U.S Healthcare terms & lecture--exam 1 Flashcards
here are the terms and lecture info for U.S Healthcare
Is health care a right?
what act tried to enforce that
what is needed for the cost of healthcare
what happens to a patient when the costs of healthcare increase
Clinical care + Standard of living + Public health measures =
Yes!
2009 Affordable Care Act (ACA)
Limits are needed on the costs of healthcare
When costs increase access to care decreases
Clinical care + Standard of living + Public health measures = Outcomes on the health of a population
What are features of health care that we should look for?
A
A
A
Hq
Accessible
Affordable
Appropriate
High Quality
Health Care Issues Include
how do people pay for healthcare?
what does healthcare make appropriate
Uninsured
Paying for health care: individuals, employers, Medicaid, Medicare, health connector
Appropriateness of care and medications
Health Care Waste Estimates in the US
what is the waste of healthcare due to
Ep
Fa
Ci
Aw
Mp
Ov
Wasted health care dollars estimate: 2019: $760-$935 Billion wasted annually
Excessive prices
Fraud and abuse
Clinical inefficiency
Administrative waste
Missed prevention
Overuse
Reasons for being uninsured among uninsured nonelderly Adults 2021
is the coverage affordable?
are they eligible for coverage?
do they need or want it?
is signing up simple and straightforward
do they find an appropriate plan that meets their need
coverage not affordable
not eligible for coverage
do not need or want
signing up is hard and confusing
cannot find a plan that meets needs
barriers to health care among nonelderly adults by insurance status
did they see a provider?
do they have a source of care?
why would they postpone care?
did they go without care for some time?
did not see a doctor/health care professional
no usual source of care
postponed seeking care due to cost
went w/o needed care due to cost
delayed filing or did not get needed prescription due to cost
View and Crisis?
“The US has least universal, most costly health care system in the industrialized world.” –Understanding Health care Policy p. 2.
What we need to learn about is:
who
how
prevention
how
how
Who gets paid how?
How is health care organized?
Prevention versus treatment?
How to reduce costs?
How to increase quality?
Excess versus Deprivation
do people have too much
too little
just right
Too much health care- Really?
Too little health care- uninsured, underinsured
Just right health care- “Goldilocks”
Access
to make contact with or gain access to; be able to reach, approach, enter
Affordability
that can be afforded; believed to be within one’s financial means:
attractive new cars at affordable prices.
Appropriateness
the quality of being suitable or proper in the circumstances.
Excess
an amount of something that is more than necessary, permitted, or desirable.
Deprivation
the lack or denial of something considered to be a necessity.
Affordable Care Act (ACA)
is the name for the comprehensive health care reform law (passed in 2010) and its amendments. The law addresses health insurance coverage, health care costs, and preventive care.
Healthcare reform makes health coverage available and more affordable for millions of Americans. It gives subsidies for those who purchase private insurance and California expanded Medi-Cal to include more people and single adults.
Health care system
an organization of people, institutions, and resources that delivers health care services to meet the health needs of target populations.
Out-Of-Pocket payments
is the direct payment of money that may or may not be later reimbursed from a third-party source. For example, when operating a vehicle, gasoline, parking fees and tolls are considered out-of-pocket expenses for a trip.
what is considered to be private insurance
Does a plan purchase through insurance company count as one too
a plan provided through an employer or union; a plan purchased by an individual from an insurance company; or TRICARE or other military health coverage
Employment-based private insurance
a health policy selected and purchased by your employer and offered to eligible employees and their dependents. These are also called group plans.
Government Financing
issuance of Parity Stock or Senior Stock to, or the incurrence of Indebtedness owed to, a local, federal or foreign governmental entity (a “Governmental Entity”), or designee thereof (in each case, excluding a sovereign wealth fund who regularly makes financial investments), in connection
Medicare
federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions.
Medicaid
is the nation’s public health insurance program for people with low income.
provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities
Uninsured
not covered by insurance.
Underinsured
having inadequate insurance coverage.
Premium
an amount to be paid for an insurance policy.
Deductibles
a specified amount of money that the insured must pay before an insurance company will pay a claim.
Copayments
a contribution made by an insured person toward the cost of medical treatment or other services.
Coinsurance
a type of insurance in which the insured pays a share of the payment made against a claim.
Health Plan
is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals.
Provider
a person or thing that provides something.
Individual Mandate
provision within the Affordable Care Act that required individuals to purchase minimum essential coverage – or face a tax penalty – unless they were eligible for an exemption.
Community rating
a rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status, or other factors.
so makes the cost of premiums the same regardless of age, gender, health status, or other factors!
Experience Rating
the amount of loss that an insured party experiences compared to the amount of loss that similar insured parties have.
Eligibility
the state of having the right to do or obtain something through satisfaction of the appropriate conditions.
Enrollment
the action of enrolling or being enrolled.
Modes of Health Care Payment
Out-of-pocket
Individual private insurance
Employment-based group private insurance (which is a health policy selected and purchased by your employer and offered to eligible employees and their dependents. These are also called group plans)
Government financing
Out-of-pocket
Need versus luxury
The unpredictability of need and cost: cannot predict illness or surgery
Point of care physician recommendations
cascade for individual private insurance
How do I get insurance if my spouse has no job with the family plan?
Individual Private Insurance Individual Health Plan Provider
You have to get private insurance
Individual Mandate
Required healthcare
Subsidies for costs help those with income between 100-400% federal poverty level
Insurance purchased through marketplaces or health insurance exchanges
have insurance thru job and entire family is covered so we meet the individual mandate
Employment-based Private Insurance
What happened for Baylor University Hospital
what happened in WWII
1929- Baylor University Hospital provided hospitalization for school teachers $6 per person per year
WWII was unable to increase wages, instead increased benefits and began to offer health insurance (this is where benefits come from)
After the war unions picked up on the healthcare option and negotiated benefits
Employer premiums are tax deductible (employers can provide healthcare cause they get a tax break)
expenses and the benefit is not considered taxable income for the employee, therefore the government “sponsors/subsidizes” employer-based health care, estimated to equal $250 billion yearly of “uncollected” “taxable” “income”.
ACA mandated employers with 50 or more employees offer coverage or pay a fee in penalties for not providing insurance.
