Midterm Flashcards
Private Sector Involvement in Health Services
Government Involvement in Health services
Which is most/lest
Entreprenuerial–most private
welfare
comprehensive
socialist
communist–most government
Canada
- –Type of system
- gov vs private
- who delivers service
- funding
- access
- problem
- Welfare
- extensive governmental control–access to quality health service
- service delivery in private hands
- Fund: tax, some out of pocket
- Access: Universal
- Problem: waiting lists
Government more than private
UK
- –Type of system
- gov vs private
- who delivers service
- funding
- access
- problem
- Comprehensive
- central government control
- local government arranges comprehensive care
- funding: TAXES–single payer
- access: UNIVERSAL
- problem: financial shortfalls
Government more than private
Germany
- –Type of system
- gov vs private
- who delivers service
- funding
- access
- problem
- Socialist
- DECENTRALIZED (more private)
- state and federal government regulated
- universal access via private insurance funds
currently private insurance is growing
Government more than private
Communist
- –Type of system
- gov vs private
- who delivers service
- funding
- access
- problem
communist
government total control
universal access but service unequal
government more than private
NO LONGER EXISTS
US
- –Type of system
- gov vs private
- who delivers service
- funding
- access
- problem
- Entrepreneurial
- DECENTRALIZED
- -large private non governmental component, smaller central government control - Private service delivery
- Selected tax funded beneficiaries (payroll, state/federal revenue), private programs
- Access income related
Private more than government
Which country?
Welfare
Canada
Which country?
Comprehensive
UK
Which country?
Socialist
Germany
Which country?
Communist
former soviet union
Which country?
Entrepreneurial
US
US Healthcare system: how diff than the world?
4
- Fed gov not responsible for health service planning (Dept of Health and Human Services only for ppl who cannot care for themselves)
- Most expenditure/person for healthcare in the US
- Not universal healthcare, public pay less of total than in other nations
- Multi-payer system: lead to inefficiencies
concerns with universal health services?
5
- How to ensure access
- cost
- quality
- quantity
- Efficiency
EU- The European Union –
improvement of social, economical and political strength
improves its members social, economic and political strength–wants to see promotion of its members
How much of GDP does the US spend on healthcare?
15.2% (but less paid for by government because more from private pay)
Gross domestic product (GDP) is the total value of all domestically produced goods and services. Its like the nation’s total wealth.
US has a federalist form of government,
what does this mean?
Separation in authority of local, state, and the federal government and favors decentralization of health services
(system of government in which sovereignty is constitutionally divided between a central governing authority and constituent political units (ie: states)
Capitalism
3
Economic philosophy: supports market orientation
- Free Market Economy
- Competition (control prices)
- reward indvs success–>benefit society as a whole
How the US healthcare system became so different:
These economic, political, and orientation factors allowed for the development of the US. Entrepreneurial health care system
The public portion of the system to those who were most needy
The private portion to those who could afford to pay for services themselves
What led to the funding gap?
- -1980 to 1985 health care cost increased (more in 1990)
- -Shift to low paying service sector jobs
–>Increased # of individuals without health insurance
thus->Providers shift costsfrom uninsured/underinsured to COORPERATE and GOVERNMENTAL payers who could pay
–businesses now had high costs for benefits, government unable to meet demands with federal deficit
What is the funding gap?
Rising Healthcare Costs
Decrease Salaries from lower paying jobs
increase number of uninsured and underinsured americans
Government and Private Industry Response to rising costs of healthcare :
Early 1980s
MEDICARE: fixed payment system for inpatient hospitalizations
PRIVATE businesses: managed care
What is the fixed payment system Medicare adopted in the early 1980s?
Medicare determine amount to pay for the service
–issue: clinicians using low cost treatments so then government said it would take back 10% if return in 30 days
What is the managed care system private business adopted in the early 1980s?
