History of Management Flashcards
Group Think:
informal groups-> subculture
Not always negative. You can have positive ones. The management theory looked at was the effect of the negative groups.
Pareto Principle:
80% of the effect or outcome comes from 20% of causes or work: Pay attention to that 20% for a more effective program. Focus on the 20.
Peter Principle:
promoting competent employee to a new job could cause person to be less competent => need to assure training at every level. As you move up in career, if the training isn’t appropriate, the employee will not be good at that job.
Medical model practice settings in OT
Acute hospital (medical or psychiatric)
Acute rehab
Sub-acute rehab
Home health
Nursing home
Free standing outpatient or outpatient at hospital
Private physician office
Medical Model: short term
includes history and physical, diagnosis, and treatment to alleviate or cure an underlying medical condition.
Educational Model:
services are aimed at adaptation and performance within the educational setting
OT practice settings in Education Model
School system
Preschool
Day Care
Early intervention home health
Early intervention outpatient clinic
Public Health Model:
achieve health of populations through
prevention of disease (prevention)
e.g., eating nutritious foods to prevent obesity and other-related diseases;
slow progress of disease to prevent disability and complications (secondary prevention)
e.g., people with high blood pressure exercising and eating well to forestall CVA; or
tertiary prevention used in advance levels of disease to limit disability and other complications
[e.g., energy conservation techniques to prevent stroke]
OT Practice Settings Public Health Model
Community Education
Health insurance company
Public health agency (CDC, APHA)
Underserved or high incidence
Private industry
Research
National Institute for Health
Not directly under and OT model
Community Model (Social Model):
longer term maintenance and episodic restorative services (health promotion and prevention of further decline)
clients with stable health conditions at risk from social isolation, reduced family support, physical frailty, or other similar characteristics
Focus is on social barriers to prevention (Scaffa, 2001)
not necessarily OT
Ot Practice settings community / social model
Senior center
Group home, independent living center
Retirement center
Sheltered workshop
Prevocational programs
Community mental health center
not necessarily OT
Challenges in US healthcare
- Rising Costs
- Emphasis on outcomes and accountability
- Lack of services to meet specific needs
- Imbalance in services available to different populations
- Frequent advances in medical technology
- Increase government scrutiny of practices
- Increase public scrutiny of care available
Blue cross blue shield is
the first commercial insurance available started by roosevelt for injuries to worker on railroads.
Legislation under President Franklin D. Roosevelt (Term 1933-1945)
Ethical responsibility of an industrialized nation
First Modern Insurance Company (1930’s)
Blue Cross & Blue Shield
Roosevelt’s Economic Bill (1944)
Set forth fundamental social and political rights part of which was the right to health.
Health insurance Now an employee benefit
Healthcare legislation in the 40’s and 50
Hill-Burton Act (1946): promoted building hospitals & free-standing health facilities
later control over-growth and duplication of services (in 70’s and 80’s)
Taft Hartley Act (1947) Required Health benefits become a condition of employment
70% had health care by 1960
1950’s funds to encourage more schools for training medical personnel
focused on physicians
healthcare legislation in 60-70’s
1965: national insurance established
Medicare (for elderly)
Medicaid (for poor)
Based on Fee for Service (FFS)
Indemnity Plan: 80/20 with no limit to costs
= 80% paid by insurance company & 20% paid for by patient
1966: Allied Health Professionals Personnel Training Act
Funding -> increased number of OT Programs
1972: Amendment to the Social Security Act:
Drove focus toward professional standards review to monitor and control costs and quality of care
1970’s & 80’s Laws Changed due to spiraling costs of Fee For Service (FFS)
Medicare is for
elderly
medicaid is for
low income
medicaid and medicare is 80/20 - what does that mean
80% by insurance, 20% by patient. often 20 is picked up by the hospital.
medicare and medicaid is funded by whom
federally funded.
1970’s & 80’s Laws Changed due to
spiraling costs of Fee For Service (FFS)
seeing your primary before you see a specialists
Established Managed Care
Integrated delivery system between payor (insurance company) and care provider (physician or hospital)
Uses gate keepers
i.e physicians that limit referral to specialists or case managers that monitor and approve usage of services
HMO (Health Maintenance Organization):
Medical care provided ONLY within their network (often in same building) of providers or no coverage
PPO (Preferred Provider Organization):
Provides better coverage if use their in-network list of approved providers; can see out of network (cost more)
POS (Point of Service):
Can select between HMO and PPO style for each episode of service
EPO (Exclusive Provider Organization):
Can only go to doctors/specialists in network or no coverage
Medicare/Medicaid Recipient can contract or the government can contract with a different insurance company to manage services
True but this Blurs the lines. Medicare / Medicaid recipient then follow rules of that insurance company
i.e., Medicare managed by CDPHP
1983: Amendment to Social Security Act
Focused on
- change to inpatient hospital care costs
- Due to rising costs with new technology
- Many community hospitals closed
1986: PPS:
Prospective Payment System
- Medicare began to look at controlling costs
- Predetermined rate is set for treatment of specific illnesses in the hospital setting
what is a DRG?
