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Health Care

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Debi O'Connell

on 23 February 2013

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Transcript of Health Care

Healthcare Delivery
Systems
Heald College, Roseville Milestones Hospital Types 1967 1949 Market Justice Social Justice Christian Barnard Performed the first heart transplant Sir Harold Ridley was the first to successfully implant an intraocular lens 1867 Lister used carbolic acid as an antiseptic 1849 Elizabeth Blackewell was the first woman to receive a medical degree in the United States 1847 Ignaz Semmelweis discovers hand washing procedure to prevent infections
Crawford Long performs surgical operation using anesthesia 1842 1796 Edward Jenner develops a smallpox vaccination method Title I. Quality, Affordable Health Care for All Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of Health Care
Title IV. Prevention of Chronic Disease and Improving Public Health
Title V. Health Care Workforce
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical Therapies
Title VIII. Community Living Assistance Services and Supports Act (CLASS Act)
Title IX. Revenue Provisions
Title X. Reauthorization of the Indian Health Care Improvement Act Affordable Care Act 1895 Wilhelm Conrad Rontgen discovers medical use of X-rays in medical imaging. HMO Health Maintenance Organizations (HMOs) are most common Managed care organizations. They provide preventive services and provide full but controlled access to health care. They may have salaried staff or capitation based contracts under which they pay a fixed amount per patient per month (PMPM) to providers including single or multiple group practices or Independent Practice Associations. HMO plans usually have lower premiums and other out of pocket expenses, are less comprehensive and usually don’t have deductibles. PPO Point of Service (POS) plans combine the best of PPO and HMO plans—controlled utilization while offering wider choice. Some HMOs also offer POS plans. POS plans have a gatekeeper to control utilization and the choice of provider is made at the Point of Service. The network providers are compensated on capitation basis, however the enrollees can choose a provider outside the network, who is reimbursed on fee-for-service basis. FFS Fee For Service (FFS) In a traditional FFS plan, the providers’ incomes are linked to the number of services delivered. In a competitive market, they may over-invest in technology to differentiate themselves. These translated to higher costs of providing care, which are sent to insurance companies. Traditional insurance companies will pass all the costs to the patients in the form of higher premiums. The other difference is that the traditional insurance companies do not cover preventive visits but cover the hospitalization quite comprehensively leading sometimes, to more services being delivered than is required in many cases. Both Medicaid and Medicare contract with HMOs. Views health care as an economic good
Assumes free market conditions for health services delivery
Assumes that markets are more efficient in allocation health resources equitably
Production and distribution of health care are determined by market-based demand
Medical care distribution is based on people's ability to pay
Access to medical is viewed as an economic reward of personal effort and achievement Major MCOs Hippocrates diagnostic sign in chronic suppurative lung disease, lung cancer and cyanotic heart disease Views health care as a social resource
Requires active government involvement in health service delivery
Assumes that the government is more efficient in allocating health resources equitably
Medical resource allocation is determined by central planning
Ability to pay is inconsequential for receiving medical care
Equal access to medical services is viewed as a basic right Eleven health insurance/managed care companies made this year’s annual Fortune 500 list of the largest U.S. corporations based on total revenue. Revenue, profits, and number of employees are included for each company ranked, and rankings from previous years can also be viewed online. UnitedHealth Group [22] Characteristics 460BC Characteristics Implications Implications Coventry Health Care Erasistratus wrote many works on anatomy, practical medicine and pharmacy Amerigroup Individual responsibility for health
Benefits are based on individual purchasing power
Limited obligation to the collective good
Emphasis on individual well-being
Private solutions to social problems
Rationing based on ability to pay WellCare Health Plans 250BC Collective responsibility for health
Everyone is entitled to a basic package of benefits
Strong obligation to the collective good
