2-organization of care

Question 1

Characteristics of the organization of health service delivery:

Answer 1

mix of organizations
divisions

interactions among these

organizations -how they get the resource

The internal administrative and management structures

Question 2

how is British NHS – an example of regionalized care

Answer 2

2/3 of UK physicians are GPs.

Secondary care – specialists, usually in hospital based clinics, consultants

Tertiary care sub-specialists – immunologists, pediatric hematologists, transplant specialists

Hospitals and provider placement follows population calculations – i.e. what number of people, with particular demographics, require what number of providers, at what level.

Dispersed model in the US – less structured approach, less oversight, regulation and guidance form government.
Patients can access specialists directly.

Question 3

what does the division of services look like in the US

Answer 3

Hospitals in US do not operate within a secondary and tertiary classifications, with many private hospital offering highly specialized services to attract patients and providers. Not efficient, or high quality.
While it may offer greater flexibility of services and convenience - top-heavy with specialists, expensive, fragmented often uncoordinated care.

Question 4

what is meant by the phrase a cottage industry

Answer 4

nonintegrated, dedicated artisans who eschew standardization.

Question 5

what are the reasons health care is fragmented in the US

Answer 5

peer accountability,

quality improvement infrastructure,

clinical information systems

Question 6

what has lead to dispersed model of care

Answer 6

Biomedical model of health care -one problem one treatment

Financial incentives

Professionalism -sovereignty of physicians as pre-eminent authorities on health care

Question 7

what % of care is self care

Answer 7

~80% of care = self care

Question 8

– treatment of rare and complex disorders

Answer 8

Tertiary

Question 9

hospital care falls under

Answer 9

secondary along with specialists

Question 10

4 characteristics of primary care

Answer 10

Initial contact
Continuous care
Comprehensive
Coordination of care

Question 11

what is gatekeeping

Answer 11

“Gatekeeping” preventing inappropriate visits to specialists or for unnecessary procedures

Question 12

how can Patient incentives improve care

Answer 12

Patients should be given incentives to choose to receive care from high-quality, high-value delivery systems. This requires performance measurement systems that adequately distinguish among delivery systems. Payment…

Question 13

how can Regulatory changes improve care

Answer 13

The regulatory environment should be modified to facilitate clinical integration among providers. Limit unnecessary duplication of facilities and services

Question 14

Full population prepayment

Answer 14

a single payment for the full continuum of services for a given patient population and period of time—should be encouraged.

Question 15

Global case payments for acute hospitalizations

Answer 15

Ideally, such payments should bundle all related medical services from the initial hospitalization to a defined period post-hospitalization (including preventable re-hospitalizations). These payments also should be risk-adjusted to avoid adverse patient selection.

Question 16

APM

Answer 16

is a system for medical reimbursement that provides additional compensation as an incentive for the delivery of higher quality and more cost-efficient health care by providers

Question 17

PPS

Answer 17

The Medicare Prospective Payment System (PPS)

A payment mechanism for reimbursing hospitals for inpatient health care services in which a predetermined rate is set for treatment of specific illnesses.

Question 18

PPOs

Answer 18

– pts can see any providers, but lower costs if using in-network. Providers agree to accept payment as set by insurer.

Question 19

HMO used to be

Answer 19

Health Maintenance Organization used to be

Prepaid Group Practice

Question 20

ACO how it different from HMO

Answer 20

HMO only covered in HMO network

you can see ACO outside
don’t cut corners, need to track care

An ACO is not a managed care system designed by an insurance company. That would be an HMO. ACO stands for accountable care organization, and ACOs are part of Medicare.

Question 21

what is risk adjustment for ACO

Answer 21

Risk adjustment helps to determine if a particular population of patients is sicker than another similar group. We have all heard physicians say, “My patients are sicker, and that is why they cost

Question 22

Beveridge” Model

Answer 22

Named after William Beveridge, the social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library.

Question 23

cost of the Beveridge” Model

Answer 23

Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.

Question 24

Countries using the Beveridge plan or variations on it include

Answer 24

its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong 
 and Cuba ( purest)

Question 25

characteristics of bevridge

Answer 25

Health care is a human right, not a privilege

Government ownership and operation of health care

National government responsibility for delivery of equitable and efficient health care

Full access to all regardless of ability to pay

Primary care physician as gatekeeper to the rest of the system

Question 26

THE BISMARCK MODEL

Answer 26

It uses an insurance system – the insurers are called “sickness funds” – usually financed jointly by employers and employees through payroll deduction.

Question 27

how does the bismarck model differ from the US

Answer 27

Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit.

Question 28

Doctors and hospitals in Bismarck model are private or public

Answer 28

Doctors and hospitals tend to be private in Bismarck countries

Question 29

payer model of Bismarck

Answer 29

. Although this is a multi-payer model – Germany has about 240 different funds – tight regulation gives government much of the cost-control clout that the single-payer

The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.
Beveridge Model provides

Question 30

. THE NATIONAL HEALTH INSURANCE MODEL aka

Answer 30

(“single payer national health insurance”)

Beveridge plus Bismarck

It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance.

Question 31

NHI system is found in

Answer 31

NHI system is found in Canada
– Taiwan and South Korea, for example – have also adopted the NHI model.

Question 32

THE OUT-OF-POCKET MODEL

AKA

Answer 32

(“market driven” health care)

Question 33

The US uses Beveredge care how

Answer 33

socialized medicine for veterans, military, Native Americans

Question 34

The US uses Bismark how

Answer 34

social insurance for most people with jobs

Question 35

The US uses National Health Insurance how

Answer 35

social insurance for most people with jobs

Question 36

The US uses Out of Pocket how

Answer 36

for those who don’t qualify or have health insurance

Question 37

what did health care look like before the ACA

Answer 37

27% of U.S. residents were covered under public programs (both Beveridge and National Health Insurance models)
56% received primary coverage through private insurers
16% lacked health insurance entirely

Question 38

US compared to other countries

Answer 38

When it comes to treating veterans, we’re like Britain or Cuba.
For Americans over the age of 65 on Medicare, we’re like Canada.
For working Americans who get insurance on the job, we’re like Germany.
For the 15 percent of the population who have no health insurance, we are like most of the developing countries

Question 39

provided, organized, directed nursing work during the American Civil War.

Answer 39

Clara Barton

Question 40

laid the foundations of professional nursing with the principles summarized in Notes on Nursing.

Answer 40

Florence Nightingale

Question 41

Nurse practitioner (NP)

Answer 41

provide a wide range of primary and preventive health care services, prescribe medication, and diagnose and treat common minor illnesses and injuries.

Question 42

the oldest of the advanced nursing specialties; administer virtually all anesthesia in some states.

Answer 42

Certified registered nurse anesthetists (CRNA

Question 43

Working in hospitals, clinics, nursing homes, private offices, and community-based settings, handle a wide range of physical and mental health problems, research, education, and administration.

Answer 43

CNS

Question 44

board certification is

Answer 44

Not required for licensure, but considered by hospitals and payers for privileges and reimbursement.

Question 45

how many years of residency training are required for liscensure

Answer 45

At least one year required for licensure

Question 46

flexnor

Answer 46

commissioned by AMA

Licensure for medical practice adopted by states

Question 47

after 1st year of residency

Answer 47

Step 3: Usmile

Question 48

after fourth

Answer 48

Step 2: USMILE