Final! Flashcards
Stakeholder
people/ organizations that influence the direction of healthcare
Course major theme 1
technological accomplishments of the US healthcare delivery system are offset by problems of access, cost, and quality
Course major theme 2
previously confidential relationships between healthcare providers are now scrutinized/ shared by insurers, payers and quality managers
Course major theme 3
historic charitable health care mission has been replaced by profit driven enterprises
Course major theme 4
the healthcare industry has v large and diverse # of stakeholders
Course major theme 5
new ACA and MACRA requirements shift focus from a dollar-driven, volume-basis to a value-driven, population impact basis
Course major theme 6
the number and complexity of ethical issues of healthcare will increase as science and medicine continues to advance
Healthcare industry stats
$3.0 trillion, 12 million+ employees, ~18% of US GDP
world’s 5th largest economy
U.S. spends almost 2x avg. GDP of other comparable countries BUT…
- poor U.S. pop. health outcomes have lowest life expectancy and high infant mortality rates
- more $ on healthcare rather than social care than in other countries
- more spending has not improved overall US health status
Tech advances did not resolve…
- conflicting objectives between gov. & private sector markets
- variations in patient outcomes, efficiency, and effectiveness
- poorly aligned infrastructure
Size and complexity contribute to problems of…
- limited access, inconsistent quality, high cost
- unnecessary and wasteful service duplications
Historical understanding of healthcare
low understanding by American public, partly bc of health professional “mystique”
Current understanding of healthcare
increase transparency evolving from demands of insurers both gov. and private, consumers and employers; patients encouraged to participate in decisions
Efforts to change healthcare…
- markets make it hard
- “putting out fires”
- 1965: medicare/ medicaid
20th century healthcare accomplishments
- prevention/ treatment of infectious disease
- psychotropic drugs
- imaging
- cardiovascular tech.
- advancing tech. encouraged medical specialization
Medicare is…
federal
Medicaid is…
state
1966: Medicare part A
hospital insurance
1966: Medicare part B
insurance for non-hospital medical services
1966: Medicaid
covg. for poor, disabled
1997: Medicare part C
private insurance (Medicare Advantage)
2003: Medicare part D
drug coverage, mid range
Massachusetts as model for ACA
- Mitt Romney moderate republican gov.
- less ‘red tape’ bc one state
- healthcare system leaders on board
- bipartisan support
- business leader support
- online access was already running smoothly for other state programs
Health-Care Double Blind (EDIT THIS)
- keeping pre-existing coverage rule will basically end up with Obamacare
Can Markets Give us the Health System we Want?
- economic theory does not provide the best guidance for health care
- at state level, budget needs to be balanced
- consumers nor providers have the info. about cost bc there is no set cost
Until 1940s nature of healthcare
- dominated by physicians/ hospitals
- patient/ MD relationships sacred: treatments and payments confidential, mostly personal payments
Shifts from personal payment –> insurance payment
- distanced patients from awareness of costs and responsibility for decisions
- created business of medicine
Historical highlights: 1800s
sickness insurance by employers/ unions
Historical highlights: 1915
drive for compulsory insurance influenced by European models
Historical highlights: 1919
AMA opposed compulsory insurance (1919) bc thought insurance would decrease physician incomes
Great Depression: genesis of hospital insurance plans
- hospitals experimented w/ insurance
- Baylor University Plan: birth of blue cross model –> teachers paid per month to guarantee paid sick days
Growth of private insurance
insurance companies increase premiums w/ out any pressure to control costs
Social Security Act of 1935
- most significant social initiative in U.S. history
- federal aid to states for public health welfare, maternal/ child health, children w/ disabilities
- legislative basis for many later health+welfare programs including medicare+medicaid, 1965 amendments
Post WWII…
federal subsidies for hospital construction, research, professional education
1960s: Kennedy-Johnson administration
- direct aid to medicine, dentistry, pharmacy, nursing, and other professional schools
- federal support for healthcare delivery initiatives
1970s: Nixon administration
“block-granted” federal funds to states for use at their discretion
1970s-80s: Increase of Medicare reimbursement rates…
set standards for all insurers, medicare is the “pace car”
Iron triangle of U.S. healthcare
- cost, quality, access
- trying to control one affects the others
- ACA tries to alter this trend w/ focus on patient care value tied to reimbursement
1980s: Reagan administration
- DRGs (diagnosis related groups) become industry standard for hospital reimbursement
- Hospital gets paid one lump sum for admitting diagnosis (ex. broken leg = $X)
Drivers for Patient Protection and Affordable Care Act of 2010
- rising medical costs for families and corporations
- rising federal deficit
- high # of un/ underinsured
Features of ACA
- reverse cost raising incentives
- address quality through reimbursement reforms and transparency (improve quality and decrease cost)
- increase access to affordable care
- new consumer protections
- hold insurance companies accountable
ACA new consumer protections
- website to compare costs/ benefits of plans
- enhanced venues for appealing coverage denials
- prohibits insurance companies from:
denying access based on pre-existing conditions/ charging higher premiums bc of health status, imposing life time $ limits on benefits, denying coverage due to technical difficulties with original app.