Community well-being supersedes that of the individual
Public solutions to social problems
Planned rationing of health care 130AD Galen demonstrated that arteries carry blood instead of air and added greatly to knowledge of the brain, nerves, spinal cord, and pulse 2600BC Imhotep wrote texts on ancient Egyptian medicine describing diagnosis and treatment of 200 diseases in 3rd dynasty Egypt. 1870 Louis Pastuer established the germ theory and today, he is often regarded as the father of germ theory and bacteriology 1901 Karl Landsteiner discovers the existence of different human blood types Medical Assistants perform everything from filing and phones to injections Radiologic Technologists carry out functions of maintaining, and promoting overall fitness and health of people who require medical care and reestablishing physical functions, meliorating mobility, and providing physical relief from pain Pharmacists dispense prescription medications to patients and offer advice on their safe use Physician: MD & DO concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury, and other physical and mental impairments. Nurses: RNs & LVNs
A profession within the health care sector focused on the care of individuals. They practice in a wide diversity of practice areas with a different scope of practice and level of prescriber authority in each. Psychologists study mental processes and human behavior by observing,
interpreting, and recording how people and other animals relate to one another
and the environment. Health Service Administrators employed at the top, middle, and entry levels of various types of organizations that deliver health services. Clinical Nurse Specialist (CNS) typically practice medicine, conduct research and manage staff within a specific type of patient population, medical specialty Disciplines and Occupations Medical Expenditure Panel Survey
http://meps.ahrq.gov/mepsweb/
• MEPSnet Query Tools
http://meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp Accessibility of care • Ambulatory surgeries •Healthcare Cost and Utilization Project
http://www.hcup-us.ahrq.gov/sasdoverview.jsp
•HCUPnet
http://hcupnet.ahrq.gov/ Emergency department visits •Healthcare Cost and Utilization Project National Data:
http://www.hcup-us.ahrq.gov/nedsoverview.jsp
•State Data:
http://www.hcup-us.ahrq.gov/seddoverview.jsp
•HCUPnet
http://hcupnet.ahrq.gov/
•HCUP Statistical Brief:
http://www.hcup-us.ahrq.gov/reports/sb_emergency.jsp Health care disparities •National Healthcare Disparities Report
http://www.ahrq.gov/qual/qrdr10.htm Health care quality • National Healthcare Quality Report
http://www.ahrq.gov/qual/qrdr10.htm
• State Snapshots
http://statesnapshots.ahrq.gov/snaps10/index.jsp Health care spending • Medical Expenditure Panel Survey
http://meps.ahrq.gov/mepsweb/
• MEPSnet Query Tools
http://meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp Health care use •Medical Expenditure Panel Survey
http://meps.ahrq.gov/mepsweb/
•MEPSnet Query Tools
http://meps.ahrq.gov/mepsweb/data_stats/meps_query.jsp Health information data element definitions, values and information models •United States Health Information Knowledgebase
http://ushik.ahrq.gov/ Hospitalizations •Healthcare Cost and Utilization Project
http://www.hcup-us.ahrq.gov/databases.jsp
•HCUPnet
http://hcupnet.ahrq.gov/ By payer •Healthcare Cost and Utilization Project
http://www.hcup-us.ahrq.gov/databases.jsp
•HCUPnet
http://hcupnet.ahrq.gov/ By States •Healthcare Cost and Utilization Project
http://www.hcup-us.ahrq.gov/databases.jsp
•HCUPnet
http://hcupnet.ahrq.gov/ For children •Healthcare Cost and Utilization Project
http://www.hcup-us.ahrq.gov/databases.jsp
•HCUPnet
http://hcupnet.ahrq.gov/ State-specific health care quality information (strengths, weaknesses, ad opportunities for improvement) •State Snapshots
http://statesnapshots.ahrq.gov/snaps10/index.jsp Study data extracted for systematic reviews •Systematic Review Data Repository™ Expand Access to
Insurance Coverage The ACA contains several provisions related to improving
quality and system performance, including, but not limited to,
the following:
• Comparative research to study the effectiveness of various
medical treatments;
• Demonstration projects to develop medical malpractice
alternatives and reduce medical errors;
• Demonstration projects to develop payment mechanisms
to improve efficiency and results; Investments in health information technology:
• Improvements in care coordination between Medicare
and Medicaid for patients who qualify for both;
• Options for states to create “health homes” for Medicaid
enrollees with multiple chronic conditions to improve
care; and
• Data collection and reporting mechanisms to address
health disparities among populations based on ethnicity,
