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PUBH 6134 - Health Services Administration



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  • 1. Georgia Southern University Jiann-Ping Hsu College of Public Health PUBH 6134 – Health Services Administration Fall 2007 Instructor: Renée Hotchkiss, Ph.D. Office: Cottage 215 Phone: (912) 871-1342 E-Mail Address: Office Hours: Tuesdays and Wednesdays 3pm – 6 pm Other times by appointment Web Page: Class Meets: Monthly on Wednesdays 6:30-9:15 Hollis Building 1118 -- Course schedules can be found at: -- Prerequisites: None Web-CT Address: Georgia Southern WebCT Portal Catalog Description: This course examines the structure and functioning of the health care delivery system. Health care organizations including hospitals, long-term care, ambulatory care, managed care, private and public insurance, public health, integrated delivery systems, and other health care providers will be reviewed. The course also examines principles of strategic management applied to health care organizations amid a dynamic/changing environment. . Required Textbook: Delivering Health Care in America, 3d Edition by Shi and Singh; Publisher: Jones and Bartlett, ISBN Number 0763731994.
  • 2. Secondary Text: Additional articles, supplemental materials, and URLs/website addresses will be supplied by the instructor and students in the course. Program Goals: At the completion of this program the student will be able to: • Contribute to the public health profession through the practice of sound professional public health attitudes, values, concepts and ethics. • Appreciate and facilitate diversity of thought, culture, gender and ethnicity through inter-professional communication and collaboration. • Integrate and apply the crosscutting knowledge and competencies within five core public health areas of knowledge (biostatistics, epidemiology, environmental health sciences, health services administration and social and behavioral sciences. • Demonstrate advanced knowledge and skills necessary for specialized roles within public health, in at least one of the five core areas of public health. • Identify the main components and issues of the organization, financing and delivery of health services and public health systems in the United States. • Describe the legal and ethical basis for public health and health services. • Explain methods of ensuring community health safety and preparedness. • Apply 'systems thinking' for resolving organizational problems. Course Objectives: At the completion of this course the student will be able to: • Define the major components of the health care delivery system and its administration amid the economic, social, technological, and political factors that influence them. • Analyze trends in planning, resource allocation, and health services financing and their effects on consumers, providers, employers, government, and payers. • Describe the professional, economic, social, technological, and legislative influences in health care.
  • 3. • Discuss values and ethical dilemmas in health care that are inherent in efforts to control costs, while assuring access and quality of care. • Apply a systematic model for analyzing health administration problems, issues, opportunities and threats. Overview of the Content to be Covered During the Semester: Week Topic Readings Assignment 1 Chapter 1 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Aug. 15 and on the Web Course. document and on the Web Course. 2 Chapter 2 See Weekly Assignments that See Weekly Assignments Aug. 22 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 3 Chapter 3 See Weekly Assignments that See Weekly Assignments Aug. 29 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 4 Chapter 4 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Sept. 5 and on the Web Course. document and on the Web Course. 5 Chapter 5 See Weekly Assignments that See Weekly Assignments Sept. 12 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 6 Chapter 6 See Weekly Assignments that See Weekly Assignments Sept. 19 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 7 Chapter 7 See Weekly Assignments that See Weekly Assignments Sept. 26 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 8 Chapter 8 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Oct. 3 and on the Web Course. document and on the Web Course. 9 Chapter 9 See Weekly Assignments that See Weekly Assignments Oct. 10 are attached to this document that are attached to this
  • 4. and on the Web Course. document and on the Web Course. 10 Chapter 10 See Weekly Assignments that See Weekly Assignments Oct. 17 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 11 Chapter 11 See Weekly Assignments that See Weekly Assignments Oct. 24 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 12 Chapter 12 See Weekly Assignments that See Weekly Assignments Oct. 31 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 13 Chapter 13 See Weekly Assignments that See Weekly Assignments Meet are attached to this document that are attached to this Nov. 7 and on the Web Course. document and on the Web Course. 14 Chapter 14 See Weekly Assignments that See Weekly Assignments Nov. 14 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. 15 Final Exam See Weekly Assignments that See Weekly Assignments Nov.28 are attached to this document that are attached to this and on the Web Course. document and on the Web Course. Samples of your work may be reproduced for search purposes and/or inclusion in the professor’s teaching portfolio. You have the right to review anything selected for use, and subsequently ask for its removal. Instructional Methods: Class meetings will be a combination of lecture, class discussion, video lecture, chat room sessions, discussion board, written discussion questions, quizzes, a final examination, computer software demonstration, and work group discussions. Written discussion questions, thought worksheet assignments, quizzes, and a final examination constitute the basis of student evaluation. Exam Schedule and Final Examination: Final Examination: Week 15 of course Quizzes: Refer to Weekly Assignments Schedule
  • 5. Grading: 1Weighting of assignments for purposes of grading will be as follows: PUBH 6134 HEALTH SERVICES ADMINISTRATION Course Point Determination, Grading Evaluation based on Points and Point Timeline Live Classroom, Week Review Thought Textbook Quizzes Online Chat & Final Exam Total of Questions Worksheet Chapter POINTS Discussion POINTS POINTS Course POINTS POINTS Board POINTS 1 1 34 10 44 2 2 33 10 43 3 3 34 10 50 94 4 4 19 20 10 49 5 5 29 10 39 6 6 25 10 60 95 7 7 26 20 10 56 8 8 25 10 35 9 9 23 10 65 98 10 10 29 10 39 11 11 20 10 30 12 12 25 20 10 75 130 13 13 11 complete 10 complete 21 14 14 17 10 27 15 complete complete complete 400 400 16 complete 0 350 60 140 250 400 1200 1200 Total Points; 900 required for an "A" grade. Grading based on Assignments and participation will be evaluated by Points the instructor and given a percentage grade, then 900 - 1000 A 800 - multiplied by the possible points listed above for each 899.99 B 700 - opportunity. The student selects what opportunities to 799.99 C pursue and complete to determine their ultimate point 600 - total that equates to a grade. 699.99 D 599.99 & below F
  • 6. The following point scale will be utilized in grading: 900 + = A 800 - 899.99 = B 700 - 799.99 = C 600 - 699.99 = D 599.99 or less = F For calculation of your final grade, all grades above will be included. Your grades will not be posted. Assignments and the final exam presentation will be graded promptly so that students may accurately calculate their grades at any point in time during the semester. There are times when extraordinary circumstances occur (e.g., serious illness, death in the family, etc.). In such circumstances, and/or if you need additional time to satisfactorily complete any course requirement, please consult with the instructor within a reasonable amount of time. Nota Bene: Extensions are not guaranteed and will be granted solely at the discretion of the instructor. Overview of Assignments: Thought Worksheet Assignments: Thought worksheets are due as assigned (see Weekly Assignments schedule) based on the issue or issues corresponding to the content of the course up to that week in the course. Please see the weekly schedule for content areas for completion of the Thought Worksheet. How you think critically, support your thoughts and communicate those ideas are most important to these assignments. Do not get behind in the Thought Worksheet assignments. The Thought Worksheets will be evaluated on 5 criteria: Logic, Consistency, Support, Context and Elements (is the worksheet complete). Review Discussion Questions: Each week/chapter/module will require each student to answer a series of questions. Each week a file named “Student PUBH 6134 Chapter X Review Questions and Answer Comparison System” contains the questions and instructions.
