPCI Advanced introduced in January 2018 • Commercial bundles • Value-based payment models (cont'd) • Medicare Access and CHIP Reauthorization Act (MACRA) • Two reimbursement tracks: 1. Merit-based Incentive Payment System (MIPS) • For providers participating in traditional Medicare Part B • Earn payment adjustments based on performance in quality of care, cost of care, clinical practice improvement, and "advancing care information"(similar to meaningful use of electronic health records [EHRs]) • Value-based payment models (cont'd) 2. Advanced Alternative Payment Models (APMs) • For providers participating in a value-based care model • Must use certified EHR technology, base payments on quality measures comparable to MIPS, and require providers to bear more than nominal risk • Value-based pricing of pharmaceuticals • Lack of transparency throughout the process of pricing and paying for drugs in the U.S. • Pharmacy benefit manager (PBM) earns rebates on each prescription dispensed • Drug manufacturers negotiate with PBMs to earn rebates.

Leading Determinants of Health: Weighting the Different Domains

• 20th century research finding: Medical care explained only 5 of the 30 years of increase in life expectancy • 1950-1990 research finding: New therapies only account for 3 of the 7 years of life expectancy increase • Medical care responsible for increasing mortality • Genetic studies inconclusive • Health behaviors are major determinants of health • Summary measures of mortality and morbidity

Four lessons for policymakers in the U.S.:

• Achieving the goal of universal health coverage requires legislation • Financing broader insurance coverage in the United States requires increasing government subsidies. • Health care systems with universal coverage rely on economic evaluation of health technology. • Containing health care costs needs price regulation and systemwide budget targets.

Who Is Part of the Health Workforce?

• All professionals and workers who contribute to the delivery of health care • Examples include physicians, radiation technicians, dental assistants, nurses • Also includes home care aides, personal care assistants, and school nurses • Largest occupation is RN • Personal care aides are second largest • Unlicensed nursing assistants are third

Challenges to More Effective Use of Information and Data

• Barriers • Technical limitations • Policy challenges • Lack of business drivers and incentives • Difficulties integrating the EHR into workflow • Decreased time for face-to-face patient interactions • Increased demands for timely data entry • Provider dissatisfaction with functionality or usability of their current EHR system • Feel stuck because of administrative challenges and costs associated with transitioning away from the current system • Willful information blocking

NHI systems Private & market-based systems

• Based on model devised by Bismarck • Found in Germany, Canada & France • Most financing from payroll taxes • Significant variations in financing & organization • U.S. & Switzerland

Health and Behavio

• Behavioral choices are key determinant of Americans' heath and well-being • Adopting healthy lifestyles falls into multiple realms • Behavioral risk factors contribute to growing burden of preventable chronic disease • Social determinants play a major role in shaping health and health outcomes

Behavioral Risk Factors: Overview & National Goals

• Chronic diseases are leading causes of illness and death • Prevalence and costs of chronic illness care will continue to rise because of aging population • Many deaths attributed to personal behavior • Most Americans have at least one risk factor; more than half have two or more B

Governance, Performance And Accountability

• Concept of the Governing Board • Types of HCO ownership • Nonprofit: • Chartered & regulated by the state • Boards are self-perpetuating • Public: • Owned by and accountable to elected public officials or to boards appointed by elected public officials • For-profit: • Corporations owned by and accountable to investors • Interests generally represented by a governing board elected by the investors • The goals of boards and those who appoint boards can differ widely • What boards do • Select, encourage, advise, evaluate, compensate, & replace chief executive officer (CEO) • Discuss, review, & approve strategic directions • Monitor management performance • Ensure organization operates responsibly & effectively • Act on specific policy recommendations; mobilize support for decisions taken • Provide a buffer for the president or CEO and "take some of the heat" • Ensure that the necessary resources will be available to pursue strategies and achieve objectives • Nominate suitable candidates for election to the board and establish and carry out an effective system of board governanceDirectors of the board must exercise duties of care, obedience and loyalty • Board is considered the conscience of the organization • Accountable to stakeholders for protecting and achieving the mission • Board members are not liable for a bad business decision as long as it can be shown to be prudent • Board members must be attuned to potential conflicts of interest • Costs of governance • Add energy and considerable resources • More balanced view of organizational situations than CEOs • Longer view of establishing and accomplishing the organizational mission • Selects the CEO • Establishes the organization's strategic direction, mission, vision, and values • Accountable for keeping these statements aligned with the HCO's current and future situation • Challenges That Boards Face • Ensuring that: • Revenues cover operating costs • Services are delivered with high quality • Patient health outcomes are positive • Boards: • Set and review metrics for performance evaluation • Might push the organization to improve the health of the community's population, rather than just focusing on patients who use their services • Influence performance by setting & overseeing strategy for an institution • Hold managers accountable for improving quality and transparency• Board composition • Some boards require members to make financial contributions • Limit terms of board member service • Some boards have an age requirement • Diversity of board members • To be effective, boards should understand what they should not do