Community versus Experience Ratings
Community Rating- All have the same premium no matter their health status: everyone paid the same $, high-risk persons (someone working on ladders, coal miners) paid the same as low-risk (bankers)
How insurances began
Difficult to be competitive because everyone pays the same
so basically, everyone in the community pays the same
Experience Rating- The base premium is decided on the average “needs” of the group
Higher premiums for coal workers, the elderly, sick
Began due to competition to bring lower premiums for groups
Appears to be discriminatory to some
so basically, you pay based off of your experience
ACA: Community versus Experience Rates
What will happen if people do not pay much for health insurance?
what if co-payments are high vs low
Insurers experience rates are limited to:
Family size
Geographic location
Age within limits of younger versus older rates
Smoking status: can be charged more because @ risk
If people do not need to pay much for health care then the use of services will increase and insurance companies will need to pay more, Having individuals responsible for part of the costs, which has been rising, causes less use of services
higher co-payments, people wait longer to be treated, if no co-payments, then they would be quick to go to the hospital
Government Financing
1950’s & 1965
1950’s:
Poor and Elderly were struggling for Health Care
Poor: Either did not have a job or jobs without fringe benefits
elderly: Could not afford the trend toward experience ratings
Less than 15% of the elderly had health insurance: so lots of out-of-pocket purchases
1965:
Medicare: For the Elderly
Large deductibles, copayments, and gaps
Covered approximately 58% of average medical costs in 2012
Medicaid: For the Poor
Also need to meet other criteria: young child, pregnant, elderly, disabled
Medicaid expansion in some states has taken away these stipulations
Medicare
Medicare enacted for the elderly in 1965
People eligible for Social Security are automatically enrolled at age 65 Under 65, disabled for and receiving Social Security for 24 month Individuals with ALS, end-stage renal disease, or transplants-no waiting period required ( so they do not wait 2 years)
Medicare Part A
inpatient to your costs
skilled nursing facility (SNF) Care to eligibility to your costs
long-term in patient care (SNF) to your costs
Financed through the Social Security System through income payments by employers, employees, and those self-employed.
Medicare Part B
Medically necessary services: lab work, x-rays, physicals…
Preventative services
Financed through income taxes, federal taxes, and premiums: some people get until 65
Medicare Part C and Part D
when prescriptions get covered
Medicare Part C: Includes more health coverage plus a full prescription drug coverage
Private health plans also called Medicare Advantage Plans
Medicare subsidizes the premium
The majority of plans are health maintenance organizations (HMOs)
Medicare Part D: Prescription Drug Benefit (drug covered only)
Criticized for: major gaps in coverage, provided through private insurance versus a federal program, non-negotiable prices with pharmaceutical companies to lower drug prices
Medicaid
for low income kids
1965-2014: Low income plus needed to fit into categories of eligibility
Children typically covered 100%
Federal government pays 50-76% of total costs depending upon per capita incomes
2015:
Medicaid expansion lifts eligibility criteria; income up to 138% federal poverty level
The federal government pays 100% of newly eligible from 2014-2016 then decreased to 90% thereafter
Undocumented immigrants are not eligible
Taxpayer contribution
Medicare: Eligible if you have paid a certain amount into the Social Security system
Medicaid: Those who contribute may not be eligible
Healthy employees tend to pay more into the system for health care than those disabled, lower income, who may be using more services
Financing Health Care
progressive payment
regressive payments
proportional payments
Progressive payments: Rising % of income taken as income increases
Increased income Increased payments
Income taxes are progressive
The more I make, the more I pay
make more, pay more
Regressive payments: Falling % of income taken as income increases (considered “unhealthy”)
Increased income decreased payments
Experience rated is a regressive method of financing
Community-rated is also regressive but less so than experience-rated
everyone pays 10% whether millionaire or poor
make more, pay same–not cool
Proportional payments: The ratio of payment to income is the same for all income classes
The ratio of income to payment same for all classes
regressive payments by year
2017:
47% of health care expenditures were out-of-pocket payments and premiums= REGRESSIVE
43% funded through government revenues= PROPORTIONAL
____________________________________
Sum Total of health care financing= REGRESSIVE
2013: Medical expenses lowered the lowest income by 47.6% compared to the top decile by a mere 2.7%- so those who make the most, pay the least
Individual private health insurance ACA
Varies based on needs and affordability
bronze
Silver
gold
platinum
Bronze: 60% coverage, premium is low, out-of-pocket is high
Silver: 70% coverage, premium is higher, out-of-pocket is less
gold: 80% coverage, premium is high, out-of-pocket is low
platinum: 90% coverage, premium is very high, out-of-pocket is very low
objectives for lecture 2
- Identify reasons for being insured
- Assess the difference health insurance may make versus those without health insurance including access and outcomes and the impact of Medicaid
- Identifying underinsurance and knowing insured does not mean guaranteed access
- Describe the impact that income and race have on health status
what happened throughout
1980-2010
2010-2013
2014
2018
1980-2010: Number of uninsured grew from 25 million to 50 million
2010-2013: States began to enroll more individuals and families into Medicaid
2014: Implementation of ACA private insurance mandates and Medicaid expansion
2014: Decrease of uninsured from 41 million to 26 million
2018: Uninsured has increased again to 28.3 million (healthaffairs.org)
2023: Decreased to 25.3 million (per CDC)
Reasons for Uninsured
- skyrocketing cost of health insurance
- economy & workforce of the U.S
- Private insurance linked to employment leads to interruption of coverage
Skyrocketing cost of health insurance
-From 2000-2014 premiums rose 160%
2014: average individual plan cost=$6,025; average family plan cost=$16,834
-Shift of employers increasing cost burden to the employee paying 29%-44% in 2014
Economy and workforce of the United States
-Decrease in manufacturing and unionized employees
-Increase in service sector, part-time employment without health benefits
Private insurance linked to employment leads to interruption of coverage
-People laid-off or people who leave their job
-Divorce or death of spouse that carries insurance
-Consolidated Omnibus Budget Reconciliation Act (COBRA) allows those who leave job to continue coverage but are responsible for the full payment of the premium
Characteristics of Nonelderly Uninsured, 2021
Family work status
family income
race/ethnicity
what Illness follows those that are Uninsured
Higher rates hypertension
Higher rates cervical cancer
Lower survival rates for breast cancer
Less frequent blood pressure screenings
Less frequent Pap Smears and Breast Exams
Uncontrolled hypertension, diabetes, and cholesterol (= Metabolic Syndrome)
what health outcomes do those with Medicaid have compared to those that are Uninsured
Better self-reported health
Improved depression scores
Increased use of preventative services
Less financial stress
Note: Having Medicaid did not increase the control of hypertension or diabetes
medicaid copayments & copay cap
pharmacy copays for drugs covered by mass health, including both first time prescriptions and refills
$1 for certain generic drugs
$3.65 for each prescription and refills for the generic, brand name and OTC meds covered by masshealth
a copay cap is the highest dollar amount that a person can be charged in copays for a given time period
there is a cap for mass health– no more than 2% of your monthly household income each month
people with inadequate insurance have more
problems paying medical bills
uninsured or underinsured adults often avoid or defer getting
needed health care and meds
people with higher deductibles more frequently report
financial problems because of medicals bills or delaying care because of cost
Nonfinancial Barriers to Health Care
Inability to Access
Language barriers:
Health literacy:
Cultural barriers:
Gender:
Inability to Access: Shortage of Primary Care Providers; lack of after hours appointments
Language barriers: Miscommunication, no understanding
Health literacy: Forms that need to be filled out can be difficult
Cultural barriers: Beliefs, values, and attitudes vary among patients and providers
Gender: Women’s health services, scope of coverage/essential health benefits
wrap up of lecture 2
Review who is uninsured and why there are still issues with uninsured.
Recognize the impact of health insurance on health outcomes.
Some with insurance are underinsured, be able to compare that with insured and uninsured.
Describe the impact of income and race on health status.
