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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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)
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