  • 7. Quizzes and Final exam: There will be three quizzes and a final exam in the course. The quizzes and the final exam will utilize a variety of testing methods to include multiple choice, true and false, short answer and short essay. Information for the exams will come from the main points/topics in the text, lectures, and assignments. Live Classroom, Online Chat and Discussion Board Participation: Each student will receive the points noted on the course points summary (above) when they actively participate in weekly activities, either in person or virtually over the Internet. Important Notes: Philosophy: This course is designed in a way that may be quite different than other courses that you have been exposed to because you will be asked to think critically about the subject matter throughout this semester. All of our activities will focus on helping you to better understand the logic of healthcare service administration, components of care delivery and national policy considerations. You will begin to think like a rational healthcare administrator, like a rational healthcare policy specialist, like a rational provider, and like a rational consumer. You will be asked to continually engage your mind during class and while preparing for class. The textbook will be used as a general resource for the course. You will learn to connect the logic of healthcare service systems (including the organization of healthcare services in the United States, medicine and technology, and patterns of illness and disease and access to healthcare), managed care and private health insurance, providers of health services (including public health, ambulatory healthcare services, hospitals and healthcare systems, long-term care, mental health services, pharmaceuticals, and healthcare professionals), and the assessment and regulation of healthcare services (including health policy and politics, quality assessment and quality improvement, and ethical issues in healthcare services), so that the subject becomes relevant to you. Academic Misconduct: 1As a student registered at this University, it is expected that you will adhere to only the strictest standards of conduct. It is recommended that you review the latest edition of the Student Conduct Code book, as well as the latest Undergraduate & Graduate Catalog to familiarize yourself with the University’s policies in this regard. Your continued enrollment in this course is an implied contract between you and the instructor on this issue; from this point forward, it is assumed that you will conduct yourself appropriately. Academic integrity relates to the appropriate use of intellectual property. The syllabus, lecture notes, and all materials presented and/or distributed during this course are protected by copyright law. Students are authorized to take notes in class, but that authorization extends only to making one set of notes for personal (and no other) use. As such, students are not authorized to sell, license, commercially publish, distribute,
  • 8. transmit, display, or record notes in or from class without the express written permission of the instructor. Academic Handbook: Students are expected to abide by the Academic Handbook, located at Your failure to comply with any part of this Handbook may be a violation and thus, you may receive an F in the course and/or be referred for disciplinary action. University Calendar for the Semester: The University Calendar is located with the semester schedule, and can be found at: Attendance Policy: Federal regulations require attendance be verified prior to distribution of financial aid allotments. Attendance will not be recorded after this initial period. One Final Note: The contents of this syllabus are as complete and accurate as possible. The instructor reserves the right to make any changes necessary to the syllabus and course material. The instructor will make every effort to inform students of changes as they occur. It is the responsibility of the student to know what changes have been made in order to successfully complete the requirements of the course. WEEKLY ASSIGNMENTS FOR PUBH 6134 WEEK 1 Start Week 1 Objectives Chapter 1 1. Understand the basics of the U.S. health care system 2. Be able to outline four components of the health care delivery system 3. Be able to differentiate the U.S. health care system and the free market
  • 9. 4. Realize the importance of and know the intricacies of the health care system 5. Have an overview of health care in four other countries Reading Assignments: a) Chapter 1, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) PUBH 6134 Course Syllabus d) Primary Care Coverage 03112006 article (online file in course) e) Review the PUBH 6134 Web Resources file that contains live URL links to websites that will be helpful to you in this course, program and career. Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation (in overview) ii. Cost Quality Access Model Assistant Presentation (in overview) b) View “What is Health Administration?” Lecture Video c) View the Week 1 Lecture Video d) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) Complete the Pre-Course Evaluation for this week before you complete any other task for this week b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 3 and the topic for you to analyze is: Universal Healthcare Coverage in the United States. Review Questions (based on your points selections): a) Complete/Answer Review Questions for Chapter 1 and email to instructor by date prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for Chapter 1 and email to instructor by date prescribed in file
  • 10. c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions at end of week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 34 points available) 1. Why does cost containment remain an elusive goal in US health services delivery? (Synthesis: 4 points) 2. What are the two main objectives of a health delivery system? (Knowledge: 1 point) 3. Name the four basic functional components of the US healthcare delivery system. What role does each play in the delivery of health care? (Knowledge, Comprehension: 2 points) 4. What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees? (Knowledge: 1 point) 5. Why is it that despite public and private health insurance programs, some US citizens are without any coverage? (Application, Synthesis: 4 points) 6. What is managed care? (Knowledge, Comprehension: 2 points) 7. Why is the US healthcare market referred to as “imperfect”? (Synthesis, Evaluation: 5 points) 8. Discuss the intermediary role of insurance in the delivery of health care. (Knowledge, Comprehension: 2 points) 9. Who are the major players in the US health services system? What are the positive and negative effects of the often-conflicting self-interests of these players? (Application: 3 points) 10. What main roles does the government play in the US health services system? (Comprehension: 2 points) 11. Why is it important for healthcare managers, policymakers, and public health professionals to understand the intricacies of the health care delivery system? (Comprehension, Application: 3 points) 12. What kind of a cooperative approach do the authors of the text recommend for charting the future course of the health delivery system? (Comprehension: 2 points)
  • 11. 13. What is the difference between national health insurance (NHI) and national health system (NHS)? (Comprehension: 2 points) 14. What is socialized health insurance (SHI)? (Knowledge: 1 point) Online Chat and Discussion Board Questions: 1. Why does cost containment remain an elusive goal in U.S. health services delivery? 2. What are the two main objectives of a health delivery system? 3. Name and describe the role of the four basic functional components of the U.S. healthcare delivery system? 4. What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees? 5. Why is it that despite public and private health insurance programs, some U.S. citizens are without any health coverage? 6. What is Managed Care? Summary of Week: CHAPTER 1 A Distinctive System of Healthcare Delivery THE PRIMARY OBJECTIVES OF A HEALTHCARE DELIVERY SYSTEM 1. To enable all citizens to receive healthcare services whenever needed—universal access. 2. To deliver cost-effective services and meet certain pre-established standards of quality (professional or national standards of care). THE QUAD-FUNCTION MODEL Functional components of healthcare delivery: • Financing—to purchase insurance, or to pay for healthcare services consumed • Insurance—to protect against catastrophic risk • Delivery—to provide healthcare services • Payment—to reimburse providers for services delivered ACCESS • Financing and insurance are the key predictors of access • Delivery and payment also influence access (accessibility), but more indirectly Access is determined by four factors:
  • 12. 1. Ability to pay (health insurance) 2. Availability of services (delivery), for example, certain rural and remote areas lack adequate services 3. Payment, for example, many providers do not accept patients covered under Medicaid because of low reimbursement limits 4. Enablement barriers, for example, lack of transportation; racial, cultural, and language barriers FINANCING AND INSURANCE MECHANISMS • Employer-based health insurance—private • Privately purchased health insurance—private • Government programs—public; Medicare—elderly and certain disabled people; Medicaid—poor (if they meet the eligibility criteria) WHYDO WE HAVE THE UNINSURED? • Unemployed • Employers are not required to offer health insurance • Employees are not required to purchase health insurance • To participate in government programs, people must meet eligibility criteria MANAGED CARE A system of health care delivery that (1) seeks to achieve efficiencies by integrating the basic functions of healthcare delivery, and (2) employs mechanisms to control utilization of medical services and the price at which the services are purchased. Financing—private or public entities, but managed care enables these entities to better manage their healthcare dollars. Two types of financing mechanisms are commonly used: 1. Capitation—For one set fee per member per month (PMPM), the MCO promises to deliver all needed healthcare services. 2. Discounted fees Insurance—MCO assumes risk and acts as an insurance carrier. Delivery—MCO arranges to provide healthcare services to the enrollees, either directly or through contracts. MCO implements various types of controls to manage utilization. Payment—MCO acts as a payer and disburses payments to providers based on capitation or discounted fee arrangements. COST CONTROL IN A NATIONAL HEALTHCARE PROGRAM
  • 13. • Global budgets are used to determine the national healthcare expenditures in advance. • Healthcare resources are allocated within the budgetary limits: • Reimbursement levels • Availability and dissemination of services and technology PRIMARY CHARACTERISTICS OF THE US HEALTHCARE SYSTEM • No central agency—global budgeting becomes impossible • Partial access—a large segment of the population (roughly 16%) is uninsured • Imperfect (quasi) market—consequences include moral hazard and supplier-induced demand • Third-party insurers and multiple payers—Insurance (commercial insurance companies or managed care organizations) becomes an intermediary function. These intermediary functions result in higher administrative costs. • Multiple third-party payers • Balancing of power among various players prevents any single entity from dominating the system • Legal actions lead to the practice of defensive medicine • Development of new technology creates an automatic demand for its use • New service settings have evolved along a continuum • Quality is no longer accepted as an unachievable goal in the delivery of health care IMPLICATIONS FOR HEALTH SERVICES MANAGERS • Help understand change (shifts occurring in the system) • Enable senior managers to take advantage of opportunities and minimize threats • Help evaluate need for training • Help understand the impact of new regulations NATIONAL HEALTHCARE PROGRAMS Other developed countries have national healthcare programs providing universal access —theoretically, no uninsured. Universal access is provided by a healthcare delivery system that (1) is managed by the government, and (2) provides a defined set of healthcare services to all citizens. Three models of national systems: 1. National health insurance (NHI)—a tax-supported national healthcare program in which services are financed by the government but are rendered by private providers (Canada, for example). 2. National health system (NHS)—a tax-supported national healthcare program in which the government finances and also controls the service infrastructure (for example, Great Britain).
