Health Systems: US Organization and Delivery Flashcards
1
Q
describe the Dawson model (UK health care model)
A
- primary-secondary-tertiary care triangle structure
- distinct functions of care and specific provider roles
- gate-keeping essential component
- stepwise patient flow puts emphasis on primary care and population health
2
Q
describe the dispersed model (US health care model)
A
- multiple access points (patient choice or doctor referral)
- more fluid roles for providers (e.g. broadens role of internists and pediatricians)
- less distinction in hospital care
- higher value on tertiary care
3
Q
describe the impact of health care dispersion
A
- positive:
- flexibility and convenience
- direct access to specialists/tertiary care
- autonomy in selecting services
- negative
- higher costs involved
- tendencies toward fragmentation
- lack of organizational coherence
- difficulty of integrating care and maintaining continuity
- unnecessary procedures/risks of medical error
4
Q
describe new medical care structures
A
- multispeciality group practice
- formally integrated specialists into a single clinic structure to encourage collaborative care
- example: Mayo Clinic
- community health centers
- emphasis on preventive care and general health; often maternal and child health
- now number almost 2000 across the US
5
Q
describe HMOs for providers
A
- physicians provide services as part of a larger organization that manages patients’ care
- physicians must share–or give up–decision-making process for patient care
6
Q
describe HMOs for patients
A
- you receive most or all of your health care from a network provider
- you choose a primary care physician (internist, family doctor, pediatrician) responsible for managing and coordinating care
- specialist care diagnostic services require an approved referral
7
Q
describe first generation HMOs
A
- full-time salaried (staff model)
- vertical integration; e.g. Kaise-Permanente
- consolidated model, salaried physicians, global budget hospitals
8
Q
describe second-generation HMOs
A
- virtual integration
- group model
- prepaid group practice
- contracts with Independt Practice Associations (IPAs)
- network model
- mix of IPAs, home health agencies, pharmacies, hospitals, etc.
9
Q
describe Independent Practice Associations (IPAs)
A
- an IPA is a loose collection of private doctors who work in their own practices
- IPA contracts with HMO on behalf of the doctors
- the IPA receives a capitation payment from the HMO and pays its doctors either through capitation or fee-for-service
- both usually involve fee-for-service referrals with bonus arrangements
10
Q
describe preferred provider organizations (PPOs)
A
- the PPO payer receives monthly premiums from subscribers and employers
- patients are required to select physicians and hospitals approved (“preferred”) by the payer
- providers discount their fees or allow payer to “manage” the care they give
11
Q
describe accountable care organizations (ACO)
A
- Affordable Care Act authorized Medicare to initiate ACO program
- private insurance and employers plans have also developed ACOs
- emphasis on regionalized, integrated care
12
Q
describe challenges for physician in managed care settings
A
- risk sharing:
- financial risk for care provided
- ethical conflicts vs. efficient care
- gatekeeper function
- problems of case management
- HMOs as gatekeepers (provide continuity of care) or gateshutters (restrict access)