Current Marketplace and Emerging Opportunities

• Consumer-facing health apps • Remote patient monitoring technologies • Telehealth • PatientPing • Uses administrative data available in admission, discharge, and transfer feeds to provide more real-time clinical event notifications to accountable providers connected to the network • Artificial intelligence tools • Use advanced analytics and machine learning to optimize health care delivery • Blockchain • Uses distributed peer-to-peer networks to support secure, decentralized data management and validated transactions

Defining and Measuring Value in Health Care

• Definition of value • Value is the pot of gold at the intersection of health care spending, patients' experiences and outcomes, and the quality of the care that providers deliver . • Health outcomes achieved per dollar spent.1 • Defining value is critical for enabling patients to understand what they are getting. • Stakeholders in health care often have conflicting goals. • Definition of value (cont'd) • Patients want the following: • Access to services that ensure best possible outcome • Care that is safe and convenient • Care delivered in a respectful and dignified way • Providers want profitability. • Payers want lowered costs. • Key challenge is the ability to meaningfully measure patient-centered outcomes and associated costs • Patient outcomes are subtle and multidimensional. • Patient-centered outcomes must capture patients' functional and psychological status, perceptions and valuations of their care, and goals for recovery. • Value in health care is that value is achieved when the health care that gets delivered helps patients achieve what matters most to them. • Patient-centered outcomes research (PCOR) • Patient-reported outcome measures (PROMs)

Emerging and Test Ideas for Better Health Delivery

• Delivery strategies that work - Care coordination - Patient engagement and team-based care • Process of involving individuals in their health care, disease management, or preventive behaviors • Works best when it involves a team that not only possesses clinical expertise, but also considers patients' socioeconomic needs and provides coordination - An integrated system • Integrated systems provide or arrange a coordinated continuum of health care services to a defined population, and hold themselves accountable for patient outcomes and health status. - Use of data in improving care (e.g., electronic health records, geographic information systems)

Evidence-Based Management

• Evidence-based management is "the systematic application of the best available evidence to the evaluation of management strategies for improving organizational performance"1 • Steps in the evidence-based management process include the following: 1. Translating a management challenge into research questions 2. Acquiring relevant research findings / evidence 3. Assessing the validity, quality, applicability and adequacy of the evidence 4. Presenting evidence in a useful way 5. Including important stakeholders in decision-making process • HCOs are more likely to practice evidence-based management: • When external incentives for performance are strong • When an HCO has a "hardwired" questioning management culture rather than a more hierarchical culture • When there is focused accountability for decision making linked to the quality and timeliness of the process • When managers participate actively in the management research

Challenges Managers Face

• External Challenges • Obtaining sufficient resources to support clinicians and satisfy customers • Internal Challenges • Measuring processes & outcomes to facilitate continual improvement • Creating an environment of excellent care • Motivating & supporting employees • It is the manager's job to do the following: • Measure operational processes • Supply needed support to clinicians given the resources available • Communicate with staff

Understanding Factors and Systems (cont'd)

• Health need factor - Physical • Characterized according to the physiological and physical status of the body • Acute/chronic conditions, disabilities - Mental (or psychological) • Characterized by emotional and behavioral health • Mental illness, alcohol or drug dependence - Social • Extend beyond the individual; include quantity and quality of social contacts with other people • Individuals experiencing homelessness, immigrants or refugees, formerly incarcerated • Predisposing factors - Preexisting characteristics that may influence a health-related behavior - Indicate the propensity for vulnerability • Enabling factors - Reflect the resources available to overcome the consequences of vulnerability - Examples: living conditions, social support, resources, skills