ACA improving quality and lowering costs - examples
- small business health insurance tax credits
- closes gap for prescription drug costs
- health plans to cover certain preventative services
- enhanced anti-fraud/ waste in federal programs
- new Medicare value-based purchasing, bundled payment programs, and ACOs
ACA increasing access to affordable care - examples
- coverage up to 26 years on parent’s plan
- expand primary care workforce
- increase funding for federally qualified health centers
ACA holding insurance companies accountable
- companies need to spend 85% of premiums for large employers and 80% for small employers on healthcare/ coverage improvements
- rebates to consumers for non-compliance
Health care inflation in cost
- expenditure growth rate outstrips general inflation by large margins
- health care almost always has higher inflation that other products in general economy
Drivers of health care expenditures
- aging population: longevity = hospital care, drugs, unrestricted high cost interventions
- medical technology: diagnostic, treatment equipment and pharm. specialties
- un and under insured
- fee-for-service reimbursement (incentive for high volume)
- labor intensity (training, credentialing)
U.S. health outcomes
- largest % of economy dedicated to healthcare but lower life expectancy/ health outcomes
- U.S. spends far less on social services
- slower growth in life expectancy (healthcare system vs. social system of prevention)
Waste in healthcare
- 30-40% of healthcare spending
- failures in healthcare delivery
- failures in care coordination: duplication of services/ bad communication of results
- over-treatment
- administrative complexity
- overpricing
ACA immediate effects
- did not change fundamental mechanism
- uninsured numbers which were previously increasing immediately dropped by 1 million when ACA allowed children on parents’ coverage until 26
Premium
how much you pay to have insurance each month, regardless if you receive care
Deductible
how much you have to pay before insurance kicks in when receiving care
Copayment
pay at time of service before seeing doctor; prevents service over use, direct to facility
Beneficiary
person covered by insurance plan
Benefits
what your insurance covers
Managed care definition
system of healthcare where patients agree to visit only certain doctors+hospitals in which cost of treatment is managed by managing company (in/out of network)
Managed care characteristics
- provider network: set of designated doctors/ healthcare facilities
- standards for selecting providers
- formal utilization review and quality improvement programs
- some emphasis on preventative care
- financial incentives to encourages efficient care (caps on spending)
- way for insurers/ providers to limit their cost of spending on insurance
Medicare year and act title
1965: Title 18 of Social Security Act
Medicare coverage
all Americans older than 65 entitled to health insurance benefits… “universal coverage for elderly,” also covers others with certain health conditions
Joint Commission
Medicare conceded hospital accredition to private sector
Medicare part A (hospital) financing
primarily payroll taxes
Medicare part B (physician) financing
primarily general taxes
Medicare part C (Medicare Advantage) financing
premiums
Medicare part D (drugs) financing
general taxes, premiums, state payments (dual eligibles)
Medicaid title
Title 19 of Social Security Act
Medicaid coverage
finances health care for those with limited income
Medicaid financing
- almost entirely taxpayer-financed program
- costs are shared by states and federal gov.