PCP refer to specialist –hopefully only for needed use
Healthcare system changes:
now
(4)
- Structural changes (i.e. Medicare, Medicaid, and private payers)
- Facility and “brick and mortar changes”(from hospital to ambulatory)
- Work force composition changes (less highly qualified staff- Physician’s Assistants, Nurse Practitioner’s, increase use of technology)
- Procedure changes in regards to health care delivery
( ie REDUCE LOS)
What we need to do in this healthcare system:
5
- understand the changes
- flexible, willing to try to understand what impact the changes in health care will have on your practice
- Success in health care today requires common sense, clinical and technical skills, as well as basic understanding of business and managerial skills .
- Understand your role in the health care delivery system, perfect your craft, and contribute as needed validating your role, and adding value to the system.
- Leadership skills are essential and creates opportunities for improvement and innovation.
Physical therapists are well suited to be leaders of change in the American health care industry and will continue to be called upon to in the future to champion such change
Direct service delivery
examples
Hospitals, home care agencies, public health departments, physicians, nurses, physical and occupational therapists
Indirect service delivery
examples
I.e.. Pharmaceutical company, medical equipment manufacturer, medical researcher, medical waste disposal company
3 ways to classify providers:
1) Type of care provided (preventative, primary, specialty)
2) Type of setting (acute, home health, subacute)
3) Patient care process of continuum of care (acute hospital–> homecare –> outpatient)
Preventative Care
what is it?
Routine health care
–check-ups, patient counseling and screenings to prevent illness, disease and other health-related problems
cheaper than corrective care
How does ACA address preventative care?
March 23, 2010 most plans
required to cover a set of preventive services at NO COST to the subscriber
(no copayment or coinsurance or their deductible)
Adults, women, children (after September 23, 2010)
Primary Care
what does it include?
Primary care is often the INITIAL POINT OF CONTACT within the healthcare delivery system
primary care health providers have DIRECT ACCESS to pt
Health promotion
Disease prevention
Health maintenance
Counseling
Patient education
Diagnosis and treatment of acute and chronic illnesses in a variety of health care settings
(e.g. office, inpatient, critical care, long-term care, home care, day care, etc.)
Does primary care have to be through physician?
No
Besides general practice physicians, the role of primary care providers have been extended to others
E.g. Geriatricians, Pulmonologists, Physiatrists, all can provide primary care in addition to their specialty practice
Non-physician providers with advanced practice can also provide primary care
I.e. Advance practice Nurses, Social works, Physical Therapists
Can PT be primary care?
YES
APTA new vision statement:
In 2013, APTA’s Vision Statement for the Physical Therapy Profession is supported by Guiding Principles to Achieve the Vision, which demonstrate how the profession and society will look when the vision is achieved
“Transforming society by optimizing movement to improve the human experience”
Specialty Care
What is it?
Provides for services, equipment, and facilities NOT offered at the primary care level
Includes specialized consultative care, usually on referral from primary or secondary medical care personnel, by specialists working in a center that has personnel and facilities for special investigation and treatment.
ie
- Specialized medical management
- Diagnostic laboratories
- Imaging
- Surgical and rehabilitative services (PT, OT, Speech)
- Sports medicine
- Day care
- Hospice
- Respite
- Substance abuse services
How can a PT deliver al types of care? (3 care types)
Preventative care- education on falls and back injury prevention)
Primary care – Evaluation of patients who are high risk for falls and/or back injury
Specialty Care- Treatment of patients with balance/vestibular dysfunction or acute lower back pain
Type of settings
What are the 3 types to categorize healthcare?
1) Ambulatory (outpatient) care
2) Inpatient care
3) Homecare
Ambulatory Care
what is it
able to arrive and depart from the care setting on the day of service
-outpatient basis
can be preventative, primary, specialty
ie rehab day programs
Inpatient Care
what is it
administered to a patient who remains in a hospital setting
(acute, post acute, skilled nursing facility)
Acute Care:There are two levels of service provision
- Secondary care
- Tertiary care
also Post acute inpatient care
Acute Care:There are two levels of service provision
- Secondary Care
- Tertiary Care
also Post acute inpatient care
Acute Care:There are two levels of service provision
- Secondary care
- Tertiary care
What is secondary care?
