U.S health - exam 3 what I did not know Flashcards
In Canada, how are you billed if you are a part of the provincial health service
In Canada, you do not get a bill if you are a part of the provincial health service
In Canada, what does the private insurance allow for
In Canada, the private insurance allows for gaps such as some pharmaceutical coverage or private hospital rooms
Canada has how many services
Canada has less services per capita
how are physicians billed
Germany
Canada
U.K
Japan
For physicians:
Germany is billed per episode
Canada is billed fee for service or capitation
U.K is capitation/preventive care fee for service/salaries
Japan: fee for service while hospitals are paid per diagnosis
Canada vs U.S:
Canada vs U.S: less admin cost., less expensive high-tech costs, lower pharmaceutical prices. Has caps on payment like Germany
For U.K, private insurance can pay for what
For U.K, private insurance can pay for care of private hospitals not NHS facilities
For U.K what do you need for a referral to go to a specialist
what about for germany
For U.K needs a referral to go to a specialist. They also have limited consultant slots so they control supply of personnel and facilities
do not need referral for germany
In japan, the gov’t strictly regulates what
In japan, the gov’t strictly regulates physician fees, hospital payments, medication pricing, number of expensive services
Employer-sponsored health plans increase -what did purchasers begin to pay attention to
Employer-sponsored health plans increase - In the 1980’s the purchasers began to pay attention because everything got so expensive. Providers take control by using capitated contracts instead of fee for service. Insurers also choose providers to contract with. Companies use HMOs to cost control. Large companies start self insurance
in coverage landscape changes
Plan becomes very specific as to where and from whom care can be provided and covered
Providers would lose contracts due to poor rates and unwillingness of insurers to negotiate
Purchasers had some negotiating power with HMOs and saw a drop in premium growth in the earlier 1990’s
Employers shop around more for insurers
in 2000’s
employee-Premiums and deductibles rise 34%
Large HMOs emerge due to buy-outs and consolidation
Provider and insurance negotiations are intense
specialists groups grow and demand higher payment rates from insurers
tiers also begin because insurers start to challenge costs
Hatch-Waxman Act or Drug Price Competition and Patent Term Restoration Act
Description: allows a drug research company the exclusive right to produce and market a new drug for a specific period of time (usually five years). During this time, no generics are allowed to come to market.
ever greening starts too - release XR as soon as 6 months is almost up
PBM (Pharmacy benefit management) is responsible for formularies
Why Digitalize Healthcare?
They can help address the following issues:
- Reduce inefficiencies,
- Improve access,
- Reduce costs,
- Increase quality, and
- Make medicine more personalized for patients
gives patient more control of care and gives providers a more holistic view of patient’s health
now more physicians and hospitals are adopting electronic health records (EHRs)
for RPM
some patients will need in-person testing and treatments and monitoring
this depends on their condition internet capabilities or personal preferences and abilities
RTM can include
devices used for RPM and disease management for therapeutic outcomes
med. adherence and physiological data
interventions can include education and coaching
CMS can include pulmonary and musculoskeletal conditions
issues with DIGITALIZATION OF DEVICES
Accuracy
data interoperability
coverage
patient education
user adherence
Limitations for CGM and benefits
Limitations still present:
- Cost barriers
- Clinician and patient buy-in
- Technology barriers
fewer pricks on the finger
digital affinity related to acceptance of use
BARRIERS TO ADOPTION
of digitalization
PROGRAM IMPLEMENTATION BARRIERS
- time/training
- education of multiple sites to have cohesive patient care
- leadership buy-in to hire staff to be a part of it
- launching RPM/Virtual services requires an initial evaluation of on-site needs and implementation considerations
PATIENT BUY-IN
- education on
- technical and physical support
- need a flexible platform
- SDoH
PAYER COVERAGE CONCERNS
- likely for fraud
- reimbursement and incentive concern
- Codes (CPT) for RPM and RTM for diabetes management
public health definition 4 parts
mission
- fulfillment
substance
- organized community efforts
organization
- encompasses both activities undertaken within the formal structure
3 core function
- assessment: diagnostic
- policy development
- assurance