- Federal Medical Assistance Percentage (FMAP): Federal matches state at least 1:1
- Medicaid Expansion = enhanced matching rates: 100% coverage of Medicaid costs for newly enrolled until 2020 and then 90%
Disproportionate Share Hospital Payments (DSH)
- since 1966, federal law requires Medicaid payments to states (DSH) for hospitals serving large # of Medicaid/ low income/ uninsured
Healthcare for the military (U.S. DOD)
- for active duty & retirees, dependents, survivors, former spouses
- Veterans Health Administration (VA): largest integrated U.S. health system
Indian Health Service (IHS)
- comprehensive care to members of federally recognized tribes and their descendants
- American Indian and Alaska Native (AIAN)
Children’s Health Insurance Program (CHIP)
- Title 21 of Social Security Act
- Federal block grants to states
- Covers children up to age 19
- No federal income threshold –> States cover children in families with incomes up to 200% FPL
Private Coverage and Cost under ACA
- insurers mandated to enroll YA until 26 under parents’ plan
- illegal to charge more/ refuse coverage for preexisting conditions
- all health plans to include certain “essential health benefits”
- fee on insurers for the privilege of selling plans through the exchanges
- MLR
- U.S. residents no longer required to have health insurance
- deductibles often unaffordable
- some large insurers left ACA exchanges
Medical Loss Ratio (MLR)
- measure of the percentage of premium dollars that a health plan spends on medical claims and quality improvements, versus administrative costs
- profits and other administrative expenses can make up no more than 20 percent (15 percent for large groups) of premiums collected
Health Insurance Marketplaces (HIMs)
provide consumers w/ web-based comparative info. on health plan choices and prices
Individual Mandate of HIM
- state option to create HIM, if not federal gov. est. and operated
- federal support for HIMS until 2015, after is self-sustaining
HIM participation eligibility
- American citizen
- legal immigrants w/out employer coverage or for whom cost is prohibitive
- acceptance guaranteed
- varying levels of federal financial assistance
North Carolina policymaking process
- 10.3 million ppl in NC
- diverse geography, culture, history, populations
- decentralized system - 100 counties, central oversight, locally administered
- strong spirit and history of collaboration/ partnerships
NC DHHS priorities
- Medicaid transformation
- Healthy Opportunities
- Early childhood
- Opioid crisis
Medicaid Transformation in NC
- build on existing infrastructure in NC and learn from best practices from other states
- focus on whole person health
- support provers and patients
- promote quality and value
- promote access to care
Healthy Opportunities NC
- up to 80% of a person’s health is determined through social and environmental factors and the behaviors influenced by them
- tackling foundational drivers of health: NC Care 360 (referral to food bank/ homeless shelter), Healthy opportunities pilots, Early Childhood Action Plan (preventative lens)
Early Childhood Action Plan NC
- brain and development
- children and families are center of work
- eliminating disparities for all NC children
Opioid Crisis NC
- coordinate infrastructure
- reduce oversupply of prescription opioids
- awareness + prevention through education
- expand access and linkage to care
Key Stakeholders (Opioid NC)
- governor - administration
- departments outside the administration
- NC general assembly
- counties
- outside stakeholders
- US Congress
- US Dept. of Health and Human Services
Opioid Epidemic Response Act
- increase access to office-based opioid treatment (OBOT) for opioid use disorder: remove duplicative state registration of buprenorphine prescribers
- allow ppl to test drugs for dangerous contaminants like fentanyl before use: decriminalize fentanyl test strips
- improve ability of syringe exchange programs to prevent the costly spread of disease: remove ban on using state funds to purchase supplies for syringe exchange programs
Plan of Safe Care
- legislation passed
- gathered stakeholders
- drafted policy
- signed off by governor
- outreach and education (ongoing)
- reporting data to US HHS
- ongoing meetings to discuss implementation
- tech. assistance from fed. gov.
- evaluation
Triple Aim in Healthcare
- improve patient experience
- better health through improved outcomes
- manage/ reduce cost
Factors the influence healthcare quality
- socioeconomic status
- physician supply
- risk behaviors
- health status
- etc.
Structural quality measures
- give consumers sense of healthcare providers capacity, systems, process
- ex.: electronic medical records, number physicians, provider to patient ratio
Process quality measures
- what provider does to maintain/ improve health
- ex.: % ppl receiving preventative care
Outcome quality measures
- impact on patient health status
- ex.: % of patients that die as result of surgery/ have complications
Data sources for quality measures
- administrative data
- patient medical records/ surveys
- comments from individual patients
- standardized clinical data
ACA: goals of improving pop. health and decreasing cost
- incentives: coordination, quality improvements
- expanding use of non-physician providers
- community outreach for proactive prevention
- healthcare entity collaboration
- tailoring care: specific patient populations
- evidence- based medicine and best practices
- EMR expansion
Improving quality and decreasing costs for populations