GENERALLY NOT HAVE FIRST CONTACT WITH PATIENTS
medical specialists / other health professionals who generally do not have first contact with patients
ie Diagnostic laboratories General and routine surgical services Women’s health services Inpatient rehabilitation
Acute Care:There are two levels of service provision
- Secondary care
- Tertiary care
What is tertiary care?
specialized consultative health care, typically on referral from a PRIMARY or SECONDARY HEALTH PROFESSIONAL
Typically occur in a facility that has personnel and facilities for advanced medical investigation and treatment
Offer a HIGHER LEVEL OF CARE
Post acute inpatient care
what is it
Pt continue to need skilled level of inpatient care but who DO NOT require the INTENSITY or VARIETY of services available in the secondary or tertiary acute care setting
ie
- -Surgical recovery centers
- -Long term rehabilitation centers (L.T.A.C’s)
- -Long term care hospitals
- -Skilled nursing facilities
- -Inpatient hospice facilities
Home Care
what is it
within the home setting
The fastest growing segment of the healthcare delivery system.
growing for PT, but a lot of paperwork
Continuum of Care
providing a diversity of services in a variety of settings to:
1) provide pt better ACCESS to a variety of specialized care needed throughout the recovery process.
2) Improve the COST EFFICIENCY - matching the resources used with care required
–>these support ambulatory and home based
services along continuum should be smooth and progressive, pt should transition between services settings without problems
–> Often transitions are not coordinated and difficult for patients to navigate
Which model is the cornerstone of an ACO model?
Continuum of Care
Which system?
Services are integrated both horizontally and vertically so that transitions between health care settings is smooth and coordinated.
ACO’s and ICN’
–in ACO government gives money to manage the patient and they have to get the patient out healthy and save as much money as possible
if patient returns in 30 days there is a penalty
**allows for horizontal and vertical integration
Horizontal Integration
Have 2 hospitals, in network with 2 and transfer between them (laterally)–may have different services
Allows for integration of services between two or more like providers (e.g. two hospitals, ambulatory care clinics, etc.)
Vertical Integration
Variety of services at different levels of care
Allows for a variety of services at different levels of care (preventative, primary care, home care, etc.) that makes up a comprehensive health care system.
acute inpatient–>
tx illness and injury –>
care each pt–>
high volume of patient care–>
fill inpatient beds–>
manage an organization –>
coordinate service–>
DECREASE COST, MAINTAIN HEALTH
acute inpatient–>continuum
tx illness and injury –>maintain health and wellness
care each pt–> care pt population
high volume of patient care–>large number of covered lives
fill inpatient beds–>provide right care in right setting
manage an organization –>manage a system of care
coordinate service–> manage care
When did hostpitals become recognized as treatment centers? What was the issue?
1920s
Hospitals = treatment centers,
inadequate medical schools closed, the number of trained physicians decreased, and fees and overall costs rose.
Increased Cost
First Hospital Prepayment Plan
1929 (great depression)
Dr. Justin Ford Kimball
Baylor Plan
1500 school teachers contributed 50 cents/month to a fund that would guarantee them up to 21 days of hospital care at Baylor Hospital.
Lumbar companies 1st insurance plans
1917: Washington
1939: California: first modern Blue Shield plan
Third party payment system
what is it
1st = patient
2nd = provider
3rd = health care plan/prepayment system
Blue Cross-Blue Shield (BCBS) association
formed by what association?
American Hospital Association (AHA)
1933
Blue cross = healthcare
Blue shield = healing and medicinal arts in greek methology
PRIVATE AND PUBLLIC
What year Blue Cross?
1929
What year Blue Shield?
1939
the nation’s oldest and largest family of health benefits companies.