The Growing Number of Health Inequities

• Factors - Rise in prevalence of chronic conditions - Shifting demographics of U.S. population • Increasing income inequality • Aging of baby boomer generation - Strained social service sector for already vulnerable communities • Prevalence of chronic conditions - Some chronic illnesses can be treated but not cured. - Require constant management - Unprecedented rise in chronic conditions in the U.S. - Vulnerable populations more likely to have a chronic illness because of disparities in resources and tools to prevent illness and maintain health and well-being • Growing income inequalities - Numbers living in deep poverty have fluctuated, reaching its highest level in 2010 - Children under the age of 18 more likely to live in poverty. - Poverty rates for African Americans (27%) and Latinos (25%) are significantly higher than for White Americans (10%) and their children (20%). - Single-parent families are also more likely to live in poverty. - People with disabilities (28%) are more than twice as likely to live in poverty as their counterparts without a disability (12%). • Growing numbers of people of color - Being a person of color intersects with socioeconomic status; thus, a person of color living in poverty will experience worsened health impacts than a person living in poverty without this identity. - Inequities in health associated with race put patients of color at risk of receiving less effective care. • They also appear to be at risk of receiving more ineffective care when they receive care. - Inequities are also associated with system related factors such as the following: • Ambulance diversion • Organ allocation protocols • Implementation of care delivery models (e.g., patient-centered medical home) • The graying of America - In 2030, when the entire baby boom generation will have turned 65, seniors will make up one-fourth of the population. - Baby boomers are living longer because of improvements in health care, technology, and lifestyles . - Rates of chronic conditions will increase. - Health expenditures are a greater financial burden for older people. - Older Americans—especially those living in impoverished neighborhoods— at highest risk of vulnerability.

Provider Payment-canada

• Fee-for-service • Negotiated annual physician fee schedule based on relative value scale for each reimbursable procedure • Variations across Canada • Blended capitation schemes -• Rely on age and gender-adjusted payments -• Financial incentives to follow "evidence-based" guidelines -• Fee-for-service to treat non-enrolled patients

General Overview of Health Care Financing

• Financing of health care • How we pay for care • Who pays for care • Transactions between users and providers • How many total dollars are spent on care • Uniqueness of health care as a commodity • Stark variation in need: 20% use 80% of services • High cost • Insurance system • Allows us to pay for services collectively; we pool our risks for needing health care • Individual pays premium • Premiums are pooled across a population of people. • Many types of health insurance; paid for through taxes, employers, or individuals • Copayments; structure varies among plans • Complex reimbursement rules; can lead to conflict between insurers and providers • Incentives must be created to avoid overuse and oversupply. • Public insurance programs • Medicare • Medicaid • Private insurance • Health care: an economic commodity or an inherent right?

Social Service Needs

• Food assistance - Supplemental Nutrition Assistance Program - Women, Infants, and Children - Other federal and private food programs • Monetary assistance - Temporary Assistance for Needy Families - Supplemental Security Income - Unemployment Insurance • Housing assistance

Challenges for Service Delivery and Payment

• Fragmented delivery system - Silo structures - care offered by multiple providers who do not consult with each other • Volume versus value - Current market-driven health care delivery and payment system gives providers financial incentives for the volume, not the quality, of services delivered • Reactive versus preventive care - Few incentives to promote prevention and early intervention, especially in the case of chronic diseases

Specialized Payment Approaches Used by Payers

• Goals: • Reduce the high rate of year-to-year cost inflation in health care • Create incentives for providers to deliver higher-quality care and to use more efficient practices to manage patient care • Elusive sweet spot • Pay providers to deliver high quality, needed services but create incentives for providers and patients • Managed care •Prepaid health plans • Health maintenance organizations (HMOs) • Receive capitated payments • Control which providers participate in their network • Most consumers today choose not to enroll in HMO plans. • Preferred provider organizations (PPOs) • Encourage plan members to use a list of physicians with whom they have negotiated discounts. • Lower out-of-pocket costs (deductibles, copays, and coinsurance) for the insured • Consumer-driven health care and high deductibles • Setting a high deductible that an individual pays before they receive benefits • Puts individual at risk to pay the bulk of care and pharmaceutical needs • Reference pricing • Efforts to improve price transparency • Fixed payment approaches • Diagnosis-related groups • Prospective payment for hospital care • Prospective rates for physician payments • Bundled payment rates • Emerging concept • Both the physician and the hospital are paid a fixed amount to provide an episode of care or, in the case of patients with chronic conditions, a specified time period of care • Prospective payment rates for physicians and other providers • Resource-based relative value scale (RBRVS) • Medicare program's approach to using standardized principles to set rates for different specialists and for patients with different medical needs • Rates are determined through detailed research measuring the expected time and other resource inputs that physicians need to deliver a specific service. • Each state's Medicaid program also developed physician reimbursement rates. • ACA mandates that state Medicaid programs raise physician reimbursement rates to at least 60% of the rates paid by Medicare