  • 14. 3. Socialized health insurance (SHI)—health care is financed through government- mandated contributions by employers and employees. Health care is delivered by private providers (for example, Germany, Israel, and Japan). TERMINOLOGY • Access—Refers to the ability of an individual to receive healthcare services when needed. In this context, need is primarily determined by the patient. It is secondarily determined by a referring physician, especially for higher-level services. • Administrative costs—Incidental to the delivery of health services. These costs are not only associated with the billing and collection of claims for services delivered, but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, costs incurred by insurance and managed care organizations to market their products, time and effort involved in the negotiation of rates, and resources used in the completion and maintenance of medical records. • Balance bill—Refers to the leftover sum that a provider bills to the patient after insurance has only partially paid the charge that was initially billed. • Capitation—A payment mechanism in which all healthcare services are included under one set fee per covered individual. The fee is generally paid per month, hence it is also referred to as per-member-per-month (PMPM). The fee covers all services an enrollee may need during the entire year. A charge is the fee (or price) set by the provider. The charge is the amount the provider generally bills for services delivered. The payer may reimburse the charges only partially, which may necessitate balance billing to the patient. • Defensive medicine—Involves the delivery of services and maintenance of documentation undertaken primarily to guard against the risk of malpractice lawsuits. These additional efforts do not generally add to the quality of care. • Demand—The quantity of health care demanded by consumers based solely on the price of those services. Enabling services, such as transportation or translation services, facilitate access when an individual already has health insurance coverage. • An enrollee—An individual enrolled in a health plan and therefore entitled to receive health services the plan provides. • A free market—Characterized by the unencumbered operation of the forces of supply and demand when numerous buyers and sellers freely interact in a competitive market. • Global budgets—Used to control costs in centrally managed systems. System-wide healthcare expenditures are budgeted. Resources are allocated within the budgetary limits. Availability of services and payments to providers are subject to such budgetary constraints. • Health plan—Two basic meanings: (1) It can refer to any type of health insurance plan. (2) From a macro-systemic perspective, a managed care organization (MCO) responsible for furnishing services under a health plan is also referred to as the health plan, in contrast to an insurance company or carrier for a traditional health insurance plan. • Inpatient care—Refers to a patient who is institutionalized (the state of being in an institution) or to services provided in institutional settings that require an overnight stay. • Managed care—Seeks to “manage” the utilization of medical services, the price at which these services are purchased, and consequently, how much the providers get paid.
  • 15. Managed care also seeks to achieve better efficiencies in these areas by integrating the basic functions of healthcare delivery. • Medicaid—The government insurance program for the indigent. • Medicare—The government insurance program for the elderly and certain disabled individuals. • Moral hazard—The term used to explain the increased utilization of healthcare services when people have health insurance coverage. • National health insurance (NHI)—A tax-supported health plan that ensures universal access. Services are financed by the government but are rendered by private providers. • National health system (NHS)—A tax-supported health plan that ensures universal access; but in this case, the government also controls the service infrastructure. • Need for health services (in contrast to demand for health services) is based on individual judgment. The patient makes the primary determination of the need for health care and, under most circumstances, initiates contact with the system. The physician may make a professional judgment and determine need for referral to higher-level services. • Outpatient care—Refers to a patient who receives services in an outpatient setting or to the services that are delivered on an outpatient basis. Such services are also referred to as ambulatory services. • Package pricing—The bundling of related services into a package, and charging one flat fee for the package. • Phantom providers—Practitioners who generally function in an adjunct capacity. The patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologists, radiologists, and pathologists. • Premium cost sharing—Refers to the common practice by employers that require their employees to pay a portion of the health insurance cost. • Primary care—Basic and routine care delivered by a general practitioner. In a managed care system, the primary care physician also makes the determination for the need for higher-level services. • A provider—Can be an individual health care professional, a group, or an institution that delivers healthcare services and receives reimbursement directly for those services. A registered nurse who is employed by a hospital is not a provider since his or her services cannot be billed for reimbursement. The same registered nurse working as a nurse practitioner in private practice could be a provider if he or she can bill for services. • The quad-function model—Includes the key functions of financing, insurance, delivery, and payment. • Reimbursement—The amount paid to a provider by the insurer. The payment may be only a portion of the actual charge. • Single-payer system—Refers to a system in which there is a single payer as opposed to multiple payers. The single payer is generally the government, as is the case in a national health insurance program. • In a socialized health insurance (SHI) system, such as in Germany, health care is financed through government mandated contributions by employers and employees. Health care is delivered by private providers.
  • 16. • Standards of participation—Minimum quality standards established by government regulatory agencies to certify providers for delivery of services to Medicare and Medicaid patients. • Supplier-induced demand—Refers to the demand for healthcare services created by providers for their own financial benefit. • System—A network of interrelated components that have been designed to work together coherently. • Third party—An intermediary between patients and providers. Third parties carry out the functions of insurance and payment for healthcare delivery. • Uninsured—People who are without health insurance coverage. • Universal access—Means that all citizens have access to at least a basic package of healthcare services. • Utilization—Refers to the quantity of health care consumed. End Week 1 WEEK 2 Start Week 2 Objectives: Chapter 2 1. Understand definitions and differences of health, illness and sickness. 2. Know the determinants of health and health status. 3. Know the American beliefs and values in the delivery of health care. 4. Understand the factors associated with the promotion of health and the prevention of disease. 5. Develop a position on the equitable distribution of health care services. 6. Identify and compute with a formula, the basic measures of health and its utilization. Reading Assignments: a) Chapter 2, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) PUBH 6134 Course Syllabus Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation
  • 17. ii. Cost Quality Access Model Assistant Presentation b) View this Week’s Lecture c) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 3 and the topic for you to analyze is: Universal Healthcare Coverage in the United States of America. Review Questions (based on your points selections): a) Complete/Answer Review Questions for week and email to instructor by date prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for week and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions at end of week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 33 points available) 1. Distinguish between illness and disease. How are these concepts related to the medical model of healthcare delivery? (Application: 3 points) 2. What is the role of health risk appraisal in health promotion and disease prevention? (Comprehension: 2 points) 3. Health promotion and disease prevention may require both behavioral modification and therapeutic intervention. Discuss. (Application: 3 points) 4. Discuss the definitions of health presented in this chapter in terms of their implications for the health delivery system. (Comprehension: 2 points) 5. What implications does early childhood development have for healthcare delivery? (Knowledge: 1 point) 6. What are the main objectives of public health? (Knowledge: 1 point) 7. Discuss the significance of an individual’s quality of life from the health delivery perspective. (Comprehension: 2 points)
  • 18. 8. The Blum model points to four key determinants of health. Discuss their implications for healthcare delivery. (Comprehension: 2 points) 9. What has been the main cause of the dichotomy in the way physical and mental health issues have traditionally been addressed by the health delivery system? (Knowledge: 1 point) 10. Discuss the main cultural beliefs and values in American society that have influenced healthcare delivery, and how they have shaped the healthcare delivery system. (Application: 3 points) 11. Discuss the main elements of Parsons’s sick role model. What implications does the sick role model have for health services delivery? (Application: 3 points) 12. Briefly describe the concepts of market justice and social justice. In what way do the two principles complement each other and in what way do they conflict in the US system of healthcare delivery? (Comprehension: 2 points) 13. Describe how health care is rationed in the market justice and social justice systems. (Comprehension: 2 points) 14. To what extent do you think the objectives set forth in the Healthy People initiatives can achieve the vision of an integrated approach to healthcare delivery in the United States? (Application: 3 points) 15. How can healthcare administrators and policymakers use the various measures of health status and service utilization? Please illustrate your answer. (Application: 3 points) Online Chat and Discussion Board Questions: 1. What implications does early childhood development have for healthcare delivery? 2. Select one of the priority areas identified by the U.S. Department of Health and Human Services published in Healthy People 2010 (e.g., priority area: Heart Disease and Stroke). Choose one of the objectives listed under this priority area. What is the objective and was it met? Explain. 3. Pick any community health problem (e.g., illiteracy, teenage pregnancy, infant mortality, heart disease). a: Identify the root of the problem. For example, if you select illiteracy, is the problem that people can't read or must you dig deeper to learn what happened in the environment that resulted in "x" number of people not being able to read? Or if you select heart disease, could the actual cause be poor diet or inactivity and could the root of the problem be stress?