Blue Cross-Blue Shield
How many providers accept BCBS>
Nationwide, more than 96% of hospitals and 92% of professional providers contract directly with Blue Cross and Blue Shield companies.
How does BCBS help medicare?
Blue Cross and Blue Shield companies have partnered with the federal government to process Medicare fee-for-service claims and payments since the program’s inception in 1965.
Employer Sponsored Insurance (ESI).
What is it?
Why did it increase after WWII?
–Due to wage freezes, employers began to offer health plan premiums as a alternative to wage increases
–War Labor Board ruled that wage and price controls did not apply to “fringe benefits” such as health insurance
GOVERNMENT MADE TAX FREE
1929-1960
What was the issue with cost of healthcare and utilization?
Cost of healthcare dissociated from pt: decreased control of utilization
Payment to hospital based on utilization –>more services were used (not quality)
Incr in service use, providers paid for service: increased healthcare system
INCREASE QUANTITY, DECREASE QUALITY
July 30th, 1965
What happened?
under the Social Security Act
Medicare/Medicaid bills
signed: President Johnson
Popular opinion: all persons were entitled to equal access to the highest quality of healthcare services
First enrolled in Medicare?
President Harry S. Truman
because in 1945 proposed the idea of national health insurance
Title XVIII of the Social Security Act
Medicare
financed through social security taxes
Title XIX of the Social Security Act
Medicaid
financed through social security taxes
Medicare/Medicaid
The aim to balance special interests of hospitals, doctors, unions, insurers:
Hospitals- financial stability
Doctors- increase profits
Union-maintain premiums + quality care
Insurers- improve access without increased cost
most significant piece of healthcare legislation ever passed by the U.S. Congress
Title XVIII of the Social Security Act was signed into law in 1965
MEDICARE
Funding of Medicare/Medicaid
Medicare: federally funded (Provider payment under Medicare was to follow the pattern established by the blues
Payment was based on a reasonable cost basis)
Medicaid:
state and the federal government.
Elligible Medicare
July 30, 1965-Elderly
1972
The Social Security Amendments
= disabilities or chronic renal disease
Usual, Customary, and Reasonable Costs (UCR)
What is it
Provider usual fee for a service that do not exceed the customary fee in that geographic area, and is reasonable based on the circumstances.
ACTUAL COST of providing services including direct and indirect costs, EXCLUDING any costs that are unnecessary in the efficient delivery of heath care services
Medicaid
- who administers it
- who it serves
- can be on medicare and medicaid?
- is medicaid mandatory?
- who funds it
- provider reimbursement
- state administered program intended
- serve the needs of the poor, elderly and disabled
- Can be supplemental to Medicare for individuals who qualify for both programs
- The Medicaid program is optional at the state level
- expenses are shared between the state and the federal government.
- providers reimbursed based on reasonable cost
Medicare’s fiscal intermediaries
Blue cross blue shield : processed claims for U.S. Medicare and Medicaid programs
= administrative agent for the federal government and was called the
Health Care Financing Administration (HCFA)
2001: President Bush: Centers for Medicare & Medicaid Services (CMS)
- ->within the United States Department of Health and Human Services (HHS)
CMS IS A GOVERNMENT RUN PROGRAM, BLUE CROSS BLUE SHEILD IS RESPONSIBLE FOR PROCESSING THE CLAIMS THAT CMS HANDLES
Issue with “reasonable cost”payment system for Medicare and Medicaid:
health care providers were financially rewarded for providing more services at a greater cost
As a result healthcare utilization and the healthcare delivery system grew
Since consumers were free from financial responsibility of health service utilization they were encouraged to utilize all services that the expanded health care delivery system offered
Nixon: why he said “health care crisis”
rising cost of medical care and the number of insured individuals
From the late 1960’s through early 1980’s employer sponsored insurance continued to expand
Employer-provided group life and health insurance plans covered more than 2/3 rds of the labor force
Why did healthcare spending increase in 1970s?
