2-organization of care Flashcards
Characteristics of the organization of health service delivery:
mix of organizations
divisions
interactions among these
organizations -how they get the resource
The internal administrative and management structures
how is British NHS – an example of regionalized care
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.
what does the division of services look like in the US
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.
what is meant by the phrase a cottage industry
nonintegrated, dedicated artisans who eschew standardization.
what are the reasons health care is fragmented in the US
peer accountability,
quality improvement infrastructure,
clinical information systems
what has lead to dispersed model of care
Biomedical model of health care -one problem one treatment
Financial incentives
Professionalism -sovereignty of physicians as pre-eminent authorities on health care
what % of care is self care
~80% of care = self care
– treatment of rare and complex disorders
Tertiary
hospital care falls under
secondary along with specialists
4 characteristics of primary care
Initial contact
Continuous care
Comprehensive
Coordination of care
what is gatekeeping
“Gatekeeping” preventing inappropriate visits to specialists or for unnecessary procedures
how can Patient incentives improve care
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…
how can Regulatory changes improve care
The regulatory environment should be modified to facilitate clinical integration among providers. Limit unnecessary duplication of facilities and services
Full population prepayment
a single payment for the full continuum of services for a given patient population and period of time—should be encouraged.
Global case payments for acute hospitalizations
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.
APM
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
PPS
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.
PPOs
– pts can see any providers, but lower costs if using in-network. Providers agree to accept payment as set by insurer.
HMO used to be
Health Maintenance Organization used to be
Prepaid Group Practice
ACO how it different from HMO
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.
what is risk adjustment for ACO
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
Beveridge” Model
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.
cost of the Beveridge” Model
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.
Countries using the Beveridge plan or variations on it include
its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong and Cuba ( purest)
characteristics of bevridge
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
THE BISMARCK MODEL
It uses an insurance system – the insurers are called “sickness funds” – usually financed jointly by employers and employees through payroll deduction.
how does the bismarck model differ from the US
Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit.
Doctors and hospitals in Bismarck model are private or public
Doctors and hospitals tend to be private in Bismarck countries
payer model of Bismarck
. 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
. THE NATIONAL HEALTH INSURANCE MODEL aka
(“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.
NHI system is found in
NHI system is found in Canada
– Taiwan and South Korea, for example – have also adopted the NHI model.
THE OUT-OF-POCKET MODEL
AKA
(“market driven” health care)
The US uses Beveredge care how
socialized medicine for veterans, military, Native Americans
The US uses Bismark how
social insurance for most people with jobs
The US uses National Health Insurance how
social insurance for most people with jobs
The US uses Out of Pocket how
for those who don’t qualify or have health insurance
what did health care look like before the ACA
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
US compared to other countries
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
provided, organized, directed nursing work during the American Civil War.
Clara Barton
laid the foundations of professional nursing with the principles summarized in Notes on Nursing.
Florence Nightingale
Nurse practitioner (NP)
provide a wide range of primary and preventive health care services, prescribe medication, and diagnose and treat common minor illnesses and injuries.
the oldest of the advanced nursing specialties; administer virtually all anesthesia in some states.
Certified registered nurse anesthetists (CRNA
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.
CNS
board certification is
Not required for licensure, but considered by hospitals and payers for privileges and reimbursement.
how many years of residency training are required for liscensure
At least one year required for licensure
flexnor
commissioned by AMA
Licensure for medical practice adopted by states
after 1st year of residency
Step 3: Usmile
after fourth
Step 2: USMILE
