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