  • 19. b: Identify the members of the community that should be involved in addressing this community health problem. Why did you select these members? Given your answer, will current national efforts aimed toward reducing this community health problem be successful? Explain. 4. You are the case manager for a private, nonprofit company. The center's physician referred a 58-year-old woman to you to help coordinate her medical care needs. The record reflects poor nutritional habits, a lack of physical activity, high blood sugar levels, and elevated blood pressure. The patient lives alone and is a nurse’s aide at a local nursing home. She quit school in the tenth grade. You make arrangements to visit the patient at home. Upon arrival, you notice the following: the apartment complex is run down, the apartment is roach infested, the refrigerator contains eggs, bacon, and grits and the cabinets contain products high in sodium and sugar. The patient tells you that she doesn't think that the medicine the doctor prescribed will help her feel any better and she doesn't feel confident about checking her urine for sugar. You are taking graduate courses at the local university to work toward a degree in public health. One of your professors lectured about the U.S. health care system and suggested that it encourages the medicalization of social ills. In other words, the United States views social problems as medical problems; for example, excess stress may be diagnosed as irritable bowel syndrome, headache, or fatigue. Describe what issues you as the case manager would address for the 58-year-old woman under (1) a market justice form of medical care and (2) a social justice system of care. Which one is likely to have more impact on the overall health of this woman? Explain why the United States would rather treat the manifestation of the social disease rather than the cause of the problem. Summary of Week: CHAPTER 2 Beliefs, Values, and Health PREDOMINANTAMERICAN BELIEFS RELATED TO HEALTH CARE 1. Belief in science and technology as panaceas 2. Belief in private initiatives instead of government involvement to deliver health care to mainstream America 3. Belief in individualism—responsibility for one’s own economic well-being CONSEQUENCES FOR THE HEALTHCARE DELIVERY SYSTEM 1. Emphasis on disease rather than health (medical model) Influence of the medical model:
  • 20. • It has established the supremacy of curative medicine over the health promotion/disease prevention model (HPDP) • Definition of health as the absence of disease • Measurement of health status: use of morbidity and mortality measures (negative health conditions) • Financing for services: traditionally, better coverage for curative services than preventive services • Training of health professionals is intervention- oriented, specialist-oriented • Status of health professionals: higher status and incomes for specialists 2. Private delivery of health care in which the government plays a lesser role • Dichotomy (separation and conflict) between public health and private practice of medicine • Emphasis on individual health rather than population health 3. Achievement of health through personal means • Privately financed health insurance that is mainly employment-based • Publicly financed health insurance for the less fortunate (Medicaid and Medicare) 4. Health care has been viewed as an economic good rather than a public resource • A system based on market justice rather than social justice PERSPECTIVES ON HEALTH • The physical view—essence of the medical model. Absence of disease. Focuses on diagnosis and relief of symptoms. • The social model—incorporates the physical and social elements of health. A person’s ability to perform the expected social roles (attending school, doing housework, going to work) is interpreted as health. Seeking medical help is recommended when a person is physically unable to perform his or her social tasks. • The WHO definition—incorporates the physical, mental, and social elements of health as necessary for individual well-being. • The holistic view—includes spiritual well-being along with the other three dimensions (WHO). A person’s spirituality can have a positive impact on the individual’s overall health. This dimension has become important in several areas of healthcare delivery, such as end-of-life care and long-term care. CONCEPTS RELATED TO HEALTH Illness and disease—recognized in reference to symptoms and discomfort • Illness—self-perceived • Disease—based on professional evaluation
  • 21. • Risk factor—an attribute that increases the likelihood (probability) that people would develop a disease or a negative health condition. A risk factor may or may not cause disease; it merely raises the probability of acquiring a disease. • Wellness—emphasizes promotion of an optimum state of well-being and prevention of disease (HPDP). Promotion of wellness is based on three factors: 1. An understanding of the health consequences of risk factors associated with host, agent, or environment. • Host—person exposed to the agent and at risk of developing a disease; genetic makeup, level of immunity, fitness, personal behaviors • Agent—a factor responsible for producing disease; bacteria/viruses, chemical agents, radiation, dietary excesses, nutritional deficiencies • Environment—set of conditions that directly or indirectly are responsible for exposing the host to the agent • Physical (sanitation, air pollution); social conditions (violence, emotional abuse, peer pressure); cultural beliefs and values; and economic factors 2. Appropriate interventions (behavior modification and therapeutic interventions) to counteract key risk factors. • Behavior modification is achieved by means of: • Education • Personal motivation • Financial incentives (tax on cigarettes) • Environmental inducements (advertising, role models) • Three levels of therapeutic interventions: • Primary prevention—interventions designed to minimize the probability of disease developing in the future (immunization, diet control, exercise programs, work safety programs) • Secondary prevention—early detection and treatment of disease (health screening, for example, blood pressure, blood sugar levels, cholesterol screening, mammography, pap smears) • Tertiary prevention—rehabilitation and prevention of further complications (restorative therapies, infection control procedures in healthcare institutions to protect against nosocomial infections) 3. Public health—application of existing scientific knowledge regarding health and disease to ensure conditions that will have the maximum positive impact on the health status of a population; quality of life; overall satisfaction with life during (processes) and following (outcomes) a person’s encounter with the healthcare system. • Process—comfort, security, independence, autonomy • Outcome—functional capacity, role fulfillment, self-perceptions of health DETERMINANTS OF HEALTH: BLUM’S MODEL In order of importance: • Environment—physical, social, cultural, and economic factors
  • 22. • Lifestyle—behaviors, attitudes toward health • Heredity—current health and lifestyle practices are likely to impact future generations • Medical care—healthcare delivery system (access, availability of services) EQUITABLE DISTRIBUTION (AVAILABILITY) OF HEALTH CARE Distributive justice: a key concept related to access • US—demand-side rationing (price rationing). Uninsured do not have access. • National healthcare programs—supply-side rationing (planned rationing). Services are not always available when needed. Concepts of justice: United States—market justice • The idea of capitalism and free markets has been extended to health care. The role of distributing economic goods is assigned to the market. National healthcare programs—social justice • The idea of collectivism and restraining of markets has been extended to health care. The role of distributing social (collective) goods is assigned to the government. Limitations of market justice • Social justice becomes unavoidable when dealing with human problems: Housing—subsidized public housing, shelters Transportation—public transit systems Education—public schools Health care—program for underprivileged populations (Medicare, Medicaid, Indian Health Service, Veterans) • Critical care is provided to the uninsured • Human problems have broader implications for society: Homelessness, crime, substance abuse Health care—people in ill health place an economic burden on the rest of society (loss of productivity, payment for critical care), and may also place the rest of society at risk (for example, AIDS) • A robust US economy and low unemployment have not reduced the number of uninsured. Therefore, it is argued that social justice may be in the best interest of society as a whole. COMMUNITY HEALTH • Goal—to keep populations healthy by addressing a variety of issues related to the environment, lifestyles, heredity (futuristic), and medical care. For medical care, it would require universal access. TERMINOLOGY
