Week 6 Strategic/Fiscal Planning and Healthcare Reform (5 Questions) Flashcards
The future of health care
- Patient centered _____ _____ allows for more t_____, less ____ based care, more c____, more e____, patient p____
- medical homes
transparency, hospital, community, education, portals
Barriers to PCMH =
= health care reform, rapidly changing technology, point of care testing, increasing gov regulation of healthcare, reduced provider autonomy
Influences of PCMH =
= rapidly changing technology, point of care testing, telehealth and internet, growing elderly population, other changing demographics, nursing shortages in acute area
Healthcare Reimbursement
*
Incremental Budgeting =
- No incentive for efficiency - is easiest but?
= facility budgets for current year are based on a certain % increase over previous year
- least valuable
Fee for Service Reimbursement =
= based on costs incurred to perform the health care service PLUS a profit
- no ceiling, so more service = more monay (volume not value)
Diagnosis Related Groups (DRG’s) =
= gov. regulations to justify need for services and to monitor quality
- doesn’t count for unexpected costs and can drastically reduce length of stay (bad if not ready to go home yet)
Prospective Payment System (PPS) =
= switch to payment according to DRG as opposed to actual costs incurred
Managed Care =
Concern =
= focuses on prevention, need for services, de-emphasis on inpatient care, and use of clinical practice guidelines or critical pathways to ensure care is best practice
= evaluation for need for services is done by INSURANCE COMPANY staff who aren’t qualified/too far removed from situation
- also might result in UNDERTREATMENT -> (capitations)
Managed Care Organizations (2)
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
2
MEDICARE
MEDICAID
HMO advantages (1) =
HMO disadvantages (2) =
= cheaper
= restrictive (limited choice of network of providers), harder to navigate (if need to see someone, need a referral even if person is within HMO)
Point of Service (POS), Exclusive Provider Organization (EPO)
PPO advantages =
PPO disadvantages =
= freedom to select provider within organization regardless of specialization you need, bigger network
= expensive
Criticisms of HMOs =
= loss of hcp-pt relationship, limited choice, lower level of continuity of care, reduced HCP autonomy, longer wait times, consumer confusion about many rules to be followed
Managed Care Organizations receive reimbursement for Medicare - eligible pts based on formula established by center for medicare/medicaid services (CMS)
They look at what factors?
Age
Gender
Geographic region
Average cost per pt at given age
(gov gives itself a 5% discount and gives rest to MCO)
Patient Protection and Affordable Care Act =
= comprehensive insurance reforms, budled payments, accountable care organizations, hospital value-based purchasing, medical home, heath insurance marketplaces
HOSPITALS THAT ARE DOING WELL GET BETTER REIMBURSEMENT
Planning =
= deciding in advance what to do, who will do it, how and when it needs to be done
(PROACTIVE, requires FLEXIBILITY and ENERGY, MANAGEMENT SKILLS)
Strategic Planning =
= examines an organizations PURPOSE, MISSION, PHILOSOPHY, and GOALS in context of its EXTERNAL ENVIRONMENT
Planning Hierarchy
Mission/Vision/Philosophy Goals Objectives Policies Procedures Rules
Why plans fail ->
- false assumptions
- not knowing overall goal
- not enough alternatives
- inadequate time or other resource
- low motivation
- sound strategies not used
- inadequate delegation of authority
- not recognizing organization goals and needs
- planning too narrow in scope
Instead of Strategic planning we want to move toward?
Proactive Planning
Proactive Planning =
- Reactive Planning =
- Inactivism =
- Preactive Planning =
= (INTERACTIVE planning), considers PAST, PRESENT, and FUTURE and attempts to plan future of org rather than react to it, dynamic and adaptive
= occurs after a problem exists
= seeks status quo
= utilize technology to accelerate change; future-oriented
SWOT =
Strengths
Weaknesses
Opportunities
Threats
Strengths -
Weaknesses -
Opportunities -
Threats -
- INTERNAL attributes that help org. reach objectives
- INTERNAL attributes that challenge org in reaching objectives
- EXTERNAL conditions that promote achievement of org. objectives
- EXTERNAL conditions that challenge or threaten achievement of org. objectives
Fiscal Planning =
= not intuitive, a learned skill critical to nurse managers bc incr emphasis on finance/ “big business” of health care
Cost containment =
= effective and efficient delivery of services WHILE generating needed revenues for continued organizational productivity
Cost effectiveness =
= producing good results FOR THE AMOUNT OF MONEY SPECT (getting your money’s worth)
- takes into account factors anticipated length of service, need for such a service, and availability of alternatives
Critical Pathways =
= strategy for assessing, implementing, and evaluating the COST EFFECTIVENESS of pt care
Predetermined course of progress that pts should make after admission for a SPECIFIC DIAGNOSIS or after SPECIFIC SURGERY
Responsibility accounting =
= each of an organizations REVENUES, EXPENSES, ASSETS, and LIABILITIES is someone’s responsibility -> person with most direct control or influence on any of these financial elements should be held accountable for them (usually leader/manager); unit manager can best monitor and eval all aspects of unit’s budget control
Budget =
= a plan that uses numerical data to predict the activities of an org. over a period of time
2) maximizes use of resources to meet short and long term goals
3) mechanism of planning and control and for promoting unit’s needs and contributions
Types of Budgets (3)
Personnel
Operating
Capital
Personnel budget =
= wages, overtime, bonuses of employees
Operating budget =
= revenue and expenses rt pt care
Supplies are 2nd largest part of budget
Capital budget =
= big things/changes/construction - unexpected things accounted for in budget
Methods of Budgeting (4)
1) Incremental Budgeting
2) Flexible Budgeting
3) Performance Budgeting
4) Zero-based budgeting
Incremental budgeting =
= EASIEST, bump up budget based on what it was last year and and this year’s INFLATION RATE
Incremental budgeting is good for what types of organizations?
Stable organizations that haven’t changed much over last 3-4 yrs
Flexible budgeting =
ex)
good for nurse ______
= takes into account how things change throughout year by looking at HISTORICAL TRENDS
ex) low pt census during christmas
managers
Performance budgeting =
= thinks about how budget performed last time, compares to now, and analyzes difference; critically thinking about what changes were and seeing if they need to be made again
good for nurse managers
Zero-based budgeting =
good for what type of organizations?
= brand new unit from scratch
Brand new
Nursing Care Hours/Per Patient Day formula =
= nursing hours worked in 24 hours/ patient census
Who is counted is nursing care hours?
RNs, LPNs, PCTs, and Secretaries count
