Delivery System Flashcards
Medicare part D?
Medicaid Part D is a voluntary program providing partial prescription drug coverage. Drug plans come with a formulary (a list of covered drugs).
Problems with Medicare Part D?
- Gaps in coverage
- Administered by insurance companies
- Too many different plans that cover different medications with different costs
- No negation for lower prices
Changes the ACA has made to Medicare?
- Not a part of the insurance marketplaces
- Preventative services are covered
- Initiatives to increase coordination among providers
- Closing the donut hole by 2020 (pay until you meet your deductible, then responsible for the full cost until you meet your yearly limit) Solution for now; discounts on brand name drugs and $250 rebate, covering more drugs.
- Trump Ad. has left this alone.
Formula bankruptcy
More people are eligible for Medicare and are staying on it longer, however, too few workers are paying into the system.
What is Medicaid?
A federal and state program that provides health coverage for certain people with limited income and assets (low income, children, pregnant, disabilities). Funded by both states and federal government by taxes.
What does Medicaid cover? Who are the mandatory benefits?
BROAD LEVEL HEALTH INSURANCE:
Inpatient and outpatient hospital services, screenings, labs, x-rays, nursing facilities, non emergency transportation to medical care, physician, midwife and nurse practitioner. services.
- Expanded states now cover all low income adults 138% of the federal poverty line.
Largest covered group on Medicaid?
Children (49%)
Most expensive covered group on Medicaid?
Those with disabilities (42%)
Problems with Medicaid before the ACA?
low payments to physicians, limited coverage
Medicaid expansion?
Cover adults 138% below of the federal poverty line, simplifies CHIP enrollment process
Why did some states opt of Medicaid expansion?
National Federation of Independent Business v. Sebelius - made expansion a choice. 37 states adopted, 14 did not. States did not want handouts, could not afford expansion and have other methods to expand access.
Consequences of non medicaid expanding states?
People go uninsured, die from illnesses that could have been prevented. (people too rich for medicaid, too poor for marketplace subsides)
Intent of work requirements, what are the (+) (-)?
Conservatives argue people shouldn’t receive government aid without working for it, democrats argue it goes against the principle idea ofd Medicaid.
(+) boost the economy, if they work- it’ll make them more healthy, ideally reduce costs, only people who truly need it are funded
(-) Harmful: irregular work patterns, people may live in high pockets of unemployment, can’t get more hours due to other obligations, cost of administrative services, Add an unnecessary, undue burden
Who are the dual eligibles?
People who qualify for both medicaid and medicare. Medicare covers medical care and medicaid covers long term care services.
Does Medicaid coverage make a difference in
access to care, use, unmet needs or mortality trends?
Medicaid increases the use of health care, hard to tell if more ultization leads to better health, DECREASED MORTALITY rates.
Incentives to provide states opting out of Medicaid expansion?
OPEN ENDED
- State mandate
- People in the coverage gap receive affordable premiums, by lowering the threshold to marketplaces
- Give states more control
- Citizens pressure through ballot measures
- introduce a block grant (federal gov gives money to a state in which they can use it on whatever)
How to measure access to healthcare?
The amount of times a person is able to use healthcare services
Primary Care
BASIC IMMEDIATE PROBLEMS:
Services that cover a range of prevention, wellness, and treatment for common illnesses.
Secondary Care
SPECIALIZED CLINICAL CARE:
medical care that is provided by a specialist or facility upon referral by a primary care physician and that requires more specialized knowledge, skill, or equipment than the primary care physician can provide
Tertiary Care
MANAGEMENT OF RARE OR COMPLEX DISORDERS:
highly specialized medical care usually over an extended period of time that involves advanced and complex procedures and treatments performed by medical specialists in state-of-the-art facilities
“The donut hole” In medicare part D
A coverage gap, the point where your prescription drug expenses exceed the initial coverage limit of your plan, but have not yet reached thecatastrophic coverage level.
The Regionalized Model: The British national health service DAWSON
Like a pyramid:
Primary care level dominated by GPs (2/3 of all physicians in the UK), Secondary care based on specialists who deal with patients on an ambulatory basis but refer them back to their GPs for ongoing care–also deal with hospitalized patients, Tertiary care are specialists located at a few tertiary care medical centers
All referrals through GPs
Based on location (why is it called regionalized?)
The Dispersed Model: US Care Organization FREEFLOWING
No gatekeeping (increasing cost, waste and no coordination) No limit on referals--the patient goes to any level they want whenever they want Primary care spred amoungst specialists to a large extent 1/3 of physicians in the US are general internists or general pediatricians
Gatekeeping
People or policies that act as a go-between, controlling access from one point to another. They may refuse, control, or delay access to services. Alternatively, they may also be used to oversee how work is being done and whether it meets certain standards.
National health service
The UK’s system of health insurance working against the costs of health. Mostly public, but also private
Sickness funds
Extended cash payments and in some cases medical benefits to members who became unable to work due to sickness or injury
Physician assistant
A physician assistant is a medical professional who operates under a doctor’s supervision.