  • 23. • Activities of daily living (ADLs)—Measure a person’s ability to function independently, especially in reference to one’s ability to perform six basic activities: eating, bathing, dressing, toileting, maintaining continence, and getting into or out of a bed or chair. • Acute condition—Relatively severe, of short duration, and often treatable. • Agent—One of the factors of the epidemiology triangle, must be present in order for an infectious disease to occur. In other words, an infectious disease cannot occur without an agent. • Bioterrorism—Encompasses the use of chemical, biological, and nuclear agents to cause harm to relatively large civilian populations. • Cases—Refers to individuals who acquire a certain disease or condition. • Chronic condition—Less severe than an acute condition but of long and continuous duration. The patient may not fully recover. • Community health assessment—A method used for conducting broad assessments of populations at a local or state level. • Crude rates—Measures referring to the total population; they are not specific to any age groups or disease categories. • Demand-side rationing—Refers to barriers to obtaining health care faced by individuals who do not have sufficient income to pay for services or purchase health insurance. • Deontology—An individualistic principle of ethics that underscores the individual’s duty to do what is right, such as the mutual responsibilities of physicians and patients. Deontology does not place responsibility on society to provide healthcare services. The principle is used to support the concept of market justice. • Development—Refers to changes in skill and capacity to function, especially in early childhood. • The presence of disease is based on professional evaluation as opposed to self- evaluation. • Emigration—Means migration out of a defined geographic area. • Environment—One of the factors of the epidemiology triangle, is external to the host. It includes the physical, social, cultural, and economic aspects of the environment. • Epidemic—Occurs when a large number of people get a specific disease from a common source. • Fertility—The capacity of a population to reproduce. • Health care—Refers to the treatment of illness and the maintenance of health. • Health risk appraisal—Refers to the evaluation of risk factors and their health consequences for individuals. Health risk appraisal is an important aspect of health promotion and disease prevention because it can be instrumental in developing avenues for motivating individuals to alter their behaviors to more healthful patterns. • Holistic health—Emphasizes the well-being of every aspect of what makes a person whole and complete. • Holistic medicine—Seeks to treat the individual as a whole person. • A host—One of the factors of the epidemiology triangle, is an organism, generally a human, who receives the agent. The host is the organism that becomes sick. • Iatrogenic illnesses (or injuries)—Caused by the process of health care.
  • 24. • Illness—Recognized by means of a person’s own perceptions and an evaluation of how he or she feels. For example, an individual may feel pain, discomfort, weakness, depression, or anxiety, but a disease may or may not be present. • Immigration—Means migration to a defined geographic area. • Incidence—Counts the number of new cases occurring in the population at risk within a certain time period, such as a month or a year. • Instrumental activities of daily living (IADLs)—Used in reference to a person’s ability to perform activities that are necessary for living independently in the community, such as preparing meals, shopping for routine items, managing money, and housekeeping. • Life expectancy—The prediction of how long a person will live. • Market justice—Ascribes the fair distribution of health care to the market forces in a free economy. Medical care and its benefits are distributed on the basis of people’s willingness and ability to pay. • The medical model of healthcare delivery presupposes the existence of sickness. In other words, health care is delivered only when a person is sick. The model emphasizes diagnosis and treatment of disease as opposed to health promotion and disease prevention. • Migration—Refers to the geographic movement of populations between defined geographic units, and involves a permanent change of residence. • Morbidity—Means disease or disability. • Mortality—The term used in the measurement of death rates. • Natality—Refers to the birth rate. • Planned rationing—See supply-side rationing. • The population at risk—Include all the people in the same community or population group who are susceptible to acquiring a disease or a negative health condition. • Prevalence—Measures the total number of cases (of death, disability, or disease) at a specific point in time in the population at risk. • Primary prevention—Refers to actions designed to reduce the odds that a disease will subsequently develop. Its objective is to restrain the development of a disease or negative health condition before it occurs. Smoking cessation, prenatal care, hand washing, and refrigeration of foods are examples of primary prevention. • Public health—Deals with broad societal concerns about ensuring conditions that promote optimum health for society as a whole by influencing the social, economic, political, and medical care factors that affect health and illness. The objective of public health is to prevent disease, prolong life, and promote health through organized community effort. • Quality of life—Refers to overall satisfaction with life during and following a person’s encounter with the health delivery system. Some of the life domains germane to quality of life are comfort factors, security, degree of independence, decision-making autonomy, and attention to personal preferences. • Risk factors—Attributes that increase the likelihood of developing a particular disease or negative health condition at some time in the future. Risk factors can be traced to the agent, the host, and/or the environment. • Secondary prevention—Refers to early diagnosis and treatment of disease. Health screening plays a key role in secondary prevention. The objective is to block the progression of disease.
  • 25. • Social contacts—Evaluated in terms of the number of social contacts or social activities a person engages in within a specified period of time. Examples are visits with friends and relatives, and attendance at social events, such as conferences, picnics, or other outings. • Social justice—Regards health care as a social good that should be collectively financed through general taxes, and made available to all citizens regardless of the individual’s ability to pay. • Social resources—Refer to social contacts that can be relied upon for support, such as family, relatives, friends, neighbors, and members of a religious congregation. They are indicative of adequacy of social relationships. • A sub-acute condition—Between acute and chronic, but with some acute features. • Supply-side rationing—Also called planned rationing because the government, faced with limited resources, makes deliberate attempts, often referred to as “health planning,” to limit the availability of healthcare services, particularly those beyond the basic level of care. • Tertiary prevention—Refers to rehabilitative activities and the monitoring of treatment regimens to prevent further complications. • Utilitarianism—A principle of ethics that emphasizes happiness and welfare for the masses, while ignoring the individual. Its main motto is “the greatest good for the greatest number of people.” • Utilization—Refers to the extent to which healthcare services are used. • The wellness model—Views health as a positive concept. The model emphasizes efforts and programs geared toward prevention of disease and maintenance of an optimum state of well-being. END OF CHAPTER 2 SUMMARY REVIEW AND DISCUSSION QUESTIONS End Week 2 WEEK 3 Start Week 3 Objectives: Chapter 3 1. Discover the history that has shaped the U.S. Health Care Delivery System. 2. Evaluate why the system has been resistant to national health insurance reforms. 3. Explore developments and key forces that help shape the delivery of health services in the U.S. Reading Assignments: a) Chapter 3, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’)
  • 26. c) Read Ten Great Achievements of Public Health (webpage html file) found in the Web Course. Lecture Assignments: a) View the Course Overview and Assignments Presentation including: i. Thought Worksheet Assignment Presentation ii. Cost Quality Access Model Assistant Presentation b) View this Week’s Lecture c) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) Thought Worksheet # 1 is due this week. Universal Health Coverage is the topic for this assignment. Email the completed assignment to your instructor. b) Your Thought Worksheet Assignment topic for you to analyze is: Universal Healthcare Coverage in the United States. Review Questions (based on your points selections): a) Complete/Answer Review Questions for Chapter 3 and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for Chapter 3 and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 34 points) 1. Why did the professionalization of medicine start later in the United States than in some Western European nations? (Comprehension: 2 points) 2. Why did medicine have a domestic rather than a professional character in the pre-industrial era? How did urbanization change that? (Comprehension: 2 points) 3. Which factors explain why the demand for the services of a professional physician was inadequate in the pre-industrial era? How did scientific medicine and technology change that? (Comprehension: 2 points) 4. How did the emergence of general hospitals strengthen the professional sovereignty of physicians? (Application: 3 points)
  • 27. 5. Discuss the relationship of dependency within the context of the medical profession’s cultural and legitimized authority. What role did medical education reform play in galvanizing professional authority? (Synthesis: 4 points) 6. How did the organized medical profession manage to remain free of control by business firms, insurance companies, and hospitals until the latter part of the 20th century? (Comprehension: 2 points) 7. Discuss the key factors that were instrumental in the growth of voluntary health insurance. (Comprehension: 2 points) 8. Discuss, with particular reference to the roles of (a) organized medicine, (b) the middle class, and (c) American beliefs and values, why reform efforts to bring in national health insurance have been unsuccessful in the United States. (Synthesis: 4 points) 9. Which particular factors that earlier may have been somewhat weak in bringing about national health insurance later led to the passage of Medicare and Medicaid? (Comprehension: 2 points) 10. Discuss the government’s role in the delivery and financing of health care with specific reference to the dichotomy between public health and private medicine. (Application: 3 points) 11. Discuss why the structure of medical care delivery in the United States did not develop around a nucleus of primary care. (Comprehension: 2 points) 12. Explain how contract practice and prepaid group practice were the prototypes of today’s managed care plans. (Comprehension: 2 points) 13. Discuss the most notable forces that are continuing to shape the healthcare delivery system. (Synthesis: 4 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. How did the emergence of general hospitals strengthen the professional sovereignty of physicians? 2. How did medical education reform change the profession of medicine? 3. List and describe two federal or state regulatory standards (e.g., laws) that apply to the private sector. What do they intend to control and are they meeting their objectives?