Units of payment
Can be placed on a continuum ranging from simplest to the most complex methods
Definitions of methods of payment important to know
Fee-for-service payment
A fee is paid for each service provided (office visit, diagnostic test, medication)
The only form of payment based on each individual unit or component of health care provided
No aggregation or grouping together of services into one unit of payment
The fee may be paid by the patient or the private insurance company
Methods of payment for providers (Physicians)
Fee-for-service
Episode of illness
Capitation
Payment for time (Salary)
Preferred provider organizations (PPO)
Loose-knit organizations where insurers contract with a limited number of providers and hospitals forming a network
Agreement is to care for patients on a discounted fee-for-service basis making use of utilization review
The insurer authorizes or denies payment (prior authorization) deemed unnecessary or expensive
Patients pay a higher share of the cost if they utilize providers or hospitals outside of the network
Fee-for-service payment
Physicians have an economic incentive to perform more services to bring in more payment
Not seen often with physicians or hospitals
The concept of risk
Risk – the potential to lose money, earn less money or spend more time without compensation for services
Payment per episode of illness
One sum is paid for all services delivered during one illness
Uses bundling together of payments referred to as payment at the unit of the case or episode
May lead to economic incentive for providers (surgeons, obstetricians) to limit the number of postop visits since they do not receive additional payment BUT may give incentive to perform more surgeries or see more patients
The more services aggregated into one payment, the larger the share of financial risk shifted from the payer to the provider
Capitation
Payment per patient
Monthly payments made to physician or group for each patient that receives care from them
Explicitly defines in advance the amount of money available to care for each enrollee
Shifts financial risk from insurers to providers
Carve-outs: reintroducing fee-for-service payments for specific services not covered by the capitation coverage:
–Specific diagnostic testing
–Specific surgical procedures
–Non-formulary medications
based on a patient not illness
if extra lab tests or services are required outside of what the insurance has paid the provider, then the provider will have to pay
hospital bills insurance and insurance covers a set amount, anything above the set amount will be paid for by the provider
Risk adjusted capitation:
utilized for patients with serious illness that require more services than what is standard
Provides higher monthly payments for elderly patients and those with chronic illnesses
Often difficult to determine who (patient or insurance company) requires the higher monthly capitation payment
what are patients required to do for capitation
what does it allow
what does it provide
does it allow for continuity of care
Patients required to register with a physician or group practice
Allows more flexibility at the practice level in how to most effectively and efficiently organize and deliver services
Provides framework for rational allocation of resources and development of better methods of service delivery
Allows for continuity of care
what are the 2 and 3 tiered structure for capitation
Two-tiered structure–
Payments are paid directly to primary care physicians and referral services
Three-tiered structure–
–An intermediary administrative structure is utilized for processing payments
–Physicians join an independent practice association (IPA) and are paid on a fee-for-service basis from a pool of money (risk pool)
–At the end of the year money left over in the risk pool is distributed as bonuses to the physicians
–Provides incentive for judicious utilization of diagnostic and specialty services
Payment per time: Salary
Physicians in the public sector (municipal, VA, state facilities) are often paid an annual salary
Also utilized in HMO’s (more to come)
Physicians paid by salary bear little to no individual financial risk
Methods of hospital payment
Fee-for-service
Per Diem
Payment per episode of hospitalization (Diagnosis-related groups)
Capitation
Global budget
Payment per procedure: Fee-for-Service
All services are itemized during a hospital stay
The itemized bill containing reasonable costs is sent to private and public payers for reimbursement
Allowed hospitals to have great influence in determining level of payment
With increased concerns with cost containment for payers methods of payment have shifted away from fee-for-service
Financial risk leans towards the payers
Payment per day: Per Diem
Where does the risk lie?
Insurers andMedicaidplans contract with hospitalsfor per diem paymentsrather than fee-for-service
The hospitalreceives a lump sumfor each day thepatient is in the hospital
Per diem paymentsrepresenta bundling of all services provided
Insurers mayperform utilizationreviewsof chartsto verify that patients needto be in the hospital
Length of stayis monitored closely
Where does the risk lie?- with insurer
risk for Per Diem
The insurer isat risk for the number of days a patient stays in the hospital because they pay by the day
The servicesdelivered in a dayis a fiscal concern (risk) to the hospital
More days in the hospitalequals moremoney the insurer is billed for
Risk is shared between the insurance and provider
insurance pays per diem (pays per day to day basis)
hospital using their services
paying for however long the patient is in hospital
Diagnosis-related groups (DRGs)
DRGpaymentslump togetherall services performed during one hospital episode
The episode under theDRG systemrefers only to the portion of the illnessspent in the acute care hospital
The amount of the paymentis dependent on the patient’s diagnosis
The insurer or Medicare programis at risk for thenumber of hospital admissions
The hospital is at risk for the length of stay and the resourcesused duringthe hospital stay
risk on hospital, lump sum payment for illness. just like per episode of illness
insurance pays set amount and if hospital wants the patient to stay for extra tests and services then the hospital will have to pay
Diagnosis-related groups
whose are risk
Hospitals conductinternal utilization reviews to reduce the costs incurred
Hospitals closely monitor the length of stay
Risk?- hospital
depends on payments or services
if the diagnosis is more than what the insurance is set to over then the hospital/provider will have to pay for the services that will be used for the progressing diagnosis
With capitation payments,hospitals are at risk for
Admissions
Length of stay
Resources used
Hospitals bear allof the risk and the insurer bears no risk
Capitationpaymentto hospitals is uncommon in the United States
Payment per Institution: Global budget
Used in large integratedhealth delivery systems
What is an integrated heath delivery system? What are some examplesof integrated health delivery systems?
The hospital is entirely at risk no matter how many patients are admittedand how many services are provided
Hospital needs to stay withinits fixed budget
This is the mostextensive bundling ofservices
Every servicegiven to every patientduring 1 year is aggregated into one payment
Global budget
Used by Veterans’ Health Administration, Department of Defense hospitals
Standard payment method in more socialized healthcare systems
Newer approaches topaying physicians and hospitals
TheNational Commission on PhysicianPayment Reform (2013) called forreformof physician payment and elimination of fee-for-servicepayment
Favors payment that rewards value rather than volume of services and patient care
Value-based payment and payment reform
Pay-for-performance
Bundled payments
Care coordination payments
Accountable care organizations
Pay-for-Performance
Involves payingnotonly for units of service butfor qualityin the delivery of those services (measures outcomes)
Public and privateinsurerssupplement basic payment methods with bonus paymentsbased ontheir achievement of a specifiedhigh level of performance on certain measures
–Preventive care
–Diabetes care
–Patient satisfaction
–Cost reduction
Bundled payments
Seen under Medicare payment reform
Bundlingofunits using episode-based rather than fee-for-servicereimbursement
Physician andhospital payments areall bundled togetherinto one singlepayment
Provides incentive for thestaff to collaborateto eliminate unnecessary costs
Places the hospital and physicianat financial risk for post-opcare expenses (shared risk)
Care coordination payments
Medicare and some private insurerspayprimary care practicesthrough a blended model
Adds a small capitationpaymentto the fee-for-service payment
May provideresources and incentivesforbetter management of patients with chronic conditions
Accountable Care Organizations (ACO)
while retaining other payment methods, what do ACOs create in terms of budget?