- CCMI: center for Medicare and Medicaid Innovation
- tests models of enhancing quality, minimizing cost, and aligning patient systems to incentivize patient centered care
Accountable Care Organization (ACO)
- group of doctors, hospitals, or other providers entering into a risk contract
- receive rewards for decreasing cost and improving quality
CMS (centers for Medicare and Medicaid Services)
- uses standard set of quality measures to assess quality, drawing data from claims, medical records, reporting and patient services
- costs measured against benchmarks
Episode based payment/ CJR
- reimbursement on basis of expected costs for clinically-defined episodes of care
- comprehensive care for join replacement model (CJR): one “episode” lasts from admission to 90 days post discharge
Medical Neighborhoods (patient-centered care)
- collaborative care agreements merging practice needs across primary/ specialty care
- BWH + San Fran Gen Hosp = streamlined care
- challenges: lost$ due to pre-consults, EMR, cooperation
Community health workers
- integrated into patient centered medical home
- increase coordination, value, cultural awareness
Culture centered palliative care model
- integrating Latina/o values, applicable to other settings
- family, interpersonal interaction, respect, trust, dignity
- making sure care is congruent w/ patient wishes may avoid misuse, underuse, and overuse of care
Cost-Quality connection
- cost of product/ services indirectly related to perceived quality
- quality experience meets a personal need/ provides benefit and is provided at reasonable cost
- quality product/ service: meets/ exceeds expectations
- connection between cost and quality is value (something of value is worth the cost)
- consumers want providers to meet their needs at reasonable cost
Six dimensions of healthcare needing improvement
- safety: care shouldn’t harm patients
- effectiveness: care should be based on scientific knowledge and provided to those who benefit; under/ over use should be avoided
- patient-centeredness: care should be respectful and responsive to patient preferences, needs and values
- timeliness: care should be provided promptly when patient needs it
- efficiency: avoid waste, including equipment, supplies, ideas, energy
- equity: best possible care should be provided to everyone regardless of demographic variables
Quality assurance
- evaluation activities aimed at ensuring compliance w/ minimum quality standards
- quality assurance = quality control
What influences measurement, assessment, and improvement activities in healthcare
- accredition standards (joint commission)
- government regulations (state, federal)
- purchaser requirements (health insurance rules)
Types of hospitals
- acute care: avg. stay less than 30 days
- long term care: psychiatric, rehab.
- teaching: med. school affiliation, student and resident
- non-teaching: not med. school affiliated but may provide educational experiences for health related students
- VA hospitals: most are med school affiliated
Status of most hospitals
non-gov. not for profit (teaching + non. teaching)
Physician owned hospitals
- major growth since 1965
- specialized in cardiology, orthopedics, surgery
- high efficiency w/ many amenities
- focus on less complex, profitable cases
- concerns regarding financial incentives, competition w/ community hospitals
- supporters point out owners’ service to community hospitals + tax payments as for-profit entities
Financial Condition of Hospitals
- declining occupancy –> major shift to ambulatory settings
- private insurer + Medicare pressures to cut utilization and cost
- increase operational and capital costs for more advanced technology
- competition w/ other facilities for profitable diagnostic and treatment services
System complexity of hospitals
- tons of ppl
- lots of inter-related services, personnel, functions and procedures
- complicated for patients and families
- patient records difficult to transfer between org.’s, non-communicating e-health records
Types and roles of patients
- historical perception of needy patient, compliant w/ authoritarian professionals … “sick role”
- today, more educated and assertive patients reject passive role and demand active participation in their care, key to quality
Patient rights and responsibilities
- rights protected by US constitution, state laws, regulations
- AHA publishes brochure for all patients “The Patient Care Partnership” which explains patients’ rights and responsibilities
- 1991 Patient Self Determination Act
Diagnosis Related Groups (DRG) hospital reimbursement
- old: volume-based, retrospective reimbursement, promoted utilization
- DRGs were medical intervention for over-use, increase costs and corporate demands
- shift to prospective reimbursement reversed financial incentives for overuse of treatments and services
- Medicare adopted in 1983, other insurers followed
Cost, quality, and access are hospital survival criteria of the future (forces of financial reform)
- curtail overuse of expensive technology w/out evidence-based patient benefits
- hospital performance is exposed: public judgement based on published outcomes criteria
- ACA shift to accountability, outside “hospital walls” requiring service coordination
- consolidations and mergers control populations
Accountable care organizations (forces of financial reform)
hospitals join legal arrangements w/ physician, other providers and suppliers to coordinate patient care across full spectrum of needs
Reimbursement and payment revisions (forces of financial reform)