  • 28. 4. You are a lead policy analyst for the Centers for Medicare and Medicaid Services (CMS; formerly known as the Health Care Financing Administration [HCFA]). A member of the U.S. Senate has contacted your boss, the head of CMS, hoping to better understand the benefits of a national health insurance (NHI) program. The senator explained that he has heard all kinds of reasons why an NHI program couldn't work in the United States and wants to get the real scoop. Your boss meets with you to discuss how best to approach the request of the senator. It is agreed that you must first research why previous proposals favoring NHI have failed in the United States. During your research you partially conclude the reason for failure is the American value system, which is based on individualism, little government interference, and free market principles. What do you also learn about past efforts? Given all your research, would Americans today support a national form of health insurance? Explain. What would it take to overcome or address these past failures? Summary of Week: CHAPTER 3 The Evolution of Health Services in the United States Professionalization of medicine started later in the United States than Western Europe. Reasons include the following: 1. Medical science, experimental research, and medical education developed later in the United States 2. American cultural attitudes—self-reliance, home remedies, and familial care PREINDUSTRIAL ERA—1700S TO LATE 1800S • Characterized by medicine as a domestic rather than a professional institution • Unorganized trade—free entry, competition, training through apprenticeship • Primitive medical procedures—bleeding, use of emetics and purgatives, purging with enemas • Missing institutional core—institutions fulfilled a charity and welfare rather than a healthcare function • Almshouses (poorhouses) and pesthouses; dispensaries (outpatient) used for apprenticeship and experimentation; a few voluntary hospitals (local charity rather than tax support) • Low demand for medical services—family-based care, self-reliance; physician services were expensive, mainly due to opportunity costs of travel; no health insurance; private fee-for-service; limited benefits from medical treatment • Disorganized medical education—schools started by physicians, no admission requirements, general studies, little training in biological sciences POSTINDUSTRIAL ERA—LATE 1800S TO MID 1900S • Characterized by professional sovereignty
  • 29. • Urbanization—proximity (reduced opportunity costs), change in the family’s social structure • Science and technology—bacteriology, antiseptic techniques, anesthesia, diagnostic equipment, new drugs • Medical practice required science-based education, skills, and expertise • Legitimacy and acceptance of professional judgment (cultural authority) • Increased demand for professional services • Institutionalization—modern hospital provided an institutional core • Physicians started many of the early hospitals with financial support from local philanthropists • Hospitals had to depend on physicians to admit patients and keep the beds filled • Hospitals became indispensable for medical practice due to advances in anesthesia and surgery, which created a demand for hospital services • Dependency—created by: Cultural authority of physicians 1. Patients in a dependent role/sick role (Chapter 2)—requires patients to seek medical help when declared sick. It also expects them to resume their regular social roles when declared well, but the latter often requires a physician’s certification. 2. Insurers became dependent on physicians’ judgment. 3. Need for hospital services for critical illness or surgery. • Professional cohesiveness—specialization, educational reform, and professionalization led to the need for patient referrals between physicians, sharing of ideas, and formal organization. American Medical Association (organized medicine)— control over medical practice, licensing, and education; for example, licensing was contingent on graduation from AMA-approved schools. Organized resistance to any interference with the private practice of medicine, such as contract practice, salaried employment, public health. GROWTH OF PUBLIC HEALTH Urbanization increased concerns about protecting the health of populations. Most states created public health departments by the start of the 20th century. Main functions: • Promotion of sanitation • Control of communicable disease • Regulation of food and water • Operation of state laboratories • Health education • Maintenance of vital statistics • Limited medical care delivery: • Child immunizations • Maternity and child welfare • School health screening • Family planning • Substance abuse and mental health
  • 30. Organized medicine kept private practice separated from public health for fear that it would invite government intervention and control. The development of public health can be credited with the remarkable drop in mortality from infectious diseases, and the dramatic rise in life expectancy. Now, chronic illnesses have become the leading cause of illness, disability, and death in the United States and other developed nations. RISE OF PRIVATE HEALTH INSURANCE Three forces led to the need for health insurance in America. 1. Technological—advanced treatments that were desirable but expensive 2. Social—desire of medical treatments, the “sick role” 3. Economic—risk of catastrophic loss Other key developments: 1. The Great Depression provided the impetus for private health insurance. People as well as institutions needed economic protection. The Baylor plan (1929) introduced the concept of hospital insurance, a prepaid plan based on capitation. This led to the creation of Blue Cross. California Medical Association started the first Blue Shield plan. 2. Wage freezes during World War II—insurance benefits became important in union negotiations. 3. Tax-free status of health insurance benefits made health insurance a more desirable substitute for cash wages. NATIONAL HEALTH INSURANCE In Europe, main reasons: • To pacify labor unrest that threatened political stability • To ensure fitness of armed servicemen • To improve economic productivity • Primary motivation was not grounded in ensuring the health and well-being of all citizens In the United States • 1914—Workers’ compensation: a social benefit • Initially covered loss of wages due to job-related illness and injury • Later, medical expenses and death benefits were added • 1917—The American Association of Labor Legislation attempted to expand its social agenda by advocating national health insurance. • 1935—Franklin Roosevelt era, New Deal (Social Security passed) • 1940s—Truman became the first president to use his office to advocate national health insurance. Private health insurance was expanding at this time. • 1992—Clinton and Bush propose health plans during presidential election • Wofford’s victory in Pennsylvania United States Senate election • Rising costs of health care were widely viewed as a major concern • Polls showed significant fear of loss of coverage, problems with receiving services
  • 31. Main reasons why proposals favoring NHI have been defeated in the United States (differences between Europe and the United States) 1. No political threats 2. Private infrastructure (physicians, hospitals) 3. Sovereignty of the medical profession (AMA opposition) 4. Opposition from insurance industry, pharmaceutical industry, business (costs) 5. Opposition from labor unions (government was viewed as a usurper of their benefactor’s role) 6. Beliefs and values of the American middle class: Market justice, Individualism and self-determination, Distrust of government, Reliance on the private sector to address social concerns 7. Tax aversion PUBLIC HEALTH INSURANCE IN THE UNITED STATES • Private health insurance for the middle-class • Tax supported programs for the elderly and poor were successful because they were viewed as charity: Rising costs of health care that these groups could not generally afford. Poorer health status compared to general population Greater incidence and prevalence of disease Greater need to utilize healthcare services • Growing size of the elderly population gave them greater political clout • Social Security Amendments of 1965 produced Medicare and Medicaid MAIN EFFECTS OF MEDICARE AND MEDICAID • Opened access for a significant proportion of the uninsured population • Significantly contributed to the growth of healthcare expenditures • Monitoring and regulation of healthcare facilities became linked to public financing • Medicare—Title 18 of the Social Security Amendment (covers the elderly and disabled), federal program • Part A—hospital care, limited nursing home care in a skilled nursing facility • Part B—government subsidized insurance for outpatient services • Medicaid—Title 19 (covers the poor, but eligibility is based on means test), federal/state program MAIN FEATURES OF THE TWO PROGRAMS Medicare—Initially created for the elderly (later disabled, and end-stage renal disease were added), federal program, allowed balance billing (higher acceptability with providers). Medicaid—Created for the poor, federal/state program, administered by each state, no balance billing (unpopular with providers)
  • 32. PROTOTYPES OF MANAGED CARE Contract practice • Direct contracting with industry in remote areas, use of salary or capitation • Hospital associations (in Oregon) Group practice • Consolidation of various types of practice, economic efficiency Prepaid group plans • Enrolled population, comprehensive services, capitated fee RECENT EVOLUTIONS • Cost escalations, rather than universal access, represent people’s primary concern. • Government has played the primary role in cost containment, but its role in managing the entire system is viewed with skepticism. • Changes in financial incentives have shifted health services delivery from inpatient to outpatient. Hospitals have diversified into post-acute extended care and home health. Particularly in long-term care, there has been a shift from institutionalization to community-based services. • Growing use of self-care and alternative remedies. • Outbreaks of disease caused by new viruses such as ebola, West Nile, and corona (associated with SARS— severe acute respiratory syndrome). • Bioterrorism has created a new awakening for the role of public health in protecting people against the threats of germs, chemicals, and other agents used as weapons of mass destruction. • An aging population forebodes a dramatic rise in chronic health conditions, with staggering costs associated with disability and long-term care services. • Quality of medical care and use of standardized treatment protocols are receiving ongoing emphasis. • The Internet has revolutionized medical information. • Diversity and minority health issues are receiving greater attention. • Growth of managed care during the 1990s was successful in containing healthcare costs, but spending has once again started to escalate. • Integrated delivery organizations evolved in response to managed care. • Physicians continue to vie for autonomy, as seen in some initial efforts to unionize, and to separate from hospitals to form independent specialty clinics. • In the maze of organizational dominance, the consumer has been practically stripped of any market power. TERMINOLOGY • Almshouse—Also a poorhouse, was an unspecialized institution existing during the 18th and mid-19th centuries that mainly served general welfare functions, essentially providing shelter to the homeless, the insane, the elderly, orphans, and the sick who had no family to care for them.