Health Care Management

• Governance: process for making and reviewing strategic decisions made by HCOs • Management: shapes and implements governance decisions • Accountability: being responsible for making informed and wise decisions that affect health outcomes and processes of care at a given level of quality and a given level of cost • Stakeholders: individuals and groups who will be influenced by or have an interest in the decisions that HCOs make

Uneven Footing After the Great Recession

• Great Recession over - Wage increases sluggish despite more fully employed people - Recovery has not been equitable. - Tax reduction plan favored the wealthy - Funding to the social service sector that aids vulnerable populations was reduced. - Supplemental Nutrition Assistance Program (SNAP) has experienced budget cuts.

Three dimensions of the U.S. health care system

• Health infrastructure and how services are financed • Health insurance • Health disparities

Federal and State Financing of Care for Vulnerable Populations

• Main payers for health care for the vulnerable - Federal government • Medicare, Medicaid, Children's Health Insurance Plan (CHIP) • Dual eligibles (individuals who qualify for both Medicare and Medicaid • Disproportionate Share Hospital program - States - Medicaid (administration) - Private sources - employers, insurers, and philanthropic organizations

Changing Provider Behavior

• IOM reports • 2001: agenda for improving health care quality • 2003: interventions for obesity and tobacco use • 2012: obesity interventions to address disparities among members of low-income, low-resource communities • Despite strong evidence for behavioral prevention in primary care, significant gaps persist between recommended and actual care • Better educational approaches and clinician training needed • Multilevel models for improving delivery of effective health behavior change interventions Practice ecology model • Emphasizes need to address individual provider behavior and effects of health care systems and environments in which they practice • Need for broad-spectrum strategies that address multiple levels of influence • Need to move toward a system that would support and pay for proactive, preventive, and behavioral care • Multilevel models for improving delivery of effective health behavior change interventions (cont'd) Chronic care model elements • Health care organization • Clinical information systems • Decision support tools • Practice redesign • Self-management support • Community resources and policies

Critical Issues for the Health Workforce

• Implementation of the ACA has brought new urgency to the need to reform the delivery of health care in the U.S. • Changes may be difficult to implement in the face of ongoing and worsening shortages of health professionals. • Critical issues facing the health workforce now include the following: • Educational reforms, including ongoing shortages • Changes in health care financing • Developing a workforce to coordinate care of patients • Integrating physical health care services with behavioral health and dental care • Optimizing the use of information technologies in care delivery and quality improvement • Revamping regulations to meet health care needs • Leveraging potential health care labor unions and labor-management partnerships • Health professional shortages - • Expansion of insurance coverage under the ACA led to surge in demand for health services • Exacerbated preexisting shortages of health professionals • Concerns that there is not an adequate workforce to meet the health care needs of the population • Increased demand may not increase supply • Wages not likely to increase because of fee-for-service system • Supply is constrained by licensure, educational requirements, and limits on educational capacity. • Geographic maldistribution of health workers (rural areas) • Some policy experts are advocating for increasing the roles of nonphysicians and allied health workers in care delivery. • Changes in health care financing and the organization of care • Some provisions in the ACA are intended to increase efficiency. • Performance-based payment programs • Medicare's bundled payment • Accountable care organization programs • Care coordination • Hospital incentives to reduce the length of hospital stay • Ambulatory care provider incentives to reduce unnecessary ambulatory care and emergency department visits • Increased importance of care coordination • Greater investments are being made in hiring and training workers for care coordination. • Preparation in the following skills will be needed as care coordination becomes more prevalent: • Team communication • Use of remote monitoring technology • Telehealth • Working with family caregivers • Integration of physical health, behavioral health, and dental care • Behavioral health includes mental health and substance abuse. • Demand for services has increased because of the Mental Health Parity and Addiction Equity Act of 2008 and the ACA • ACA included mental health care as one of 10 essential benefits. • National shortage of behavioral health providers • Challenges in assuring access to behavioral health care workers include the following: • Lack of growth in the number of psychiatry trainees • Psychiatric mental health nurse practitioners' scope of practice limitations • Maldistribution of the available workforce geographically and between public and private practice • Stigma of working in behavioral health • Integration of physical health, behavioral health, and dental care (cont'd) • Oral health impacts physical health. • Medicaid plans insure oral health services for children. • Some providers integrate dental and medical services. • Some federally qualified health centers and private medical groups have trained pediatricians to provide enhanced dental screening and apply fluoride varnish to children's teeth. • Information technologies and the workforce • Electronic health records • Enable health workers to exchange information rapidly • Help providers engage patients more actively in care. • Facilitate greater use of telephone communication; decrease in primary care visits and fewer hospitalizations • Improve efficiency and quality • Disrupt workflow in the short term; challenging for workers with poor typing and computer skills • Require redesign of workflow and computer training • Telemedicine • Allows patient access to remote specialists for consultation • The need for regulatory reform • Increased role of nonphysician providers • Reconsider scope-of-practice limitations and regulations • Potential for nurse practitioners to provide more primary care • Health care unions and labor-management partnerships • ~14% of health practitioner and technical workers represented by unions • Unionized workers receive higher wages • Other concessions sought from employers include the following: • Fixed nurse-to-patient ratios • Preferred shifts based on employment tenure • Improved health and retirement benefits • Participation in strikes and labor actions • Unions are politically active, supporting legislation and candidates. • Kaiser Permanente is one model of a collaborative labor-management approach.

