Week 10; Systems and Finance Flashcards
Health Care Funding From:
Private Insurance, government Insurance, people pay themselves – out of pocket
Private Insurance
Purchased from for profit and not-for-profit insurance companies; examples include: Blue Cross, Blue shield, HMO’s such as Kaiser. Most private insurance is purchased by employers for their
employees, costs shared by employer and employee
What is an HMO?
Health maintenance organization; a type of health insurance plan that limits coverage to care from doctors who work for or contract with the HMO. Generally won’t cover out-of-network care except in an emergency. May require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
What is a PPO?
Preferred provide organization, most popular type of insurance. Allows you to visit whatever in-network provider without requiring a referral from pcp, freedom to choose
What is a CCO?
Coordinated Care Organization, a network of all types of health care providers (physical health care, addictions and mental health care and dental care providers) who work together in their local communities to serve
people who receive health care coverage under the Oregon Health Plan (Medicaid). CCOs focus on prevention and helping people manage chronic conditions, like diabetes. This helps reduce unnecessary
emergency room visits and gives people support to be healthy.
Patient protection and Affordable Care act (2010)
Also known as Obamacare. Health care reform to increase availability, affordability, and use of health
insurance.
Medicare –
Funds for elderly, the disabled, and people receiving
long-term dialysis from government
Medicaid –
funds health care for people living below poverty
level and/or have disabilities through government
CHIP –
Children’s Health insurance plan – coverage through
Medicaid and separate Federal chip program. Low to modest incomes. Provides no-cost or low-cost health coverage for eligible children in Oregon. These programs provide health coverage for children
so that they can get routine check-ups, immunizations and dental care to keep them healthy, even if a child has been turned down in the past or parents don’t know if they qualify, a child may be able to get health coverage.
Tricare
Covers approximately 9 million active duty and retired military personnel and their families. TRICARE is the worldwide health care program for uniformed service
members and their eligible family members
Medicare Part A –
hospital insurance
Medicare Part B –
medical insurance
Medicare Part C–
now called medicare advantage plan, cover A and B and most offer drug plan AND vision and/or dental
Medicare Part D –
prescription drug plan; Medicare Supplemental or Medigap plan – extra health insurance to pay some or all of the 20% of bills that medicare doesn’t cover
Supplemental security income (SSI)
Federal income supplement program funded by general tax revenues not social security taxes. Designed to help aged, blind, disabled people who have little or
no income. Provides cash to meet basic needs for ford, clothing, and shelter.
Social Security Disability (SSDI)
Federal funds to help people with disabilities. Available to workers who have accumulated a sufficient number
of work credits. Differs from SSI is available to low-income individuals or those who have never worked.
Veterans Health Administration
Government operated health care system comprehensive health care to eligible veterans
According to many, there are two primary causes for such high healthcare costs:
US health Care model, changes spur demand and raised
costs.
Chronic diseases: diabetes and heart disease – responsible for 85% of costs
Limiting Access
Insurance companies have refused to cover people with pre-existing conditions. Stopped coverage for high end users. Denied certain procedures, medications. Limited number of visits that are reimbursed. Increased deductibles and copays. Insurance only covers partial payment for procedures or large copay for inpatient or surgery.
Negative Effects
People will avoid getting healthcare including preventative care, i.e. flu vaccines. Women may avoid screening tests. Then if cancer develops, it may be advanced by the time they go to a physician. Complex or complicate procedures such as referrals and prior authorizations limiting access to care.
Eliminating Unnecessary Care
Defined as care that does not improve health. Difficult to recognize and to eliminate. Various organizations develop guidelines. Different organizations have different guidelines. Estimated that 1/3 of health care costs occurred in the last year of life. Palliative and hospice may not be covered.
Improving Health
Increasing use of inexpensive services that help prevent
disease may reduce need for more expensive services. For example, early mammography may identify early breast CA and avoid need for more expensive procedure such as a radical mastectomy. Other areas often identified are colon cancer, obesity and/or diabetic management, smoking campaigns, BP management, Increase number of PCPs who can provide screening, eliminate co-payments for preventive services, financial incentives to providers for following preventive care
guidelines, use of RN Care managers or RN Case Managers, use of Health Coaches, reimbursing GYM memberships.
Decreasing reimbursement for Care used
Lower fees, insurance companies and the government may negotiate lower fees with hospitals or they simply dictate set fees. In the US, medicare and Medicaid determine reimbursement rates. These tend to influence other plans. Providers may be reimbursed less.