who is at risk, physicians or hospitals, and for what
who do they create for their budget (same as the first question)
what does it allow physicians and hospitals to do in terms of upside risk if they are willing to assume what and pay money back if _______
what does it provide for all providers in hopes of collaboration in elimination of _______ healthcare _______
Whileretainingother payment methods,ACOscreate an overall budget target
Putsphysicians and hospitalsat financial risk for overall expenditures
ACOs create an overall budget target
Allows physicians and hospitals toretain a largershare ofthe upside risk if they are willing toassume some of thedownside risk and pay money back iftotal costs exceeda target threshold (shared risk)
Provides incentivefor all providersto collaboratein elimination of wasteful healthcare spending
community rating vs. experience rating
Community Rated premiums are calculated based on everyone’s medical claims within a community (or risk pool)
Experience Rated premiums are calculated based on each individual’s claims history.
deductible
If your plan’s deductible is $1,500, when will health insurance pay for your bill?
what id the bill was $1,500 and your deductible was $1,000
the amount you pay for health care services before your health insurance begins to pay. How it works: If your plan’s deductible is $1,500, you’ll pay 100 percent of eligible healthcare expenses until the bills total $1,500. health insurance will be paid if the bill exceeds $1,500
so if your deductible was $1,000
you would pay $1,000 and the insurance will pay $500
what will there be more of a demand for as the population ages?
On LTC delivery
What compromises independent living
HSHT etc
Health, social, housing, transportation, and other supportive services needed by persons with physical, mental or cognitive limitations
what are 2 categories of independent living
activities of daily living (ADL)
Instrumental activities of daily living (IADL)
what are activities of daily living (ADL)
FDBTB
they are basic human functions such as
- feeding
-dressing
-bathing or showering
-getting to and from the toilet and caring for incontinence
-Getting in and out of a bed or chair
what are instrumental activities of daily living (IADL)
House_____ & _____dry
P M
S for G
U T
M F
M K appointments
Meds
activities necessary to remain independent
-Doing housework and laundry
-Preparing meals
-Shopping for groceries
-Using transportation
-Managing finances
-Making and keeping appointments
-Taking medications
Long-Term Care - Cost
How many Americans over the age of 65 will require long-term care services?
what does LTSS stand for
52%
long term services and support
does health insurance cover long-term care
does Medicaid?
no, it does not
Medicaid only helps if one meets specific requirements
Who Pays for LTC?
Direct out-of-pocket payments by patients finance 15% of the $236.15 billion on LTC in the US
how much does medicare fund for LTC
about 21% of the time
What is covered by Medicare for LTC?
Skilled care: services required by registered nurses (nursing facility, hospital, home care service), physical therapists, occupational therapists, and speech therapists
what is not covered by Medicare
Custodial care: assist with ADL/IADL rather than treat a condition or provide rehabilitation
how long will Medicare cover
Only pay for a short duration:
-100% for 20 days
-Any cost exceeding $167.50 from days 21 to 100
what will Medicare Part A pay for
will pay for ______ care in certain situations
prior ________ stay of at least _______
-Admitted to ______ facility within _____ days of ______ stay
-Require ________ or skilled nursing
Part A will pay for skilled nursing care in certain situations
-prior hospital stay of at least 3 days
-Admitted to nursing facility within 30 days of hospital stay
-Require physical therapy or skilled nursing
Will Medicaid Pay?
what do you have to do before Medicaid pays for LTC?
What will they do prior to the application?
how much care will they cover in a nursing home?
will they pay for home 24-hour care
-Medicaid finances 40% of long-term care
-Must first spend down savings and assets
-Will assess available funds up to five years prior to application
-Will cover complete care in a nursing home
-May NOT for home 24-hour care
Medicaid Eligibility
how much does your monthly income and assets have to be
when do you qualify for Medicaid?
what will the state review, and what will warrant a penalty disqualification period?
MassHealth Standard (Individual)
-Monthly income at or below $1,133*
-Assets at or below $2,000
Before Medicaid assists with coverage, will require patients and family spend down their assets until they qualify for Medicaid
“5-year lookback”
-State will review any gift within 5 years preceding the date of Medicaid application
-Gifts added together result in a penalty disqualification period
basically, be poor to have access
worst case scenario for LTC
what happens to a patient who needs LTC but does not have enough money
patient needs LTC but because they do not have enough money, they cannot afford the care that they need so they die due to inadequate care
what role do Private LTC Insurance have in LTC
Who is private insurance’s largest market and why
have premiums increased over the years for private insurance, if so how much
Minor role in LTC
The largest market is the elderly
–Experience-rated
–Pay more because are at high risk of needing LTC
Premiums have increased up to 90% since 2010
–Generally considered a poor investment
who provides LTC
Informal caregivers
- Over 66 million people serve as unpaid caregivers
-The majority are women over the age of 60 (wives, daughters)
Struggle with job loss (40%) cause they can’t keep a job due to caring for family members and depression (70%) because they see their loved one suffering
Community-based and home health services for LTC and nursing homes
what are some options for LTC?
What do nursing homes provide in terms of quality?
who provides most of the care in nursing homes and why
Home care
Adult daycare
Hospice
Mental health care
Assisted Living
Nursing homes
- wide variation in quality
-Nurse aids provide much care to keep costs down
What would you want the pharmacist to be able to do to help with LTC for a relative?
- simplify/consolidate med
-deprescribe
- pill packs and calendar: helps manage complexities
Pharmacy services in LTC
what do pharmacies pack for delivery in LTC?
What do pharmacies provide for assisted living facilities?
what are some examples of LTC facilities in MA?
Medication packaging and delivery services
Work with assisted living facilities to provide pharmacy services for patients
–Medication management
–May be contracted with / required for a long-term care facility
Examples in MA:
–Eaton Apothecary
–Greater Boston Long-Term Care Pharmacy
–Prescott Pharmacy LTC
Improving LTC
Who should be funded
where will that money come from to finance LTC?
Where do we want to shift care?