What the Money Buys and Where It Comes From

• In 2016, the total national bill for health care was $3.3 trillion, which represented 18.2% of the national gross domestic product that year. • How individuals pay for health care • Insurance coverage • Out-of-pocket cash • Attempt to obtain the service free • Charity case; often through a safety-net provider • Public programs • Medicare • Medicaid • Children's Health Insurance Program (CHIP) • Veterans • Public employees • Members of the armed services and their families • Native Americans • Private insurance coverage varies • Small employers buy from commercial companies • Individual insurance • May buy insurance through commercial companies • Can buy insurance through exchanges established by the ACA • Large employers can buy from commercial companies or can selfinsure • Publicly financed programs • Medicaid • 64% of expenditures support care for the 35% of enrollees who are elderly or disabled. • Medicare • Part A, hospital insurance • Part B, supplemental medical insurance covering physician services and outpatient care • Part D, pays for a substantial share of pharmaceutical costs • Programs for active duty and retired military personnel • Indian Health Service • Workers' Compensation • Privately financed health care • Employer-based insurance • Emerged during WWII as employment benefit • Covered 64% of Americans in 2002; 49% in 2016 • Individual insurance • ACA offers substantial subsidies for many Americans to purchase insurance as individuals. • Consolidated Omnibus Budget Reconciliation Act (COBRA) • Reduces gaps in insurance coverage between jobs • Employer must extend insurance for up to 18 months after employee leaves • Employees generally pay entire premium for coverage

At the core, is health care a right or a good?

• In the U.S. it is a patchwork not a right: entitlements, prerequisites, and services • Shaped by political debates

How Providers are Paid for the Health Services They Deliver

• Insurance payments • Fixed rates from Medicare & Medicaid • Negotiated rates from private insurers • Physicians often at disadvantage • MDs driven to join PPOs or to take salaried positions • Hospitals able to negotiate better rates • Any provider that does not negotiate rates with an insurer through a contract is considered an out-of-network provider by that insurer • Private insurers pay the best rates; Medicare second-highest; Medicaid tends to pay the lowest rates • Financial viability relies on payer mix • Payments made directly by patients • Individuals without insurance must pay cash for services • Individuals who use out-of-network providers pay cash, then seek reimbursement • Increasing number of physicians have decided to be out-of-network providers, putting more payment responsibility on individual patients • Insurers are contributing to the growth • Prices charged vary; rarely transparent

How Do We Improve Quality?