- value based rather than volume based purchasing of health services by payers
- readmissions reduction programs
- bundled payments for care improvement initiative
Ambulatory care (outpatient)
- medical care not requiring overnight hospitalization
- continuing volume shift from hospitals
- advanced tech. led to safety increases and decrease cost; patient satisfaction
- payer incentives to decrease inpatient stays
- consumer and physician preferences
Components of ambulatory care
- private medical office practice/ other (non-physician) ambulatory care practitioners
- ambulatory care services of hospitals
- hospital emergency services
- free-standing (non-hospital based) facilities
Medical office practice
- predominant mode of ambulatory care
- visit rate females > males
- age 0-64 primarily private insurance while 65+ primarily Medicare
- compared w/ adults, larger % of visits by children were either for preventative care/ new problem
- larger % of adult visits included an imaging service
Freestanding facilities definition and examples
- non-hospital based facilities, owned/ operated by hospitals, physician groups, for-profit, not-for-profit entities, corporate chains
- urgent care centers
- retail clinics (CVS, Walgreens)
- ambulatory surgery centers
- federally qualified health centers (ex. Lincoln)
- public health ambulatory services
- not-for-profit agencies
Urgent care centers
- walk in, extended hour access for acute illness/ injury care beyond scope of availability of typical primary care/ retail clinic
- operate under licensed physician auspices
- ownership for profit
- primary care physicians, PAs, nurses, ancillary services (lab, radiology(
- since 1997, AM Board of Urgent Care Med certified primary care MDs in UrgentCare
- payments by insurance, cash or card
Retail clinics
- operated by pharmacies and supermarkets
- staff: PA, nurse practitioners, MDs available by phone
- treat narrow scope of minor illnesses
- strong insurer and employer acceptance to decrease cost and avoid EDs
- American Academy of Family Practice Physicians recognizes need and physician opportunities but opposes expansion beyond minor illnesses (clinics may be components of PCMH and ACO care networks, recognition of patient preferences)
Ambulatory surgery centers
- surgical and non surgical procedures performed on an outpatient basis in a hospital/ freestanding center
Primary drivers for ambulatory surgery centers, accredition and endorsement
- 1970s: improved operative technologies including anesthesia, and reimbursement changes
- physicians led development
- accredition by Medicare, Joint Commission, Association of Ambulatory Healthcare, Association for the Accredition of Ambulatory Surgery Facilities
- physician and patients endorse for convenience, safety, quality
Federally Qualified Health Centers
- 1960s: US office of Economic opportunity, urban and rural locations, multidisciplinary, comprehensive
- serve medically needy/ underserved
- comprehensive services w/ fees based on ability to pay
- federal funding: health resources and services administration
Leadership in Federally Qualified Health Centers
- leadership: local health departments, part of not-for-profit corporation, stand alone not for profit
- sound clinical and financial management
- governed by representative board of directors
- staff: multidisciplinary teams: physicians, PA, nurse practitioners, social workers, dental providers, other
Telehealth
- provides care in remote locations
- connects homebound patients w/ providers
- slow adoption due to definition for insurance billing
- insurer support increase be of patient demand and potential cost saving
Health disparities vs. healthcare disparities
individual vs. system
Contributing aspects of US healthcare as viewed by international observers (Health Affairs paper)
- no such thing as system
- healthcare as a privilege not a right
- problem of price
- problem of accountability
Healthcare disparities
differences in the quality of healthcare that are not due to access-related factors, clinical needs, preferences or appropriateness of intervention
- often racial/ ethnic: women, minorities, non-English speakers, 65+
- same insurance but different care: white –> hispanic –> black
Institute of Medicine Report, 2002
- “racial + ethnic minorities tend to receive a lower quality of healthcare than non-minorities”
- less likely to receive: cancer screening, cardiac procedures, dialysis, transplants, hip+knee replacements, pain meds in ER
- more likely to receive: amputations, orchiectomy
For many disease processes, black individuals have increase prevalence and increase in morbidity+mortality
diabetes, hypertension, end stage renal disease, stroke, cancer, heart disease
Patient factors that influence healthcare
- knowledge
- cultural beliefs+attitudes
- health behaviors
- language and health literacy
- social support
- religious beliefs
- fears
- self-efficacy
- preferences
- socioeconomic status
- trust
- genetics
Lung Cancer example
- more prevalent in African Americans
- lower survival
- discrepancy in early-stage resectable diseases: African Americans less likely to receive surgery even when offered it
Provider factors that influence healthcare
- knowledge
- attitudes
- bias
- stereotyping
- lack of technical/ interpersonal skills
- communication
- decision-making style
- physician social concordance with patient
- organizational culture
Bias
- an inclination/ preference that influences even judgement - prejudice in favor of/ against one thing, person, or group compared w/ another, usually in an unfair way
Stereotyping