who should be trained and supported
what should be expanded
Role of social security and taxes
–Fund Medicaid programs
Social insurance to finance LTC
Shift care from nursing home to community by improving funding (want patients to stay home)
Train and support family
Expand the number of comprehensive acute and LTC organizations
how Is healthcare organized (part 1)
into
primary
secondary
tertiary care
the goal of healthcare organization is to assure that the right
The right patient receives
The right health care services
At the right time
In the right place
By the right caregiver
what are the 2 contrasting approaches to primary, secondary and tertiary care
which approach do traditional British National Health Service (NHS) and some integrated systems in the U.S
which approach does US health care as a whole follow
-Dawson model of regionalized heath care
-A free-flowing model
US health care as a whole follows the more dispersed for format
what is primary care
care that addresses common health problems and preventive measures (acute minor illnesses, well visits, and preventive care) – account for 80 – 90% of visits to a physician or caregiver
ooohhhh PCP: primary care provider
what is secondary care
addresses health issues that require more specialized clinical expertise such as hospital care for acute renal failure, routine surgeries
go to see a specialist
what is tertiary care
at the apex of the organizational pyramid
involves the management of rare disorders: congenital malformations, and complex chronic diseases
is the Dawson model highly structured
what is the Dawson model based on
yes It is a highly structured system
Based on a regionalization concept: The organization and coordination of all health resources and services within a defined area
what do we also need to understand outside of U.S healthcar
need to understand the British National Health Service in order to compare it to the United States
is the British NHS a regionalized model
is it organized
yes it is a regionalized model
yes it is organized health care
what is primary care in the British NHS
what is secondary care in the British NHS
what tertiary care in the British NHS
: general practitioners (GP) practicing in small to medium sized groups, main responsibility is ambulatory care, accounts for about 50% of all physicians
specialists in internal medicine, pediatrics, neuro, psych, OB/GYN, general surgery. Located at hospital-based clinics, consult on referrals from GP. Physicians also provide care to hospitalized patients in their specialty
subspecialists (cardiac surgeons, immunologists, pediatric hematologists) located at a few tertiary care medical centers
for the British NHS, is the hospital model the same as the physician model
how does patient move through the British NHS
who do general practitioners work closely with
what does the British NHS utilize in terms of teamwork, patients and universal health care
yes Hospital model the same as physician model
Patient care moves in a stepwise process across the different tiers
GPs work closely with practice nurses, home health visitors, public health nurses and midwives
utilizes teamwork, accountability, a defined population of enrolled patients, universal health care coverage
is Traditional United States Health Care organized
is it more structured to the levels of care compared to the British NHS
what can insured patients do
who do the patients directly take their symptoms to
what is the approach to the Traditional United States Health Care
The dispersed model
A far less structured approach to levels of care
Insured patients traditionally able to refer themselves and enter the system directly at any level
Many take their symptoms directly to a specialist of their choice
Approach to primary care has been to broaden the role of internists and pediatricians, family medicine
what do PCP do in Traditional United States Health Care
who utilizes the hospital in Traditional United States Health Care
some physicians in the secondary and tertiary level act as what
where are NPs and PAs more likely to work as providers
PCPs, both adult and pediatric
–are in secondary care positions both outpatient and inpatient
–they are about 33% of all physicians
hospitalists (physicians who exclusively practice within the hospital) mostly use hospital
Some physicians at the secondary and tertiary level act as PCP’s also
Nurse practitioners and physician assistants more likely to work in primary care settings as providers
in Traditional United States Health Care, is the hospital restrained to the rigid secondary and tertiary approaches
what do all hospitals aspire to do
rural hospitals lack what
what is the orientation more geared to
does it lack organization structure
Hospitals not constrained by rigid secondary and tertiary care boundaries
All hospitals aspire to offer specialized care
Rural hospitals lack specialized units
Top-heavy specialist and tertiary care orientation (leads to shortage of primary care physicians)
Lacks organizational structure
the objective of how healthcare is organized lecture
-Describe models of organizing care
Primary, Secondary and Tertiary Care
-Compare the regionalized model to the dispersed model
Understand the value of primary care in the U.S. Health Care System
-Describe the Patient-Centered Medical Home
-Identify forces driving the organization of health care in the U.S.
The Biomedical Model
Financial incentives
Professionalism
-Describe models of organizing care
Primary, Secondary and Tertiary Care
-Compare the regionalized model to the dispersed model
Understand the value of primary care in the U.S. Health Care System
-Describe the Patient-Centered Medical Home: a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal of obtaining maximal health outcomes.
-Identify forces driving the organization of health care in the U.S.
The Biomedical Model
Financial incentives
Professionalism
what is the goal of primary care
what can you think of a PCP as and what do they manage
that we do not have to go over primary care (PCP (NP, PA etc) to see a secondary or tertiary provider
that patient would not need anything beyond primary care
you can think of a PCP as a gatekeeper who manages chronic problems such as dyslipidemia, HTN, and diabetes–these can be easily managed with meds and easily solved
who do PCPs work with in the British NHS?
public health nurses, midwives etc as a team to ensure quality patient care
who does a PCP see?
is a pediatrician PCP in the U.S
sees pediatrics, adults, and seniors within the scope of family —mom, dad, and baby may have the same provider
The pediatrician is a primary care provider in U.S healthcare
What can a PCP do in an outpatient clinic in the U.S. system?
why is there a shortage of PCP in the U.S
do rural hospitals provide specialized care?
can provide secondary care
PCP makes less money than specialists so not a lot of people do it–because the U.S. HealthSystem is top-heavy in where the money goes (more money goes to the secondary and tertiary systems)
Rural hos. Has not a lot of beds do not have as much specialized care and take care of acute care to discharge quickly
can most illnesses and common disorders be managed by Primary care–what do PCPs need to make sure that they are doing
do a minority of patients with severe conditions require secondary or tertiary care?
most money goes where–to primary secondary or tertiary
Most illnesses or common disorders can be managed by primary care physicians/providers –they need to know when to refer you to someone else!
The minority of patients with severe conditions require secondary or tertiary care
What percentage of resources should be spent on primary, secondary, and tertiary care?
who out of the primary, secondary, and tertiary is the first to be contacted and therefore a very important part of patient care and medical management
PCP care is considered since it happens for a long time like for 20 years
what does a PCP need to make sure they are doing for the wide range of health care needs of a patient
what does a PCP do to integrate their service with secondary and tertiary providers?
The first contact is PCP
Longitudinally: sustaining a patient-caregiver relationship over; care over a period of time
Comprehensiveness: ability to manage a wide range of health care needs
Coordination: integrates services delivered by other caregivers through referral and follow-up; they should be aware of other care and coordinate all of that!
what are examples of PCP in the U.S
what is the goal of primary care
Family physicians
General internists
General pediatricians
Nurse practitioners
Physician assistants
This should lead to a high level of preventive services should want all patients to get physical and high meds compliance
what does/should PCP lead to in terms of
care & patient satisfaction
preventive services
med compliance
hospitalizations and emergency room visits
cost of the healthcare system
outcomes of patients
should people be going to the emergency room for earache and sore throat?
Continuity of care associated with greater patient satisfaction
Higher use of preventive services
Higher medication compliance
Reductions in hospitalizations and emergency room visits
Overall lower costs to the healthcare system
Better outcomes for those that utilize it appropriately
People go to the emergency room and urgent care for ear aches sore throat etc
what can PCPs be compared to
what do PCPs do in terms of
navigating patients
advocacy of patients
partnership with patients and secondary and tertiary providers
they are gatekeepers!