Diagnostic related group
money is budgeted for the diagnoses. hospital gets paid per dx.
1986
Hospitals now paid for care based on DRGs
DRG:
Diagnostic Related Groups
467 categories initially
patients ICD = International Statistical Classification of Diseases
Problematic: Inpatient Psychiatric care - why?
because every person is different and often they need to stay longer than prescribed.
Prospective Payment System: Pushed for less emphasis on hospitalization…incentive to move patients out of hospitals as fast as possible. Encouraged expansion of community services:
Home health care
Nursing facilities
Hospice
Subacute beds
Designated psychiatric beds
Rehab Beds
Outpatient surgery
Day treatment centers
Outpatient therapy services
1986: Legislation in part expanded coverage of outpatient and rehab-based OT services by expanding funding for Medicare Part B
What does A and B do?
Medicare Part A: inpatient hospital insurance
Medicare Part B: supplementary medical insurance
1993: Clinton health care plan:
FAILED to PASS
Universal Health Care through a national plan
Blocked by
lobbyists representing AMA and private health insurance companies
1997: State Children’s Health Insurance Program (CHIP) (based on Hillary Clinton):
Program to cover uninsured children in families with too high of income to qualify for Medicaid
1996 HIPAA:
Health Insurance Portability and Accountability Act (Clinton)
Assures insurance coverage during times of employment change
Gives small businesses insurance options
Protects patient’s privacy rights regarding their medical record
What is the impact of HIPAA on OT
OT impact: can’t leave charts out,
charts locked at night, can’t talk to
person about who you saw at clinic,
can’t look in others medical records
HIPAA in 2008
Health Insurance Portability and Accountability Act
Passed in 1996, but not really enacted until
2008 amendment which included:
Funding to enact legislation
More specific language to ensure follow through
Added Mental Health Parity and Addiction Equity Act (MHPAEA)
Assuring MH and substance abuse coverage at the same level as medical/surgical coverage
1997: Individuals with Disabilities Education Act (IDEA)
Mandated service delivery in the school system
Part B mandates special ed services to preschoolers (3-5 years) up to 21 years
Also referred to as section 619
Part C mandates services for 0-3 years
How did this impact OT
Large growth in OTs working in school and early intervention
-> Previously mainly in residential housing programs for developmentally delayed/medically fragile children
2003: Bush Era
Medicare prescription Drug Act (D)
HSA: Health Savings Account
2006: Massachusetts
1st state to require all adults purchase health insurance or face legal consequences
2007: Recession:
Resulted in reduction in employee provided health insurance
2008
NY: Child Health Plus & CHIP (federal)
Provides children 19 years and younger affordable healthcare (above Medicaid criteria)
Cost pro-rated based on income
NY: 1992 Passed- but limited funding
Federal: 1997 CHIP (Child Health Insurance Program) Federal program: matches states
NY: 2008 Amendment increased eligibility & marketing
What is the impact on OT
44% of children are covered by CHIP, 62
% by private (only 5% without insurance in 2021)
2008 HIPAA
Health Insurance Portability and Accountability Act
Passed in 1996, but not really enacted until
2008 amendment which included:
Funding to enact legislation
More specific language to ensure follow through
Added Mental Health Parity and Addiction Equity Act (MHPAEA)
Assuring MH and substance abuse coverage at the same level as medical/surgical coverage
2010: “ACA” or “Obamacare
Patient Protection and Affordable Care Act
Signed into law March 2010
Goal of full enactment by 2017
Requires most US citizens and legal immigrants to have healthcare coverage
2010 affordable care act - what were insurances plans no longer able to do
Insurance plans were no longer able to deny based on previous illnesses or conditions.
AOTA main role in OT?
Monitors Insurance Legislation and Policies
A review of individual ACA Marketplace plans revealed:
Many (all but 9%) comply with describing the essential health benefits related to rehabilitative care and habilitative services as a benefit
OT not always listed when describing Rehabilitation or Habilitation care
Potential limits on services as many unclear about number of visits allowed
2017: American Health Care Act (AHCA)
Put forth by Trump administration
Failed to pass
GOP (Republican Congress) considering ways to make changes without repealing ACA
Successful at repealing mandate requiring all to have health insurance
Goals: AHCA Would: (failed to pass)
Increase tax credits
Reduce number who are eligible for Medicaid
Obamacare rose to 138% of poverty line
Require a person to work if receiving Medicaid
except pregnant, disabled, or student
Not fund abortion
Stabilize state insurance markets
Create grants for opioid crisis
2018 Bipartisan Budget Act
Repealed Medicare Caps
limit on how much outpatient care monies could cover OT/PT/SLP
Changed the Home Health Care Payment
eliminating some basic thresholds that needed to be met
Changed OTA reimbursement to only 85%
How does Health Care Legislation and the populations demographics affect where OT’s work?
Accessible:
OT provides culturally responsive and customized services
Guideposts for Centennial Vision 2025
Collaborative:
OT excels in working with clients and within systems to produce effective outcomes
Guideposts for Centennial Vision 2025
Effective:
OT is evidence-based, client-centered, and cost –effective
Leaders:
OT is influential in changing policies, environments, and complex systems.