- a “fixed” way of thinking about people in which you classify others into specific categories without room for individualism/ variation
- “cognitive shortcut”
Implicit bias
- thoughts/ feelings outside of conscious awareness and control affect judgement/ behavior
- leads to involuntary “blind spots” in virtually all of us
Uncertainty
- a plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural/ linguistic background
Patient-physician race-concordant vs. race-discordant visits
- longer
- higher ratings of patient positive affect
- more participatory
- greater satisfaction
- black women significantly less likely to be referred for catheterization than white men
System factors that influence healthcare
- availability of providers
- types of providers and resources
- background
- language
- skin color of providers
- location of services
- organization of care
Effect of military history
civilian treatment now based on previous med. experience from military/ war
Barron Larrey (Military history)
- Napoleon’s surgeon
- 1792: Ambulance Volante
WWI (Military history)
- Mr. Thomas British surgeon: developed traction splint to decrease mortality
- Post war insight: shock/ physiology; time/ speed recognized as critical to survival
WWII (Military history)
- fluid resuscitation w/ blood/ plasma
Korean War (Military history)
- MASH (Mobile Army Surgical Hospital)
- helicopter evacuation
Vietnam (Military history)
- trauma field research
- “golden hour”: care in this hour gives best chance of survival
Iraq/ Afghanistan (Military history)
- traumatic brain injury –> hallmark: improvised explosive devise injury
- federal funding for simultaneous civilian research
1947 Civilian history
Beck develops defibrillation
1958 Civilian history
Safar rediscovers CPR
1966 Civilian history
National Highway Safety Act
- important bc speed, safety belts
1967 Civilian history
Pantridge describes mobile intensive care units
- put in practice in Belfast, all patients resucitated
1971 Civilian history
Emergency Care and Transportation of the Sick and Injured (textbook published)
1973 Civilian history
- Emergency Medical Services Act defined and funded elements of EMS nationwide
- “law forbids withholding emergency medical care services to any patient because of inability to pay”
Basic Life Support
- EMT
- defibrillation
- oxygen
- basic assessment and treatment skills
Advanced Life Support
- advances EMTs and paramedics
- advanced assessment and treatment skills
Medical oversight of EMS
standing orders: previously agreed protocols, actions do not require on-line physician contact, specific limits set by protocol (defibrillation, incubation, ACLS)
On-Line Medical direction (radio/ phone)
- specialized procedures
- controlled substances
Prospective oversight
- involvement in training
- protocol development
Real time oversight
- field observation
- tele/ radio
National Trends and Issues in health response
- limited resources: longer response times, poor outcomes, volunteer vs. paid, reciprocity w/ other towns/ cities
- shifting reimbursement structures
- military/ civilian integration
Continuum of care
- patient wishes vs. nearest hospital vs. triage to regional centers: trauma, pediatric trauma, burn center, hyperbaric, heart/ stroke
How do we pay for EMS?
- taxes mostly
- some billing, esp. if contracted w/ private EMS firm/ hospital
Billing case example: DC
lots of various ppl from all areas/ states so billing not taxes (would promote uneven payer spread)
Hospital emergency care
- estimates of Emergency Dept. of care as % of national health care costs = 2-10%
- total amt. of % going to emergency care may be less important than making sure that emergency rooms are used for the right types of care
- ER costs»_space;> primary-setting care
Emergency department care post ACA
- Illinois data: increase use of ER by 18-64 year olds; increase # of Medicaid insured, people still waiting too long to seek care, their issue progresses to urgent/ emergent
- Mass. data: fewer consultants to see patients; workforce not keeping up w/ increase number of patients, some lack of motivation given low Medicaid reimbursement
Caregiving as an unseen/ assumed aspect of health care delivery
- 41.3 million ppl age 15+ provided unpaid eldercare during 2015+16
- 34.2 million Americans were unpaid caregivers to 50+ yr. olds in past 12 months
- 75+ year olds account for 47% of those cared for
Economic toll of caregiving
- $522 billion/ yr. in opportunity cost
- 30 billion hrs. of uncompensated care
- caregivers spend their own $ directly on recipients’ care
Financial burden of caregiving
- 2/3 caregivers report providing financial support related to their role
- largest monthly expenses for US caregivers are medicine/ medical supplies, food and personal care items
- 50% of caregivers did not know in advance that they would be stepping into that role
Caregiver burden (caregivers report)
- financial, emotion and physical strain
- poor health themselves, at baseline
- caregiving resulting in worse personal health
- strain on schedule
Caregiver support
- pilots and small programs in care of patients with stroke, dementia, TBI, cancer, heart failure, PTSD
- usually focused on training and improving skill to patients’ care (quasi-nursing skills)
- sometimes focused on resilience, peer-support
- infrequently focused on social and practical needs related to caregiving (food, shelter, clothing, transport, child care)
Why is caregiving compensation difficult
health care billing is linked to patients’ care
Lifespan care needs vary in intensity and duration ….