• Measure what you are doing and with what result. • Know what works clinically and make sure you are doing it. • Look at how care is organized and delivered and what process improvements might be made. • Prioritize quality and safety. Dimensions of quality 1. Structure • Facilities and health care professionals providing care • Measures are the easiest to conduct, but the most remote from the outcome 2. Process • Set of services provided • Measuring process can bring you closer to the outcome, but does not guarantee the outcome 3. Outcomes • End results people experience and care about • Ensure that there are no other, unmeasured factors intervening to produce poor outcomes, even with good process scores • Scope of measure • Growing interest in measuring quality of entire episode of care, not individual services • Major challenge to achieve evidence-based, credible, and reliable measures that cut across services and even sites of care • Data • Good measures are meaningless without good data. • Readily available as a by-product of care process • Recent enough to permit analysis and improvement in close to real time • Detailed enough to enable posing and testing of hypotheses • External benchmarks can be usefu • Know what works clinically • Health care quality is the sum of multiple individual interactions between clinicians and patients. • Most widely used process measures derive from scientific evidence about which treatments work best and for whom. • Valid measures reflect strong evidence and professional endorsement. • Developed from practice guidelines • Organizational levels • Micro: patient and physician • Team: surgeon, clinicians, nurses, etc. • Meso: interactions between teams • Macro: interactions between organizations and environment • Five C's • Culture • Capacity • Capability • Consistency • Candor

Behavioral Risk Factors: Overview & National Goals (cont'd): Obesity

• Nearly 70% of all American adults are overweight or obese . • Strong links between obesity and many chronic diseases • Even modest weight loss (e.g., 5% to 10% of body weight) can reduce risks • Prevalence of overweight and obesity among children and adolescents (ages 6 to 19), has increased significantly over the past 30 years • Highest and fastest-rising rates of childhood obesity are seen among the following:

Behavioral Risk Factors: Overview & National Goals (cont'd): Physical Activity and Sedentary Lifestyle

• Numerous associated health risks • Engaging in physical activity has many benefits. • At least 60 minutes/day of moderate-to-vigorous physical activity recommended for children and teens • There are groups more at risk for physical inactivity • Healthy People 2020 includes policy objectives that promote physical activity in childcare settings and in schools.

Driving Forces Shaping the Use of Data and Health IT

• Office of the National Coordinator for Health IT (ONC) • Federal entity charged with coordination of nationwide efforts to implement and use HIT • Includes oversight of relevant efforts across the federal government's health programs administered by CMS, Veterans Health Administration, Defense Health Agency, and other regulatory agencies such as the Federal Communications Commission and National Institute of Standards and Technology • Administers Health IT Certification Program • Goal is for information to follow a patient where and when it is needed, across organizations, IT systems, and geographic boundaries, and to make patients' medical records available to them in electronic format •2009 Health Information Technology for Economic and Clinical Health (HITECH) Act • Stimulated unprecedented growth in the adoption of EHRs • Hospitals: 96% (2016) • Physician's offices: 78% (2016) • 21st Century Cures Act passed in 2016 • Designed to accelerate interoperability • Important provisions include the following: • Combating and penalizing information blocking • Establishing or recognizing a trusted exchange framework • Requiring conditions and maintenance of certification by developers participating in the Health IT Certification Program • HIT represents a key strategy for curbing health care costs. • HIT is required by value-based care models to manage population health and better coordinate across systems of patient care. • Medicare's Quality Payment Program • Builds on meaningful use requirements for provider use of certified EHR technology

Delivery System Reform

• Patient centered medical homes • Patient-centered • Comprehensive • Coordinated • Accessible • Committed to quality and safety • Accountable care organizations (ACOs) • Medicare ACOs • Medicaid ACOs • Commercial ACOs • Employer-driven ACOs • Oncology care model • Other novel programs for delivery reform • End-stage renal disease care model • Independence at home demonstration • Home health value-based reimbursement pilot • State-driven value-based initiatives • Maryland all-payer model • Vermont all-payer ACO

The Role and Impact of Primary Care Interventions

• Patients expect and value advice from their providers about diet, exercise, and substance use and are motivated to act on this advice . • 5 A's, an evidence-based, practice-friendly intervention model • Ask • Advise • Agree • Assist • Arrange follow-up