- growth in medical treatment,
- for-profit hospitals,
- market inflation
(sustained increase in the general level of prices for goods and services)
As a result the cost burden of healthcare began to get the attention of employers as well as the state and federal government
(healthcare spending 7.1% of GDP )
1970s:
how
cost-based reimbursement
resulted in healthcare crisus
Payer responsible and at financial risk for the cost of health care
cost and utilization of healthcare increased
The increase was the passed to the employer or the taxpayer
- *payer has no control over utilization or cost
- *consumer no incentive to stop utilization of services
This resulted in skyrocketing costs found throughout the healthcare system leading to the healthcare “crisis”
What is the FUNDING GAP?
–rising healthcare costs and individuals covered
–falling private of public funding for health insurance
increase in difference between cost of healthcare and funding = The Crisis
How did healthcare cost in 1980 compare to 1970?
Health care spending was now three times higher than in 1970, at $257 billion, about 10% of GDP.
In the early 1980’s employers and the federal government took action to contain cost utilization and the cost of health care
(healthcare becoming more privatized)
What change did Reagan implement 1983?
from fee for service to capitation
prepaid fee per person/ diagnosis rather than fee per treatment.
Capitation
prepaid fee per person/ diagnosis rather than fee per treatment.
Strategies to control rising healthcare costs 1980s
- Managed Care
- increased deductible and copay
- Control use and cost ie cap # of visits
- Outcome Measures
- Need to go to restricted provider
What does pt give up under managed care?
What does provider give up?
What new role does insurance have?
Gave up exclusive rights to choose health care providers and services
Health care providers also lost the exclusive role as decision maker regarding the health care delivery process
Insurance chose the right location, the level, and type of care needed to achieve the health outcomes at the least possible cost
How managed care control use and cost? What incentives?
Shift cost and financial risk to provider and patient
- change payment method :
- Tax Equity and Fiscal Responsibilities Act of 1982
- Balanced Budget Act of 1997
- Tax Relief and Healthcare Act 2006 - higher deductibles and copays
- utilization management (outcome measures)
- restrictive guidelines for provider participation under their insurance plans
- Stark Law
- Anti-kickback
Tax Equity and Fiscal Responsibilities Act of 1982 (TEFRA)
changed reimbursement : Cost based reimbursement method that limited payers financial risk
PPS: Prospective Payment System
–>categorize patients into Diagnostic Related Groups (DRG):
assign a case payment rate and the provider is paid a fixed rate regardless of the cost incurred for the patient
Balanced Budget Act of 1997
to balance federal budget by 2002
CMS needed to implement new pay system for medicare services
CAPS: Limited amount of therapy patient allowed to have (PT splits with speech)
Tax Relief and Healthcare Act 2006
PAY FOR PERFORMANCE (more $ if perform better)
- Development of measures + performance standards
- Rewards (typically financial incentive) —for those who meet or exceed the criteria/standards
Which act pay for performance?
Tax Relief and Healthcare Act 2006
Which act Caps?
Balanced Budget Act of 1997
Which act PPS? Prospective Payment System
Tax Equity and Fiscal Responsibilities Act of 1982 (TEFRA)
Which act categorize patients into DRG?
Tax Equity and Fiscal Responsibilities Act of 1982 (TEFRA)
Deductibles:
Deductibles: specified amount of money that the insured must pay before an insurance company will pay a claim
Co-payment/Co-insurance:
Co-payment/Co-insurance: specified amount of out-of-pocket expense for health-care services such as doctor visits and prescriptions drugs at the time the service is rendered, with the insurer paying the remaining costs
The Ethics in Patient Referrals Act of 1989- Stark Law
Referral for profit relationship
It prohibits physician referrals of designated health services (“DHS”) for Medicare or Medicaid patients if the physician (or an immediate family member) has a financial relationship with that entity
Medicare Patient Protection Act- “Anti kickback” statue
Service over-utilization
Prohibits the exchange (or offer to exchange), of anything of value, in an effort to induce (or reward) the referral of federal health care program business
National Insurance Health Security Plan
Health Reform in 1990s
Under Clinton to reform healthcare for all
it failed , but gave idea for today
Health Reform in 1990s
increased enrollment
providers and employers want to regain control
Health reform 1990s
medicare and medicaid: how did they change
Some states moved to managed care (healthfirst, metroplus)
Medicare made best practice centers of excellence :Selection of providers based on historical ability and patient outcome
Health reform 2000s
(costs increased 73%)
increased cost: 2/3 of all families struggling to pay medical bills have insurance.