Help patients navigate the complexities of the healthcare system
Advocate on behalf of their patients–The PCP should act as a conduit for ESL and advocate for them
Work in partnership with patients to integrate services from secondary and tertiary care providers to avoid
duplication of services, enhance patient safety and care for the whole person
why was the patient-centered medical home made
what does it address in terms of PCP meeting patient needs
what does it address in terms of gaps in the quality of care?
what does it address in terms of salaries between PCP’s and specialists
Developed to address a perceived crisis
The PCP’s ability to meet patient demands for accessible, comprehensive, well-coordinated medical care
Gaps in quality in primary care
An ever-widening gap between the salaries of PCPs and specialists
who was the patient-centered medical home issued by
what need do they want to meet
The American Academy of Family Physicians
American College of Physicians
American Academy of Pediatrics
American Osteopathic Association
for the Patient-Centered Medical Home
is this a new model
who are the patients
do you need an appointment for care?
is health standardized and based on what
how frequently is quality measured and what does it do over time
what do a team of professionals do in terms of this
what are tracked and followed up on
is this an interdisciplinary team
New model primary care
Patients are those registered in PCP’s medical home
Care is proactive to meet health needs, with or without a visit
Care is standardized based on evidence-based guidelines
Quality is continuously measured and improved at all times
A team of professionals works with patients to coordinate care
Tests, consultations, and ED visits are tracked and followed up
Interdisciplinary team
what force drives the organization of health care in the U.S
what does it focus on
what is it associated with
what is this considered to be in the context of medicine?
is this evidence-based
The Biomedical Model
Focuses on the physical and biological aspects of disease and illness
Associated with the diagnosis and treatment of disease
The science behind the practice of medicine
Evidence-based (been Studied, compared to other treatments, and determined to diagnose and treat)
what forces drive the organization of health care in the U.S
what can we say about the salaries of PCPs and specialists?
how does federal involvement fall under financial incentives
what is professionalism
biomedical model, financial incentives, professionalism
Financial Incentives:
–The growing differential in payment/salaries between PCPs and specialist physicians
–Federal involvement:
Changes in Medicare
Shifts in the insured
Professionalism
–Autonomy and authority of health care providers—be a hospitalist who does not have as much autonomy as a PCP practicing in a group
Barriers
a fence or other obstacle that prevents movement or access.
Health Services
a public service providing medical care.
Health Outcomes
those events occurring as a result of an intervention.
Gaps of Coverage
you were uninsured for a period of less than three consecutive months during the year.
woman’s health
category that includes health issues that are unique to women, such as menstruation and pregnancy
Health Status
a measure of how people perceive their health
Consolidated Omnibus Budget Reconciliation Act (COBRA)
what does it mandate
what does it give some employees the ability to do after leaving employment
law in the U.S. that mandates an insurance program
gives some employees the ability to continue health insurance coverage after leaving employment.
Preventative Services
the application of healthcare measures to prevent diseases
health literacy
being able to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.
Fee for service
MassHealth pays providers directly for each covered service received by an eligible MassHealth member
Episode of illness
the total allowable remittance for a patient’s sequence of care related to a single episode or medical event is predetermined, instead of separate compensation for each service and provider along the way.
Capitation
is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care
Diagnosis related groups
defined based on the principal diagnosis, secondary diagnoses, surgical procedures, age, sex and discharge status of the patients treated. Through DRGs, hospitals can gain an understanding of the patients being treated, the costs incurred and within reasonable limits, the services expected to be required.
global budget
providers are paid a fixed amount for treating a patient population over a defined period, instead of being paid for each service piecemea
Preferred provider organizations
A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians.
Risk
the chance to lose money
Value based payment
programs reward health care providers with incentive payments for the quality of care they give to people with Medicare
Accountable care organizations
groups of clinicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care a designated group of patients.
Primary, secondary and tertiary care
Primary care is when you consult with your primary care provider.
Secondary care is when you see a specialist such as an oncologist or endocrinologist.
Tertiary care refers to specialized care in a hospital setting such as dialysis or heart surgery.
Regionalized model of health care or dawson model
British system
the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region.
Dispersed model of health care
U.S system
people can go to a specialist of their choice without seeing their provider first
Patient centered medical home
an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system.
Prepaid group practice
complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. PGPs’ ability to manage their physician staffing efficiently must be placed in context with the cost and quality of their care.
Health maintenance organizations
is a medical insurance group that provides health services for a fixed annual fee.
Vertical integration
when physicians work directly for hospitals, rather than in independent practices
there should be greater efficiencies through economies of scale, and better quality of care for patients through coordination and information sharing.
Virtual integration
what does it want to link
what does it focus on
to link different parts of the healthcare ecosystem so that patients receive better care.
virtual integration doesn’t achieve this through acquisition.
virtual integration focuses on patient management agreements, provider incentives and information systems.
Accountable care organizations
groups of clinicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care a designated group of patients.
the objective of the health delivery systems lecture :)
Define prepaid group practice
Describe the evolution of Health Maintenance Organizations
Compare vertically and virtually integrated HMO models
Understand the role of Accountable Care Organizations
Discuss medical homes and medical neighborhoods
Define prepaid group practice: complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system
Describe the evolution of Health Maintenance Organizations
Compare vertically and virtually integrated HMO models
Understand the role of Accountable Care Organizations
Discuss medical homes and medical neighborhoods: are groups of health care providers that work as a team to coordinate care for a group of patients, with the goals of providing high-quality, patient-centered care and reducing costs.
Prepaid Group Practice and Health Maintenance Organizations
what is an example of this
what is It trying to meld together
what is the purpose of premiums/what do they serve to do
who is care provided by and who do they work under
what is this whole structure called
Example: Kaiser Health Plan
Attempt to meld the financing and delivery of health care into a single organizational structure
Premiums serve to directly purchase in advance (prepaid) health services from a particular system of care
Care is delivered by a large group of practitioners working under a common administrative structure or group
Currently called health maintenance organizations (HMO)
First-generation HMO’s (Vertical Integration)
what does the kaiser foundation health plan do/function as
what do the Kaiser Foundation Hospitals Corporation own and do
what is shared between the health plan and hospital corporation
who are the Permanente medical groups and what do they do and for whom
Kaiser Foundation Health Plan – performs functions of the health insurer
Kaiser Foundation Hospitals Corporation – own and administer Kaiser hospitals
Shared Board of Directors for Health Plan and Hospital Corporation
Permanente medical groups – physician organization providing medical services to Kaiser plan members under a capitated contract
Vertical integration
are they dispersed or under one roof
what ownership do they share in the primary to tertiary care
what ownership do they have to provide full spectrum of care
Kaiser-Permanente
how are the physicians paid
what budget system do the hospitals utilize
where are the tertiary care services provided
Vertical integration
Consolidating under one organizational roof
Common ownership of all levels of care from primary to tertiary care
Common ownership of the facilities and staff necessary to provide the full spectrum of care
Kaiser-Permanente
Physicians paid salary
Hospitals utilize global budget
Regionalized tertiary care services
Vertically Integrated System
what do they own and require their members to utilize