Spending Levels and Cost Growth

• Per capita health care spending • 1960: $1,184 (inflation-adjusted) • 2016: $10,348 • A 775% increase • Average annual growth in health care spending between 1960 and 2016 was ~9%. • Gross domestic product growth during this period was 6.5% • Other reasons for concern about spending levels • Health care costs are being shifted to patients/consumers (e.g., higher insurance premiums and higher coinsurance) • Strain on taxes paid by workers and employers • Fewer tax funds available for other needs (e.g., education, infrastructure) • Fewer employers continue to offer group health insurance to employees—or they limit dependents of employees who can access coverage. • Increasing health insurance costs decreases full-time employment. • Also decreases hours worked for employees who work part time • Burden on family budgets

Provider Payment- China

• Physicians paid by salary • Subnational governments regulate prices •- Pay-for-performance incentives • Expansion of private health insurance • Goal to reduce kickbacks (medical device & pharma companies)

Behavioral Risk Factors: Overview & National Goals (cont'd):Diet and nutrition

• Poor diet and nutrition has contributed to a surge in overweight and obesity. • Four of the 10 leading causes of death are associated with an unhealthy diet. • Gaps exist between recommended guidelines and the actual diets of American children and adults. • Access to healthy food limited for low-income communities, communities of color, and rural communities

Public Health is Different from Individual Health Care

• Prevention and Health Promotion at a Population Level • Changes in policy or law • Consensus of professional societies • Range of organizations about prevention efforts • Incorporating considerations in decisions of sectors Primary Prevention -Helping people avoid the onset of a health condition, including injuries Secondary Prevention- Identifying and treating people who have risk factors or preclinical disease Tertiary Prevention -Treating people with an established disease in order to restore their highest functioning, minimize negative impact, and prevent complications Healthy People 2020 • Comprehensive review with specific objectives • Priority health risks • Effective strategies • Public health focus areas for the nation • Universal Prevention • Targeted Prevention Increasing Focus on Health Equity • Eliminates health disparities or inequalities • Has a fair and just opportunity to be healthier • Removes obstacles to health and their consequence • Addresses immediate and concrete issues or upstream social determinants of health • Appeals to social justice and utilitarian factors • Not a zero sum game • Never intended to impair other people's opportunities to be healthy

Organization and Financing of Health Care

• Public hospitals - Provide services to large portions of people who are uninsured, underinsured, and those on Medicaid - Often serve some of the sickest, poorest, and most vulnerable - Provide care to the most vulnerable groups within a community (e.g., homeless, disabled) - Provide services to the incarcerated - Respond to disasters within communities - Provide trauma care - Administer behavioral health and substance abuse treatment when necessary • Federally qualified health centers (FQHCs) - Safety-net providers - Serve predominantly vulnerable groups living in underserved communities - Overseen by Health Resources and Services Administration of the U.S. Department of Health and Human Services - Must meet specific criteria - Examples • Community health centers • Migrant health centers • Health care for the homeless centers • Public housing primary care centers

Rural Health Clinics and Rural Health Networks

• Rural health clinics (RHCs) - Created as a result of federal legislation that provided reimbursement for services provided by full-time doctors and for preventive and primary care services done by mid-level providers (e.g., nurse practitioners, physician assistants) at clinics in underserved rural areas across the U.S. • Rural health networks (RHNs) - Systems of care in rural areas that include at least one rural hospital and two other separate community health organizations (e.g., nursing home, public health unit) - Pool resources to develop continuing education programs, invest in electronic medical record systems, and support advocacy activities within the communities served by the RHN • Indian Health Services • Mental health and chemical dependency services - Community-based mental health centers are underfunded and understaffed. - Transinstitutionalization • Prisons, instead of psychiatric or detoxification facilities, become the main providers of highly structured, controlled living environments for the severely mentally ill and chemically dependent. • Special populations: HIV/AIDS programs