- level of support required for optimal functioning may vary over time continuum
- service locations vary w/ type and intensity of needs (home –> institution)
- services range from intense medical to social support, many combinations
Formal vs. informal long term care
institutionally based or operated vs. family and friends as caregivers
Why does LTC need to increase
increased longevity
Social structures which can preclude family/ informal care
- small family size
- single parenting
- divorce
- delayed retirements
- family geographic distance
Long term care definition
services and supports needed when ability to care for self has been reduced by chronic illness, disability or aging
Who provides LTC services
- family and friends at home
- home/ community based services: home health care, personal care and adult day care
- institutional settings: nursing homes or residential care facilities
LTC abuses (1970s Congressional hearings report)
- lack of resident activities
- untrained, inadequate staff
- unsanitary conditions
- over- and under- medicated
- discrimination against minorities
- reimbursement fraud
- inappropriate physical restraints
LTC abuse reforms
- Medicare and Medicaid certification
- state nursing home/ home care certification
- staff credentialing
- Joint Commission accredition
- elder abuse reporting clauses
- regulations on physical and chemical restraints
- Ombudsman programs
Major modes of LTC service delivery
- community: home care, adult day care, hospice
- institutional: skilled nursing care, hospice
- custodial: assisted living facility
Medicaid’s LTC populations include ppl w/ diverse needs
- mental and developmental disabilities
- mental illness
- spinal cord injuries
- TBI, Alzheimers, dementia, neurodegenerative conditions (CP, MS)
- children w/ special health care needs
LTC cost (v expensive)
- nursing home care: $95K
- personal care: $10,000
- home health aide: $20/ hr
Who pays for LTC care?
- Medicaid
- out of pocket –> self and families
- Medicare: under certain conditions, the program will help pay for post-acute care –> brief stay in nursing home, hospice care, home health care
- private LTC insurance: decrease in rates of insured bc v expensive
Medicare definition
federal health insurance program for seniors and ppl under 65 w/ permanent disabilities
LTC benefits that Medicare covers
- home health services to beneficiaries who are homebound, need part-time skilled nursing/ therapy services and are under care of physician
- provides limited nursing home care (100 days) for those recently discharged from a hospital (aka post acute care)
Who qualifies for Medicaid LTC?
- over 65+ or disabled
OR - v low income and limited assets (savings accounts) to qualify
- many ppl w/ long term care needs not eligible
- for low-income Medicare beneficiaries who do qualify, Medicaid fills the gaps in Medicare coverage
Mandatory Medicaid LTC benefits
nursing facility
Optional Medicaid LTC benefits
- personal care
- care management
Annual Medicaid expenditures
managed care > LTC > physician/ lab > inpatient services > admin > prescription drugs
(LTC, physician/ lab, inpatient services and drugs are fee for service payments)
Increasing pop. of older Americans…
increases demand for LTC services and concerns about costs
LTC organization, staffing, and payment sources…
vary widely by type of service
Social and demographic changes result in more institutionally-based LTC…
smaller family size, divorce, delayed retirement
Major component of LTC continuum
hospice
What plagues LTC industry?
chronic staffing shortages
Innovative LTC services
- “aging in place”
- NORCS
ACA includes many initiatives to promote …
community based care versus institutionalization
1948 WHO definition of health
state of complete physical, mental, and social well being not merely the absence of disease or infirmiry
Healthcare need (National Framework for NHS continuing Healthcare)
need related to treatment, control, or prevention of a disease, illness, injury or disability, and the care/ aftercare of a person w/ these needs (whether or not the tasks have to be carried out by a health professional)
Social determinants of health (WHO)
conditions in which ppl are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life including economic policies and systems, developmental agendas, social norms, social policies and political systems
Social Care Need (National Framework for NHS continuing Healthcare)
proving assistance w/ activities of daily living, maintaining independence, social interaction, enabling the individual to play a fuller part in society, protecting them in vulnerable situations, helping them to manage complex relationships and (in some circumstances) accessing a care home or other supported accommodation
US spends least (9% GDP) on social care and more (16%) on healthcare yet has higher values of…
- chronic disease
- infant mortality
- lower life expectancy
than comparable nations
What is social spending
transportation, housing, nutrition
Greater social spending (transportation, hosing nutrition) relative to healthcare spending is associated w/ reduced…
- chronic disease
- disability
- mortality
Why is social support especially important for seriously ill patients, older patients and their families
- large out-of-pocket costs: med. expenses, caregiving even without insurance
- decrease in caregiver income from missed work, childcare duties
Robert Wood Johnson foundation survey (2011)
- 4/5 physicians lack confidence in their capacity to meet patients’ social needs and that this deficit has impacted their ability to provide high quality care
- 4/5 physicians say unmet social needs directly lead to worse health for all Americans
- 4/5 physicians say patients’ social needs are as important to address as their medical conditions, esp. for low income urban pop.