what is available under one roof
Often owns and requires members to utilize
–Their pharmacies
–Their group physician practices
–Their hospital(s)
–Their home health agencies
Often everything is available under one roof (physician, lab, x-ray, pharmacy, specialists)
Second-generation HMO’s (Virtual Integration)
Network model HMO’s
what makes it different than prepaid group practices
what can a hospital or insurance company recruit for their network
who can physicians still continue to see
what can physicians establish with HMO’s and IPA’s
Easier to organize than prepaid group practices
A hospital or insurance company could recruit office-based, fee-for-service physicians practicing in the community into a network
Physicians can continue to see their non-HMO patients
Physicians can establish contractual relationships with numerous HMO’s and IPA’s
Second-generation HMO’s (Virtual Integration)
who do Health plans contract with
in terms of
providers
location for care
places to get medication
resident health agencies
Many groups of physicians and specialists
Multiple hospitals
Multiple pharmacies
Multiple home health agencies
Preferred Provider Organization (PPO)
why was this developed for the patient
what does it allow the patient to do and is it cheaper
what do physcians joining the PPO do in hopes of getting more patients
patients did not want to see a limited amount of providers
Allows patients to see physicians outside of the network but requires patients to pay a higher share of the cost out of pocket
Physicians joining a PPO agree to accept discounted fees hoping that by being listed as a preferred provider they will attract more patients to their practice
Independent Practice Association (IPA)
what does it serve on the behalf of physicians
what does it do with HMO’s and other health plans
Serves as broker/middleman on behalf of physicians
Negotiates and administers contracts with HMO’s and other types of health plans
Integrated Medical Groups (IMG’s)
what does it have in terms of structure
are physicians employees and do they own their own practice
what can it have with many managed care plans and HMO’s
can physicians still see out of network patients
Tighter organizational structure
Physicians are employees, do not own their practices
Can have contractual agreements with multiple managed care plans and HMO’s
Physicians can care for out of network patients
Physician Hospital Organizations (PHO’s)
Another organizational structure
why was it developed in terms of the IPA model
who do the physicians partner with to contract with who and get what out of it
are physicna independent practiotioners on what staff with who
Developed as an alternative to the IPA model
Physicians partner with a hospital to jointly contract with health plans for both physician and hospital payment rates
Physicians are independent practitioners on the hospital’s medical staff and physicians directly employed by the hospital
Comparing Vertically and Virtually Integrated Models
how does the vertical model progress
how does the virtual model progress
Vertical – first generation – staff model HMO (and group model HMO)
Virtual – second generation – network HMO – Utilizes IPA, IMG’s, PHO’s
Comparing Vertically and Virtually Integrated Models
what does virtual lead to in terms of contractual links, brick and mortar, and common ownership
what does virtual lead to in terms of who physicians can see in the IPA and non-IPA
Virtual = contractual links, no brick and mortar, no common ownership
Virtual – physicians can see IPA and non-IPA patients
Comparing Vertically and Virtually Integrated Models
Vertically integrated HMO’s
what kind of patient portal does it use to facilitate communication between physician and patient
what can it improve for patients and how do the patients feel about the physicians
what can it be an obstacle in and why is this the case
Often use web-based “patient portals” to facilitate communication between physicians and patients
Can improve patient satisfaction (patients feel that their physician knows them well)
Can be an obstacle to patient satisfaction (fewer choices in where care and services will be covered)
Accountable Care Organizations (ACO’s)
who leads an ACO, what do they manage and are accountable for a defined population
what did the ACA authorize medicare to do in 2012
what has risen since 2010 and how many lives does it cover by 2020
what does it span
ACO – A provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population
The Affordable Care Act authorized Medicare to initiate an ACO program beginning in 2012
The number of ACO’s in the US has risen dramatically since 2010 and is projected to cover 70 million lives by 2020
Span a spectrum of organizational structures
From Medical Homes to Medical Neighborhoods
what does it describe in terms of services, providers and organizations in a health system
who does it contribute care to
Describes the grouping or bundling of
Services
Providers
Organizations in a health system
Contributes to the care of a population of patients
From Medical Homes to Medical Neighborhoods
what does it include
related services are needed by who and to meet what need
what type of care does it provide in terms of function and structure
Includes primary, secondary and tertiary care
Related services needed by different patients at different times to meet their comprehensive health care needs
Provides care that is functionally integrated but not necessarily structurally integrated
Structurally integrated organizations
what do they include
in terms of
Primary ______ groups
Multi______ groups
A ________ electronic medical _________
Interdisciplinary ________________
A quality __________ infrastructure
Primary care groups
Multispecialty groups
A unified electronic medical record
Interdisciplinary health care teams
A quality improvement infrastructure
lecture 1 objectives
Explain briefly, an overview of US Health Care and answer,
“Why do we need to study this?”
Identify the features of health care and all the players
Define the terminology of key components of health care do you know the terms?
Begin to formulate an answer as to why insurance is important, or is it?
Explain briefly, an overview of US Health Care and answer,
“Why do we need to study U.S Healthcare?: a lot of money is wasted annually, it is a right, it is sometimes unaffordable and because of that people do not have access to it, there are lots of barriers to it
Identify the features of health care and all the players: the features are: accessible, affordable, appropriate and high quality (who are the players)
Define terminology of key components of health care–terms
Begin to formulate an answer as to why insurance is important, or is it?- protects you from unexpected, high medical costs
objectives from lecture 2 :)
Identify various models of health care payment/insurance
Discern the variations of health care cost options provided through private insurance and the arguments of ratings-Community rating versus Experience rating
Build the foundational knowledge of Medicare and Medicaid options, how they are financed and basic eligibility
Reason the various types of payment classifications and how each type impacts those making the payments-Progressive, Regressive, Proportional
Identify various models of health care payment/insurance:
–out-of-pocket
–individual private
–employment based private
–government financed
Discern the variations of health care cost options provided through private insurance
-bronze: 60% coverage, low premiums, high out of pocket
-silver: 70% coverage, higher premium, low out of pocket
-gold: 80% coverage, high premium, low out of pocket
-platinum: 90% coverage, very high premium, very low out of pocket
the arguments of ratings-Community rating: everyone has the same premium no matter health status, this is how health insurance began, it is difficult to be competitive
Experience rating: premium decided on average needs, coal miners, elderly and the sick have higher premiums, began due to competition to bring lower premiums to groups, appears to be discriminatory to some people
Build the foundational knowledge of Medicare and Medicaid options, how they are financed and basic eligibility
medicare eligibility:
-people eligible for social security are enrolled at 65
-under 65, disabled and receiving social security for 24 months
-mostly financed by the government
medicare part A: covers inpatient services financed by SS
Medicare Part B: covers medically necessary preventive services. financed by income taxes, federal taxes, and premiums
medicare part C: more health coverage + full prescription coverage, subsidizes premiums
medicare part D: prescription drugs
medicaid:
-poor
-mostly financed by the government
-young child, pregnant, elderly, disabled
Progressive: make more, pay more
Regressive: make more, pay less
Proportional: make more, pay accordingly; The ratio of payment to income is the same for all income classes
difference between premiums and out of pocket payments
Health insurance premiums are what you pay to have coverage, while out-of-pocket costs like deductibles are what you pay when you need care. Lower premiums are generally tied to a higher deductible. Higher premiums usually mean you have a lower deductible.
medicare simplified
Part A provides inpatient/hospital coverage: Skilled nursing facility care. Nursing home care
Part B provides outpatient/medical coverage:
Part C offers an alternate way to receive your Medicare benefits
Part D provides prescription drug coverage.