Increased use of primary care
Decreased use of inpatient by increasing use of primary care. More procedures done on outpatient basis. Encouraging med students to choose primary care. Government may provide more funding for primary care training than specialty training. Primary care made more “attractive” – unclear how this will be done. Use of Patient-Centered medical home.
PCMH
Emphasizes team based care. Communication and coordination. Studies have shown it has led to better care. Aligned with payers. Improved staff satisfaction. Improved patient satisfaction. Better management of chronic conditions. Improved patient access to care/ Lower costs.
Prospective payment plans
Providers paid a fixed amount regardless of how
much care they provide
Reward less expensive care
Quality control systems put into place to make sure
quality is maintained
Providers have no financial motivation to care for
people with complex health problems
Accountable Care Organizations (ACOs)
Medicare Shared Savings program – 2012
For medicare beneficiaries
Groups of health care providers who agree to provide
coordinated high quality care
Medicare patients assigned to them
Reimbursed based on measure of health care quality
and reductions in cost rather than volume of services
How ACOs can improve care
The ACO model has doctors and hospitals working together to treat patients across the care continuum and across different care settings
Effort to reverse the incentives in the fee-for-service model that reward volume rather than value and coordinated care
Stepping-stone to different payment methods, including more population-based payment methods
Medicare’s Triple AIM
Institute for Health improvement (IHI) introduced concept of Triple aim
Medicare has adopted to help optimize healthcare systems
Goal is to:
Improve patient care
Reduce costs
Improve population health
Utilization review
Process used to make sure health care services are used properly
Patients receive care needed by appropriate provider and in appropriate setting
Done by insurance companies, but can be done by hospitals and other care providers
Often done by RN’s
Hospital UR nurse works closely with insurance company UR nurse
Nursing Shortages
Can be cyclic in nature, worse in rural areas. When shortage, employers are forced to compete for the same available pool of nurses and may nee to increase wages in order to hire and retain nurses. Trends in healthcare over the past 20 years have added to the complexity of the problem. Many issues with shorter length of stay, have required more nurses necessary in home health. Nursing positions change in certain locations and has resulted in less direct care nurses.(Pearson, “A Concept Based Approach” 2nd edition). Nurses felt they could no longer provide quality care, which resulted in disillusionment and leaving the profession.
Population health
Is not public health
Population health examines wide variety of groups,
looks at outcomes of communities or select
populations
Public health looks at entire population, all members
of the general public, what we as a society do
collectively
Analyzes population
Sets goal for a population
Implements plan based on a protocol or institution policies
Evaluates plan and makes adjustments
Example: smoking cessation targeting smokers, managing
diabetes
case management
a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet and individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomesCase managers are often RN’s or social workers. Work with complicated or complex cases, follow a patient from first contact to end of need for services or discharge and sometimes into outpatient care.
Care manager
Model using multidisciplinary approach (Rn, SW, Pharm,
dietician). Care manager is often an RN, works with clients to develop a plan of care with specific goals. Usually time limited. Focused on chronic diseases
Example: reduction of BP, medication compliance and
education, weight loss, smoking cessation, diabetes
management
Three levels of HealthCare settings
Primary
Secondary
Tertiary
Primary Care
Delivered in physician/NP office, clinics, public health services
Often point of entry into the healthcare system
Routine health maintenance
Physical exams
Treatment of acute illnesses
Ongoing treatment of chronic disease
Secondary Care
Hospitals, OP surgical center
Surgery
Treatment of acute illnesses that require higher level of care
Treatment of chronic illness with exacerbation or requires surgical or diagnostic intervention
Tertiary Care
Skilled nursing, Rehab, Extended Care facility
Select complicated diagnostic or therapeutic procedures
Primary Prevention:
Take action to prevent disease in generally health people
Examples are education of individuals, families, groups on nutrition, exercise, hygiene, prenatal care
Secondary Prevention:
Detect and then treat identified injuries and diseases early so they can be cured or associate symptoms and complications can be prevented or limited
Examples: Risk assessments for people with risk factors for specific diseases such as coronary artery disease diabetes. Encourage regular vision and medical screening exams. All settings, develop and implement treatment plans to prevent complications such as a NCP to prevent pressure ulcers
Tertiary Prevention:
Begins after a condition is treated and stabilized or recognized as incurable. Examples include: Referral to ostomy nurse, Diabetes Nurse specialist working with a diabetic patient, Chronic Pain management