geographic location, gender, disability status and language. BIG DATA RESOURCES Abbreviations and Definitions HIPAA
Health Insurance Portability and Accountability Act Confidentiality and protection for patients health information HMO
Health Maintenance
Organization JCAHO
Joint Commission on Accreditation of Healthcare MCO
Managed Care Organization NCQA
National Committee for Quality Assurance ACA of 2012
Patient Protection and Affordable Care of 2012 CMS
Centers for Medicare and Medicaid Services DHHS
Deparrtment of Health and Human Services DRG
Diagnosis-related group DHHS
Department of Health and Human Services HEDIS
Healthcare Effectiveness Data and Information Set CANADA
The best-known type of hospital is the general hospital, which is set up to deal with many kinds of disease and injury, and normally has an emergency department to deal with immediate and urgent threats to health. Larger cities may have several hospitals of varying sizes and facilities. Some hospitals, especially in the United States, have their own ambulance service. A district hospital typically is the major health care facility in its region, with large numbers of beds for intensive care and long-term care. A teaching hospital combines assistance to patients with teaching to medical students and nurses and often is linked to a medical school, nursing school or university. Canada Health Care on the street interviews GERMANY QIO'msonitor the quality of care provided to Medicare beneficiaries The Health Care Quality Act of 1986 was established to alleviate the malpractice crisis Germany's Health Care: Quality Care for All The Center for Medicare and Medicaid Services promotes quality measures for its beneficiaries to encourage healthcare accountability and quality. The spiraling cost of the healthcare system / People & Politics (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important data elements of care and services UNITED KINGDOM National Quality Forum has developed 21 measures for care of long and short term patients. Patients and family members need reliable information on the quality of care provided in skilled nursing homes (SNFs) to make an informed decision on placement. Public Perspectives on healthcare in the UK Quality & Improvements Payment & Reimbursement CAPITATION is a payment arrangement for health care service providers that pays a physician or group of physicians a set amount for each enrolled person assigned to them, whether or not that person seeks care. These providers contract with a (HMO) or other similar organizations, insurance companies, etc. The amount of capitation is based on the average expected health care utilization of that patient. Rates are also affected by age, race, sex, type of employment, and geographical location, as these factors typically influence the cost of providing care. 2020 The Blind will see WellPoint Humana Aetna Cigna Health Net Organizations and Providers FFS is a payment model where services are unbundled and paid for separately Discounted FFS works in a similar way to FFS except that physicians are reimbursed a specific dollar amount or percentage of their total charge CMS Acute Inpatient PPS (IPPS) IPPS is the Medicare PPS used for acute care hospital inpatient stays. Under the IPPS, each case is categorized into a diagnosis-related group (DRG) with a payment weight assigned to it based on the average resources used to treat patients in that particular DRG. CMS Outpatient PPS (OPPS)OPPS is the Medicare PPS used for hospital-based outpatient services and procedures. Under the OPPS, payment is predicated on the assignment of ambulatory payment classifications (APCs). CMS Skilled Nursing Facility PPS (SNF PPS) The SNF PPS is a per diem reimbursement system for all costs (routine, ancillary, and capital) associated with covered skilled nursing facility services furnished to Medicare beneficiaries. Under the SNF PPS, each case is categorized into a resource utilization group (RUG) with a payment weight assigned to it based on the average resources used to treat patients in that particular RUG. 85% of all U.S. hospitals/non-federal, short-stay hospital whose services are available to the general public. Community General District Teaching Specialized Only admit certain types of patients or those with specified illnesses or conditions Rural Health Clinic Usually located in medically under-served areas in the U.S. and has a separate reimbursement structure from the standard medical office under the Medicare and Medicaid programs. The program was established to address an inadequate supply of physicians serving patients in rural areas and to increase the utilization of non-physician practitioners. Countries-Systems Videos
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