objectives for lecture 3
Identify reasons for being uninsured
Assess the difference health insurance may make versus those without health insurance including access and outcomes and the impact of Medicaid
Identify underinsurance and know insured does not mean guaranteed access
Describe the impact that income and race have on health status
Identify reasons for being uninsured:
-healthcare is expensive: premiums rose 160%
-economy and workforce of U.S: more part time employees, less manufacturing and unionized employees
-private insurance linked to employment lead to interruption of coverage: laid off or leave job, divorce or death of spouse with insurance,
-COBRA: can leave job and be covered but pay more for premiums
Assess the difference health insurance may make versus those without health insurance including access and outcomes and the impact of Medicaid
-insured: better self reported health, improved depression scores, increased use of preventative services, less stress
-uninsured: higher rates of HTN, DM2, TC/HLD, cervical and breast cancer, little to no blood pressure screening, no pap smears and breast exams
Identify underinsurance and know insured does not mean guaranteed access
- underinsurance: does not have adequate insurance to meet health services needs
- insured does not always mean access
Describe the impact that income and race have on health status
- wealth linked to longevity
- lower socioeconomic status people eat worse, smoke and do not exercise
- women with care get check ups more
- minorities die sooner than white, get diseases less likely to be treated
lecture 4
Define methods of payment for health care providers
Physicians:
Fee for service
Episode of Illness
Capitation
Payment per time
Hospital:
Fee for service
Per diem
Diagnosis-related groups
Capitation
Global budget
whose at risk for each
Understand value-based payment and payment reform
Physicians:
Fee for service- pay for each service provided
Episode of Illness- 1 sum payment for 1 illness, the more services aggregated into 1 payment the $ risk for provider
Capitation- payment per patient, monthly payment made to physician for each patient, risk on provider
Payment per time- Salary; physicians are paid an annual salary, bear little to no $ risk, used in HMOs
Hospital:
Fee for service- itemized bill from hospital sent to private an public payers for reimbursement, risk on payers
Per diem- hospital get slump sum for each day the patient is in hospital, length of stay is monitored closely, risk is with insurer because they pay by day, the more day spent then the risk becomes shared
Diagnosis-related groups- lump together all services performed during one hospital episode, insurer at risk for number of hospital visit of patient, hospital also at risk for the services used so risk is shared
Capitation- hospital at risk for services used and length of stay, risk all on hospital
Global budget- hospital given a budget and need to stay in budget
Understand value-based payment and payment reform
- Pay-for-performance
- Bundled payments
- Care coordination payments
- Accountable care organizations
lecture 5
Identify the different activities of daily living
IADL: HLMGTFAM
ADL: FDBTB
Understand and describe long term care
Recognize limitations and pitfalls of the long term care system
–Costs
–Medicaid
–Impact on family and quality of life
Describe the mechanisms to improve long term care
Identify the different activities of daily living
IADL: Housework, laundry, meals, groceries, transportation, finances, appointments, medications
ADL: feeding, dressing, bathing, toilet, bed
Understand and describe long term care
- consequences of illness, accident and old age
- projected increase soon
- IADL & ADL needed by a person who cannot provide for themselves
-
Recognize limitations and pitfalls of the long term care system
–Costs: health insurance does not cover and medicaid only covers a little bit, medicare does not cover LTC or custodial services like ADL &I ADL only 21% if needed for skilled care like RN visits, PT visits, OT, ST visits, costs are paid out of pocket most times, medicare part A will cover a short period of LTC
–Medicaid: medicaid only covers a little bit if you have no more money and after looking at 5 years preceding date of medicaid application
–Impact on family and quality of life: wives an daughter suffer by leaving jobs and having depression
Describe the mechanisms to improve long term care
- fund medicaid (role of SS and taxes)
- shift care from nursing home to community by improving funding
- train and support family
- expand number of comprehensive acute and LTC organizations
lecture 6
Describe models of organizing care
Primary, Secondary and Tertiary Care
Compare the regionalized model to the dispersed model
Understand the value of primary care in the U.S. Health Care System
Describe the Patient-Centered Medical Home
Identify forces driving the organization of health care in the U.S.
–The Biomedical Model
–Financial incentives
–Professionalism
Describe models of organizing care
Primary: for common health problems for preventative measures, accounts for most visits to a physician or caregiver
Secondary: specialized care like renal failure and routine surgeries
Tertiary Care: rare disorders, congenital malformation ties, chronic diseases
regionalized model: care provided regionally Dawson model, vertical model, define population receiving care from same group, primary: GP, secondary: ob/gyns, general surgery, etc, can lead to good (builds relationship with caregivers and gets to know them more) or bad patient satisfaction (limited in who they can get care from)
the dispersed mode/U.S system: patient refer themselves to caregivers, specialist can act as PCPs, NPs and PAs work in primary care setting
Understand the value of primary care in the U.S. Health Care System: preventive measures so good that patient would not need secondary or tertiary care–have a comprehensive knowledge of health to provide, gate keepers to care, able to give referrals and follow ups to connect patient to secondary or tertiary professionals
- first contact
- Longitudinality
- comprehensiveness
- coordination
Describe the Patient-Centered Medical Home
–Developed to address a perceived crisis
–The PCP’s ability to meet patient demands for accessible, comprehensive, well-coordinated medical care
–Gaps in quality in primary care
–An ever-widening gap between salaries of PCP’s and specialists
–Patients are those registered in PCP’s medical home
–Care is proactive to meet health needs, with or without a visit
–Care is standardized based on evidence-based guidelines
–Quality is continuously measured and improved
Identify forces driving the organization of health care in the U.S.
–The Biomedical Model: Focuses on the physical and biological aspects of disease and illness
–Financial incentives: specialists make more $ than PCPs, changes in medicare, shifts in the insured
–Professionalism: autonomy and authority of heal care providers
lecture 7
health care Is all over the place
the notes I took after class :)
IPA (negotiate for doctors to be part of insurance provider)
IMG (physicians work for hospital, contracts with HMOs)
HMO (prepaid to physicians to provide care)
ACO (if we pay for healthcare, it should be high quality)
vertical (tightly organized, brick and mortar, less expensive, can have high or low patient satisfaction)
virtual (patient can pick whoever they want to see, more expensive, not brick and mortar
medical homes (individualistic to patient, tries to limit if patient needs to go to secondary or tertiary care)
medical neighborhoods (focused on population health)
lecture 7
Define prepaid group practice: essentially HMOs
Describe the evolution of Health Maintenance Organizations
Compare vertically and virtually integrated HMO models
Understand the role of Accountable Care Organizations
Discuss medical homes and medical neighborhoods
Define prepaid group practice: essentially HMOs: Premiums serve to directly purchase in advance (prepaid) health services from a particular system of care
Describe the evolution of Health Maintenance Organizations
Vertical Integration:
- all care under 1 roof
- Common ownership of all levels of care from primary to tertiary care under one common ownership
- Physicians paid salary
- Hospitals utilize global budget
- Regionalized tertiary care services
- Limits where patients are able to get their health services –can lead to patient dissatisfaction
- patients have same care givers which can make them happy
Virtual Integration
- Easier to organize than prepaid group practices
- A hospital or insurance company could recruit office-based, fee-for-service physicians practicing in the community into a network
- Physicians can continue to see their non-HMO patients while. In vertical the physicians are prepaid and only see patients that are in the plan
- Physicians can establish contractual relationships with numerous HMO’s and IPA’s
- Many groups of physicians and specialists, Multiple hospitals, Multiple pharmacies, Multiple home health agencies
- patients get a wide variety of options of care
- more expensive for patients cause they get more
Compare vertically and virtually integrated HMO models–look above
Understand the role of Accountable Care Organizations: they ensure that the care that you get is what you pay for; are ppl getting good healthcare and it correctly priced
Discuss medical homes and medical neighborhoods
- medical homes using interconnected team to follow patients with illness
-medical neighborhoods looks at overall patient population