Cost Drivers and Barriers to Value

• Spending = quantity × price • Fee-for-service (FFS) payment models • FFS made sense when providers saw patients for acute problems • Most health care spending now is devoted to treating chronic illnesses over long periods • Rarely provided by a single physician; team-based medicine is the modern norm • Categories of wasteful health care spending • Failure of care delivery • Failure of care coordination • Overtreatment • Administrative complexity • Fraud • Pricing failures • Failure of care delivery • Patient services received that do little to advance their treatment or that case harm • Need to provide the right care, to the right patient, at the right time • Failure of care coordination • Duplication of services • 30-day hospital readmissions • Poorly coordinated care is more costly than for the most complexly ill patients • 5% of the total U.S. population accounts for 50% of all health care spending, and 10% accounts for 66% of spending . • Bottom 50% of the population accounts for just under 3% of spending • Overtreatment • Where you live matters. • Geographic differences in ability to access care, quality of care received, and outcomes • Some health care services are overused and generate cost and waste. • Overscreening • Costly end-of-life care • ~32% of Medicare spending is related to patients in their last two years of life suffering from chronic illnesses. • Overuse • Administrative complexity and fraud • Hodgepodge of public and private insurers, operating under different federal and state laws and regulations, and paying for services under different payment models • Dishonest actors • Generate fake bills for services they did not provide • Efforts to detect and stop fraud are costly. • Pricing failures • U.S. physicians earn higher salaries than those in most other countries. • Pharmaceutical prices are much higher in the U.S . • Hospital prices are much higher. • Hospital administrators earn more in the U.S. than elsewhere • Lack of information and transparency is a barrier to understanding the role price plays in the driving of overall costs.

What Are Major Recent Developments Affecting Quality?

• The Patient Protection and Affordable Care Act (ACA) • Incentives for performance transparency • Improving measure selection • Testing new models of care • Supporting research about treatments • National Strategy for Quality Improvement • Building on current efforts • Testing new approaches • Primary care (or patient-centered) medical home (PCMH) • Role of nongovernmental organizations • Developing and endorsing measures • Accrediting health care organizations • Conducting research on quality improvement at the micro- and macrolevels • Using market power to encourage change • Facilitating use of emerging evidence to bring about transformation • LEAN • Five-step process for improving quality 1. Specify value from standpoint of end customer 2. Identify all steps in value stream 3. Make value-creating steps occur in tight sequence 4. As flow is introduced, customers pull value from next upstream activity 5. As value is specified, value streams are identified, wasted steps removed, and flow & pull introduced • Patient and family engagement • Patient engagement is the "blockbuster drug" of the 21st century • Some states are requiring all hospitals to have a formal patient and family advisory council • Role of social media • "Good news" - generates greater information sharing and dialogue • "Bad news" - information sharing and greater dialogue may amplify misleading and erroneous information

Core Competencies for Health Administrators

• The bottom line for all health care facilities—and therefore the priority for administrators—will be an explicit focus on care quality. • Health care administrators need the following: • Solid grounding in quality measurement • Understanding of design and evaluation of interventions and programs to improve quality • Performance data is a core competence. • A focus on improving quality and safety cannot be outsourced to the quality department or team. • Success of health administrators will likely depend on their willingness and skill to engage clinical colleagues, payers, and the broader community to achieve shared goals.

Overview of US health care system

• U.S. most expensive health care system in the world • Not universal • Large inequities • Costs are a source of financial strain • American's have high rate of mortality • Medical professionals and the public are dissatisfied with the system

Standards

• Vocabulary • Coding • Terminology • Content and structure •Implementation specifications • Administrative

Privacy and Security

•Issues of privacy and security are a significant barrier to more ubiquitous availability and exchange of health information • Trusted exchange framework • Cybersecurity • Hacking • Identity theft • Service disruption • Malicious software

The Complex Tasks of Leadership and Management

•Managers create and maintain the environment that supports clinicians in their work •Ways of looking at what managers do include the following: • Functions managers perform • Responsibilities they are accountable for • What choices managers make in how they spend their time and effort • With whom they spend their time •Managerial functions • Managing unit or area performance • Coaching and mentoring associates • Promoting employee and physician engagement • A manager's scarcest resource may be his or her own time • Managers choose whether to do tasks themselves, delegate work to others, or not do the work •Effective managers • Meet their goals • Includes helping the team and the HCO accomplish goals and exceed the expectations of key stakeholders • Have a high degree of "emotional intelligence" (i.e. self-awareness, selfregulation, motivation, empathy and social skills) • Work collaboratively with clinicians • Understand the needs of clinicians in delivering high-quality and efficient care • Effective Managers - People Skills • Efficiency orientation • Planning • Initiative • Attention to detail • Self-control • Flexibility • Empathy The Complex Tasks of Leadership and Management (cont'd) • Persuasiveness • Networking • Negotiating • Self-confidence • Group management • Developing others • Oral communication Conceptual Skills • Use of concepts • Systems thinking • Pattern recognition • Theory building • Technology • Quantitative analysis • Social objectivity Reasoning Skills • Written communication • Analytical reasoning