59% of companies with less than 200 employees offer health benefits, down from 68% (and compared with 60% of companies overall);
More than 1/3 of these workers receive no health care cost contribution from employe
On March 23, 2010
The Patient Protection and Affordable Care Act (PPACA),
commonly called the
Affordable Care Act (ACA)
(3)
President Obama
1) increase the QUALITY and AFFORDABILITY of health insurance,
2) lower the UNINSURED rate by expanding public and private insurance coverage,
3) and reduce the COSTS of healthcare for individuals and the government.
healthcare trend
1965-1980
growth and development of healthcare system
healthcare trend
1981-1990
cost containment
- reduce LOS after implement PPS
- lest dx tests
- more outpatient
- increase use of post acute service
Healthcare industry response to changes
- decrease inpatient bed use-excess
- decreased profits for hospital and dr
- decreased profits cause financial limit on technologies and facilities
- providers competing
- cost reduction (staff reduction)
- diversification: new payment methods –alternative care options to reduce LOS and get additional revenue
1985-1990s: increase in the # inpatient rehab facilities, long term care hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities and outpatient physical therapy providers certified to provider services under the Medicare program
because PPS exempt
Horizontal integration
partnership with like providers in the marketplace
—Affiliation of several hospitals resulting in the formation of regional networks
Vertical integration
used to link a continuum of services under one umbrella
Primary care, hospital care, ambulatory care, home care, rehabilitation, and long term nursing care
“One stop shopping for the consumer”
When did NYS PT become direct access?
2012
How have efforts to manage health changed?
Efforts to manage healthcare continue however with the emphasis on disease management and the control of long term costs rather than episodic care consumption
What is incentive to managed care medicare/medicaid from traditional programs?
Incentive to enrollment is paid medications- not covered under traditional Medicare
What are best practice centers of excellence? How do they provide high quality, high cost services?
Centers of excellence receive one bundled payment for all related physician and hospital services from pre-operative care to discharge
unintended consequences of healthcare changes:
Increased UTILIZATION
- Increased moral hazard- a term describing how behavior changes when people are insured against losses (people are more risky)
- Increased litigation
Increase in SERVICES provided- increased SPECIALIZATION
Shift from inpatient to OUTPATIENT care- using less costly resources
Expansion of REHABILITATION Services- increase in recognized abilities of rehabilitation practitioners
Shift from a provider-centric to PATIENT CENTRIC model
Generalists, Specialists and the use of extenders
The current payment trend is towards limiting the financial benefits of specialization in favor of better compensation for generalist practitioners
Most evident with the use of Physical Therapist Assistants and a growing trend for other medical and allied health to use extenders as well
The use of extenders reduces costs of delivery by increasing productivity of the better paid professional
Impact of changes in the Healthcare Delivery System on Physical Therapy
Benefits:
1) increased demand since medicare/medicaid in 1965–more access, services grew with expansion of third party payer system and employer sponsored health care benefits
2) good reimbursement
3) compensation rate higher than of similar professions (demand)
4) can reduce long term costs of disease (chronic, disabling) with wellness and prevention
ACA:
Good
Bad
Good
1) more people eligible -more coverage
2) many PT seeing more patients/day (high demand)
3) new business opportunities in prevention and wellness
4) will become more involved in post hospital stay treatment plans
Bad
1) lower reimbursements in rehab (by 20-40%/visit) –result in increase patient volume
2) more expensive to provide coverage to employee
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