Lecture 23+FC+DLA Flashcards
what is primary care?
common health problems, minor interventions, preventative measures
can be taken care of by general practitioner
80-90 of health care visits
what is secondary care?
problems that require more specialized care,
clinical expertise
usually involve hospital setting for care and specific specialties such as general surgery
what is tertiary care?
more complex and often rare disorders, requiring extensive clinical expertise and hospital care
Involves subspecialties such as cardiac surgeons, immunologists, hematologists
dispersed model of healthcare
multiple access points (patient choice or doctor referral)
more fluid roles for providers
less distinction in hospital care
higher value on tertiary care
HMO for patients
health maintenance organization
most of your care is from a network provider
you choice of a primary care doctor
specialist care diagnostic services require an approved referral
first-generation HMO
Consolidated model, salaried physicians, global budget hospitals
vertical integration (Kaiser-Permanente)
second-generation HMO
virtual integration
group model:
prepaid group practice
IPA’s
network model:
Mix of IPAs, home health agencies, pharmacies,
hospitals, etc
IPA’s or independent practice associations
An IPA is a loose collection of private doctors
who work in their own practices
IPA contracts with HMO on behalf of the doctors
IPA receives a capitation payment from the HMO and pays its doctors either through capitation or fee-for-service
Preferred Provider Organizations (PPO)
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
Accountable Care Organizations (ACO)
Affordable care act allowed Medicare to start this program
financial barriers to healthcare
lack of insurance (part time workers, low-income employee’s)
underinsurance: does not guarantee financial access to care limited coverage gaps in medicare high co-payments and deductibles
non-financial barriers to healthcare
lack of prompt access gender race literacy level disability status sexual orientation location age
Children Health Insurance Program
Covers low income children, up to age 19, who
are not eligible for Medicaid but who cannot
afford health insurance.
Consolidated Omnibus Budget Reconciliation Act
(COBRA) 1985
Allows workers who lose their health insurance benefits because of job loss the right to continue under group coverage
up to 18 months
must pay the premium
Emergency Medical Treatment and Active Labor Act (EMTALA) 1986
To prevent hospitals «dumping» indigent or uninsured patients
All hospitals receiving federal payments must screen and stabilize ER patients
The causes of health disparities
Social determinants of health
Behavioral determinants of health
Environmental determinants of health
Biological and genetic determinants of health
fee-for-service
unit of payment = visit/procedure preformed
physician / hospital is paid a free for each treatment
FINANCIAL RISK
potential to lose money, earn less money, or [as a
physician] spend more time without additional payment on a transaction
for a fee-for-service system, the party paying the bill absorbs the the risk (ex. insurance)
bundling of services
in this type of system some of the financial risk is transferred from the payer to the doctor
more treatments bundled into one payment the larger the financial risk
unit of payment
The physician is paid one sum for all services
delivered during one illness/surgical procedure
economic incentive for surgeons to limit post-operative visits and preform more surgery
Capitation
monthly payments made to a physician for each patient
signed up to receive care from them—usually for primary care physicians
It requires patients to register with a physician/group of physicians
Shifts financial risk from INSURERS to PROVIDERS
Methods to decrease financial risk of capitation
- carve outs
specific services not covered by capitation & paid
separately as fee-for-service - risk-adjusted
patients with greater health needs need more time with their physician – thus higher monthly payments for elderly patients & those with chronic illnesses
benefits of capitation
Controls cost versus the inflationary tendencies of fee-for-service
monitoring appropriate use of services & planning for patients’ needs
better allocation of resources & develop better ways for service delivery
TWO – TIERED CAPITATION (UK)
under the NHS each person enrolls with a general practitioner
One tier: is the HEALTH PLAN (the Government in the UK)
Other tier: is the INDIVIDUAL PCP/GROUP PRACTICE (w/ several physicians)
THREE – TIERED CAPITATION
HMOs do not pay capitation fees directly to doctors
IPA’s still are private, but join physician groups
payment per time - salary
physicians in the public vector are normally salary
they have little financial risk
high volume of patients
no over time pay
health plan… prepaid group practice… doctor
payment per procedure (fee for service)
private & public payers question hospital charges & negotiated lower payments → shifts financial risk to hospitals
: insurance companies made fee-for-service payments to private hospitals based on “Reasonable Cost” → hospitals influenced payment amt.
payment per day / per diem
Many insurance companies & Medicaid plans contract with hospitals for per diem payments
Per diem payments: bundles all services provided for a patient on one day into one payment
This bundling of services into one fee removes the hospital’s financial incentive as it loses money by performing expensive studies
the insurer is at risk for the number of days (utilization reviews are done to limit days)
the hospital is at risk for the number of services
Diagnosis related groups (DRG)
DRG payment lumps together all services performed during one acute care hospital episode vs per diem payment lumps together all services performed during 1 day
medicare is at risk for the number of admissions
the hospital is at risk for the length of stay and number of treatments (use internal utilization reviews to reduce cost)
PAYMENT PER INSTITUTION (global)
A fixed payment made for all services performed on every patient during 1 year
Used in Veterans Health Administration & Department of Defense hospitals in the United States
hospital is at full risk
financing controls
Limits how much money flows from individuals &
employers to health care plans
difficult to do in the US
reimbursement controls
Control how much money flows from insurance plans to
doctors/hospitals/etc.
price controls
Utilization controls
Restrict consumption by patients & avoid excessive
care by physicians
patient cost sharing - out of pocket costs
reducing supplier induced demand:
with utilization reviews
value based payment or pay for performance
paying for units of service [visits, hospital episodes, or hours of work] & how well physicians/other providers deliver those services