Nurse Practitioner
An advanced practice registered nurse. Trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, prescribe medication and formulate treatment plans
PCMH
Bottom up solution:
Primary care level:
A team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes. Focus on meeting the needs and presences of patients. Care is tailored towards you.
ACO
Bottom up solution:
Hospital level:
A network of providers—including primary care doctors, specialists, hospitals, and home health care services— that agree to work together to better coordinate the patients’ care. Intended to lower health care costs, improve quality outcomes and improve the experience of care.
Value based payments
Value based payment
A payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures
Fee for Service Payment
Payment dependant on quantity of care. # of patients you see.
Characteristics of the Regonalized Model?
Government finances healthcare with taxes and pays providers directly, all residents are covered, residents receive comprehensive care with no copays. Control the flow of patients across levels of care in an orderly fashion.
Characteristics of the Free flowing Model?
Patients can take their symptoms directly to a specialist
Overlapping roles among generalists; GPs, family physicians, general internists, and general pediatricians. B&G 55-58
Benefits of Primary Care?
Helps increase access to health services, a strong emphasis on preventative interventions, recommend screening measures to detect early changes that could be indicative of specific diseases. Greater emphasis on the health of the whole person rather than a specific organ or system. Implemented in a timely and helpful manner can also reduce the need for specialist care,
How can we increase the number of primary care physicians? Done by the ACA
1) Increase reimbursement rates, higher salaries
2) Increase the number of health care providers in primary care
3) Reforms in primary care delivery-PCMH
4) COGME (Council on Graduate Medical Education) recommended that at least 40 percent of the physician workforce should practice primary care and that their salaries should average no less than 70 percent of specialists’ salaries
5) pay off student debt if you enter PCP
Issues facing rural healthcare system?
Shortage of doctors, a wave of hospital closures and a widening gap of life expectancy favoring urban over rural residents.
What did the Flexner Report (hired by Medical Association to evaluate medical schools in the U.S.) recommend and what were the consequences of these recommendations for the American health care system?
- Schools are very important in professionalization and rising authority of doctors.
- recommended that remaining schools should be modeled after the Johns Hopkins Medical School
- consequence: high criteria to enter medical school
What are the defining characteristics of Physicians Assistants (PAs)? What do they do?
- PAs must practice under a supervising physician.
- acquire new skills over time as they gain experience through supervised practice.
- ability to change specialty or area of practice
- different levels of autonomy
What would have happened to insurance coverage of rural residents if Republicans in the first two years of the Trump Administration succeeded in repealing the ACA?
…Check slides
According to Song and Lee article, why do we need to reform our delivery system?
Shift the culture of medicine—deliver better care at lower cost—they can begin to change the culture of medicine, toward lower-cost, higher-value health care.
Lack of coordination, highly fragmented, inefficient (waste or scarcity), Engleheart lack of primary care physicians
Are ACO providers rewarded?
Rewarded financially if they can slow the growth in health care costs, while maintaining or improving quality of care.
What has the ACA done to save money?
The ACA has instituted financial penalties for hospitals with “excessive” readmissions and aimed to limit readmissions by sending social workers or nurses to patients’ homes, or providing scales to heart failure patients in their homes—all free of charge.
How does the British health care system ensure that everybody is covered and everybody is entitled
to the same package of benefits?
Funded by the taxpayer . Healthcare is a right.
Who owns the majority of hospitals in the UK? Where do GPs work and are they government
employees?
NHS, the government because they employ the medical professionals
What are the problems of British and German systems?
Longer waiting times for elective surgeries, waiting for diagnostic technology, not as innovative and top notch technology, NHS struggle with staffing issues, German don’t get paid enough.
How does the German health care system ensure that everybody is covered and everybody is entitled
to the same package of benefits?
Most people pay into a mandatory sickness fund, employees pay a portion as well as employers. Collected by the government ran health fund, which distributed the money based on risk adjustment.
Why are costs higher in the American health care system compared to other industrialized countries?
And why are these high costs a major problem?
Higher drug prices, higher salaries for doctors and nurses, higher hospital administration costs and higher prices for many medical services.
Delivery Reform…(Service)
Focuses on the culture of medicine, lead a cultural shift toward lower-cost, higher-value health care.
Issue facing rural residents?
higher rates of smoking, hypertension, obesity, and less physical activity.
Solving the rural workforce shortage?
Hired more APRNs, PAs, and community health workers to expand the staff. Medical schools 30% increase in first-year enrollment.
Solving the rural hospital shortage?
Critical Access hospitals receive Medicare payment adjustments
Germans who are unemployed…
The government pays the person’s percentage for health insurance that they would have paid if they had a job. Only for 1 YEAR.
German hospitals are
Private, non-profit, religion affiliated
Similarity between G and U?
German and US are employment based systems.
German - % of your income
U.S. - no logic without connection to income