- 3/4 physicians say they wish the healthcare system would cover costs associated w/ connecting patients to meet their social needs (fitness programs, nutritious food, transportation, employment assistance, adult education, housing)
Financial burden of care-taking may make it difficult to pay for basic needs (food, housing, utilities, transportation) and affects…
- lower financial resources at baseline
- minority group members
- lower education
- unmarried or widowed women
What happens when social needs are not met
- compromised patient quality of life
- increase caregiver burden
- use of avoidable acute care services (increase cost)
Paper: Variation in health outcomes: The role of spending on social services, public health, and health care
- suggests that higher social care to health care spending at the state level leads to better outcomes in:
- adult obesity
- asthma
- mentally unhealthy days
- days w/ out activity limitations
- mortality rates for lung
Paper: Strong social support services, such as transportation and help for caregivers can lead to lower healthcare use and costs
more research is required to determine which social service components yield desired outcomes for specific patient populations
4.5 million direct care workers in the US demographics
- 9/10 are women
- 59% are ppl of color
- 1/4 is an immigrant
- half have high school education or less
Growth of care from 2008-2018
- home care grown 4x
- residential care increased slightly
- nursing homes decreased slightly
Divers of increase in home care
- growing population of older adults
- consumer preferences for care
- policy programmatic changes
Projected job growth 2018 –> 2028
- 1,054,400 homecare
- 168,400 residential care
- (-)19,300 nursing home
Additions to home care workforce
- expected to add more new jobs than any other single occupation in the US
- home care will also rank among the top 5 occupations w/ the most job openings
Homecare wages
- many home care and nursing care workers are impoverished (20,000 yr. income)
- nursing home > home care slightly
Elements of a quality job
- compensation
- supportive suppervision
- training
- career advancement
- engagement and recognition
- hours and scheduling
- employment supports
Binge eating disorder
- not the same as “overeating”
- most common eating disorder, 1-3% of gen. pop.
- “newest” ED to be formally recognized
Binge eating disorder definition
- loss of control over your eating resulting in: eating rapidly, eating even when not hungry, eating until uncomfortably full, eating by yourself due to shame, feelings of disgust/ guilt, NO purging
- eating a lot of food in a short amount of time (2 hrs.)
Clinical presentation of BED
- stockpiling food to consume in secret later on
- eats normally in presence of others, but gorging when by themselves
- binge eats to feel numb/ to “escape”
- often long history of dieting/ binge eating
- history of sneaking food in childhood
- recently found out BED is a “real thing”
Relationship between BED and Obesity
- BED diagnosis: 70% more likely to be obese
- weight loss treatment: 9-29% have binge eating symptoms
- recurrent over eating between binge eating episodes contribute to weight gain and obesity
What contributes to obesity
- society, environment, genetics
- weight gain in college
- psychological factors: depression, weight stigma
BED and psychological factors
- depression
- low self esteem
- high emotional distress
- lacking emotion regulation skills
- stigma and negative body image
- poor structure around eating
- strong all or nothing mentality
- strong inner critic, perfectionism
- life stress
(same as those w/ obesity, but worse off)
Why might binge eating increase in college
- loss of support/ structure
- loneliness
- uncertainty about future
- rigorous course requirements
- internal/ external pressures
- sport expectations
- prior binge eating
Patients w/ BED and obesity
- weight management programs: lose weight, but BED not treated
- eating disorders programs: improve BED, but lack weight loss
- future best practices –> integrated binge eating/ weight management treatment, controversial
Why do patients w/ BED need more than typical treatments for obesity and ED?
- weight loss will only be temporary “surface successes”
- must get to the root of binge eating
- binge eating isn’t the problem, is actually a solution to some other problems
Binge eating as a “solution” to some other problems: a vicious cycle
self-hatred –> sadness –> depression –> seek comfort –> binge eat –> repeat
Patients w/ BED
- perfectionistic thinking
- constant attempts to gain control over themselves
- ongoing shame and low self worth
Treatments for BED
- internal family systems therapy
- cognitive behavioral therapy/ dialectical behavior therapy: identify the function on BE, learn how to manage triggers, develop healthy relationship w/ body, self-care and self-compassion instead of self-destructiveness
- medication
- healthy weight management
All hospice care is palliative…
but not all palliative care is hospice care