  • 33. • Balance bill—The practice of billing the patient for the balance remaining after insurance has paid its share of the total charges. • Capitation—A payment mechanism in which all healthcare services are included under one set fee per covered individual. The fee is generally paid per month, hence it is also referred to as per-member-per-month (PMPM). The fee covers all services an enrollee may need during the entire year. • Cost shifting—Occurs when losses experienced in one area of healthcare delivery are made up by charging more in another area. For example, shortfalls in revenues from providing charity care are made up by charging more to private payers. • Cross-subsidization—See cost shifting. • Cultural authority—Refers to the general acceptance of professional judgment as valid. Physicians’ cultural authority is reflected in the reliance placed on their evaluation of signs and symptoms, diagnosis of disease, and suggested prognosis. • Fee-for-service—The practice of billing separately for each individual type of service performed. • Gatekeeping—Requires patients to initially make contact with a generalist who provides basic and routine care, evaluates the need for specialized services, and makes referrals to specialized care if it is determined to be appropriate. • Means test—Income-based determination of eligibility to receive healthcare services or to participate in a program such as Medicaid. • Medicaid—The program that provides health care to the poor through federal matching funds provided to the states based on each state’s financial needs. • Medicare—The publicly financed health insurance program for the elderly and certain disabled persons. • Organized medicine—Refers to the concerted activities of physicians through the American Medical Association (AMA). The term has been used to distinguish collective efforts from the uncoordinated actions of individual physicians competing in the marketplace. • Part A of Medicare—Provides coverage for hospital care and limited nursing home care. • Part B of Medicare—Government-subsidized voluntary insurance for physician services and outpatient services. • Pesthouse—Operated by local governments during the 18th and mid-19th centuries to quarantine people who contracted a contagious disease such as cholera, smallpox, or typhoid. The primary function of a pesthouse was to protect the community from the spread of contagious disease; medical care was only secondary. • Primary care—The delivery of routine and basic care in which the primary care physician also ensures the continuity, coordination, and appropriateness of medical services received by a patient. • Title XVIII—Or more precisely, Title XVIII (18) of the Social Security Amendment of 1965 refers to the Medicare program. • Title XIX—Or more precisely, Title XIX (19) of the Social Security Amendment of 1965 refers to the Medicaid program.
  • 34. End Week 3 WEEK 4 Start Week 4 Objectives: Chapter 4 1. To recognize the different types of health service professionals. 2. To differentiate between primary and specialty care, and the causes for imbalance between the two in the U.S. 3. Discuss maldistribution in the physician labor force. 4. Develop a potential plan to help overcome the physician imbalance and maldistribution. 5. To understand the role of non physician providers. 6. To identify Allied Health professionals and their roles. 7. The discuss the functions and qualifications of health service administrators amid the various professional settings of the career. Reading Assignments: a) Chapter 4, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) Study the file “Learning Map Orchestrating Great Care” found in the web course and think about what it takes to lead healthcare professionals and manage healthcare resources. Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) Complete Quiz 1 on the WebCT Course Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 6 and the topic for you to analyze is: Increased Utilization of Customized Medical Products (such as Pharmaceuticals, Implants, Prosthetics, etc…).
  • 35. Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 19 points) 1. Describe the major types of health services professionals (physicians, nurses, dentists, pharmacists, physician assistants, nurse practitioners, certified nurse midwives), including their roles, training, practice requirements, and practice settings. (Comprehension: 2 points) 2. What factors are associated with the development of health services professionals in the United States? (Comprehension: 2 points) 3. What are the major distinctions between primary care and specialty care? (Comprehension: 2 points) 4. Why is there a geographic maldistribution of the physician labor force in the United States? (Synthesis: 4 points) 5. Why is there an imbalance between primary care and specialty care in the United States? (Comprehension: 2 points) 6. What measures have been or can be employed to overcome problems related to physician maldistribution and imbalance? (Application: 3 points) 7. Who are nonphysician primary care providers? What are their roles in the delivery of health care? (Comprehension: 2 points) 8. In general, who are allied health professionals? What general role do they play in the delivery of health services? (Knowledge: 1 point) 9. Provide a brief description of the roles and responsibilities of health services administrators. (Knowledge: 1 point) ONLINE CHAT & DISCUSSION BOARD QUESTIONS
  • 36. 1. What settings and challenges (situations for management and leadership) are possible for entry to middle level of health services administrators? 2. A primary care office located in a predominately African-American urban community provides a full range of health care services including obstetrics, pediatrics, and geriatrics. The clinic is staffed with international physicians and licensed practical nurses (LPNs). There continues to be reports that large numbers of people in your community are not accessing needed services and the health of the community is worse than in neighboring urban communities. Describe how the use of non-physician health care practitioners (certified nurse practitioner, physician assistant, or certified nurse midwife) could affect access, cost, and quality in this community. Summary of Week: CHAPTER 4 Health Services Professionals NEGATIVE CONSEQUENCES OF SPECIALTY MALDISTRIBUTION 1. High volume of intensive, expensive, and invasive medical services (overuse of medical services) with increased healthcare spending. Society receives lower value for the healthcare dollars spent. 2. Increased demand for specialist care. 3. Specialist services have less impact in improving overall health status. 4. Problems with access to care by the underserved. OTHER DOCTORAL-LEVEL PROFESSIONALS Optometrist (OD)—vision correction Psychologist (PhD)—mental health counseling and psychotherapy Podiatrist (DPM)—diseases and deformities of the feet Chiropractor (DC)—literally, hand manipulation. It is rooted in the belief that the health of the spinal column and nervous system is central to well-being. Studies show that chiropractic is an effective form of treatment for back pain. NURSES • Constitute the largest group of healthcare professionals. • Two basic levels of licensed nurses: 1. RN—three avenues of RN education/preparation: Associate degree (ASN, Associate of Science in Nursing, 2 years), Diploma (hospital program, generally 3 years), and Bachelor’s degree (BSN, 4 years)
  • 37. 2. LPN (LVN)—1 to 2 years at a community college Impact of decline in hospital stay: Growth of other settings such as home health and nursing homes, which has led to a growth in nursing employment in these settings. Other growth areas for RNs: • Case management • Utilization review • Quality assurance • Prevention counseling • Training of other nurses • Primary care Advanced practice nurses (APNs): • Have attained education and training beyond the RN level. • Four main categories: 1. Clinical nurse specialists—Work in hospitals (vs. home health, clinics, or nursing homes). Specialize in fields such as cardiac care, oncology, neonatal care, psychiatric care. 2. Certified Registered Nurse Anesthetists—Trained to manage anesthesia during surgery. 3. Nurse Practitioners—Trained to provide primary care services, often ndependent of physicians. 4. Certified Nurse Midwives—Deliver babies and manage the care of mothers and newborns before, during, and after delivery. NONPHYSICIAN PRACTITIONERS (NPPS) NPPs practice in areas similar to those in which physicians practice, but they do not have MD or DO degrees, and they mainly practice in primary care settings. Their practice results in improved access to primary care. Care rendered is often equivalent in quality to that provided by physicians, and is cost effective. Patients generally express a greater degree of satisfaction with care from NPPs, as compared to care received from physicians, due to better communication with the NPPs and the fact that NPPs generally spend more time with patients than do physicians. • Physician assistants (PAs)—Most graduate from bachelor’s degree programs. Work in a dependent relationship under a supervising physician (onsite or off-site). • Nurse practitioners (NPs)—Often have master’s degree plus advanced clinical training. They can practice independently of physicians. In most states, NPs can receive direct Medicaid and Medicare payments for their services. • Certified nurse midwives (CNMs)—Can substitute for obstetrician/gynecologist. Handle routine pregnancies as competently or better than physicians do. ALLIED HEALTH PROFESSIONALS Need created by the growth of technology and specialization in medicine. They function in roles that are complementary to those of physicians and nurses. Two main categories:
  • 38. 1. Technologists and therapists—PTs, OTs, Speech therapists, Dieticians, Medical technologists, etc. 2. Technicians and assistants—PT and OT assistants, laboratory technicians, emergency medical technicians, dental hygienists, etc. HEALTH SERVICES ADMINISTRATORS • Organize, coordinate, and manage the delivery of healthcare services. • Provide leadership, direction, and strategic planning in health services organizations. • Challenges faced: • changes in financing and reimbursement • impact of new public policies • competition • pressures to provide uncompensated care, particularly by non-profit organizations • accountability for quality • integrity, ethics, and public’s trust TERMINOLOGY • Advanced practice nurses (APNs)—Nurses who have education and clinical training beyond that required for an RN. The four areas of specialization in nursing include clinical nurse specialist (CNS), certified registered nurse anesthetist (CRNA), nurse practitioner (NP), and certified nurse midwife (CNM). NPs and CNMs are also categorized as nonphysician practitioners. • Allied health—Includes a large number of health-related areas, its main function being to complement the work of physicians and other healthcare providers. Examples include anesthesiologist assistants, cardiovascular technologists, emergency medical technicians/ paramedics, medical assistants, medical laboratory technicians, medical record administrators, medical record technicians, occupational therapists, radiographers, respiratory therapists and technicians, specialists in blood bank technology, surgeon’s assistants, and surgical technologists. • Certified nurse midwives (CNMs)—Registered nurses with additional training from a nurse-midwifery program in areas such as maternal and fetal procedures, maternity and child nursing, and patient assessment. • Chiropractors—Provide treatment to patients through chiropractic (done by hand) manipulation, physiotherapy, and dietary counseling. They typically help patients with neurological, muscular, and vascular disturbances. Chiropractic is based on the belief that the body is a self-healing organism. • Comorbidity—Refers to the condition when patients have multiple health problems. • Dental assistants—Work for dentists in the preparation, examination, and treatment of patients. While dental assistants do not have to be licensed to work, there are formal training programs available that offer a certificate or diploma. • Dental hygienists—Provide preventive dental care, including cleaning teeth and educating patients on proper dental hygiene. Dental hygienists must be licensed to practice.
  • 39. • Dentists—The major providers of dental care and must be licensed to practice. Their major roles are to diagnose and treat dental problems related to the teeth, gums, and tissues of the mouth. Eight specialty areas are recognized by the American Dental Association: orthodontists (straightening teeth), oral and maxillo facial surgeons (operating on the mouth and jaws), pediatric dentistry (dentists for children), periodontics (treating gums), prosthodontics (making artificial teeth or dentures), endodontics (root canal therapy), public health dentistry (community dental health), and oral pathology (diseases of the mouth). • Generalists—Physicians trained in family medicine/general practice, general internal medicine, and general pediatrics in the United States. They are considered primary care providers. • Licensed practical nurses (LPNs)—Called licensed vocational nurses (LVNs) in some states, care for patients under the direction of physicians and registered nurses. They must complete a state-approved program in practical nursing and a national written eamination. • Maldistribution—Refers to either a surplus or a shortage of the type of health providers (typically physicians) needed to maintain the health status of a given population at an optimum level. Maldistribution can occur both geographically and by specialty. • Nonphysician practitioners (NPPs)—Providers who practice in many areas similar to those in which physicians practice, but they do not possess a doctoral degree. NPPs are sometimes called midlevel practitioners because they receive less advanced training than physicians do, but more training than registered nurses. They are also referred to as physician extenders because in the delivery of primary care they can, in many instances, substitute for physicians. NPPs typically include physician assistants (PAs), nurse practitioners (NPs),and certified nurse midwives (CNMs). • Nurse practitioners—Advanced practice nurses (APNs) who have completed a program of study leading to competence as RNs in an expanded role. NPs are trained to practice independently of physicians, and can often substitute for primary care physicians. • Occupational therapists (OTs)—Help people of all ages improve their ability to perform tasks in their daily living and working environments. They work with individuals who have conditions that are mentally, physically, developmentally, or emotionally disabling. • Optometrists—Provide vision care, including examination, diagnosis, and correction of vision problems. They must be licensed to practice. • Osteopathic medicine—Emphasizes the musculoskeletal system of the body, such as correction of the joints or tissues, and stresses diet and the environment as factors that might influence natural resistance. • Pharmaceutical care—Refers to a mode of pharmacy practice in which the pharmacist takes an active role on behalf of patients by assisting the prescribers in appropriate drug choices, effecting distribution of medications to patients, and assuming direct responsibilities collaboratively with other healthcare professionals and with patients to achieve the desired therapeutic outcomes. • Pharmacists—Dispense medicines prescribed by physicians, dentists, and podiatrists, and provide consultation on the proper selection and use of medicines. All states require a license to practice pharmacy. The role of pharmacists has expanded over the last two
  • 40. decades to include drug product education and serving as experts on specific drugs, drug interactions, and generic drug substitution. • Physical therapists (PTs)—Provide care for patients with movement dysfunction. • Physician assistants (PAs)—Work in a dependent relationship with a supervising physician to provide comprehensive care. PAs assist physicians in the provision of care to patients. The major services provided by PAs include evaluation, monitoring, diagnostics, therapeutics, counseling, and referral. • Physician extenders—See nonphysician practitioners. • Podiatrists—Treat patients with diseases or deformities of the feet, including performing surgical operations, prescribing medications and corrective devices, and administering physiotherapy. They must be licensed to practice. • Primary care—First-contact care or the portal to the healthcare system. Primary care focuses on the person as a whole. It seeks to balance the multiple requirements for which a patient’s condition may call and refers patients to appropriate specialty care when needed. Primary care should incorporate continuity, comprehensiveness, and coordination with other levels of care. • Psychologists—Non-physicians who are trained to provide mental health care using counseling and psychotherapy. They must be licensed or certified to practice. • Residency—Graduate medical education in a specialty that takes the form of paid on- the-job training, usually in a hospital. • Registered nurses (RNs)—The major caregivers of sick and injured patients, serving their physical, mental, and emotional needs. All states require nurses to be licensed in order to practice. An RN must complete an associate’s degree (ADN), a diploma program, or a bachelor’s degree (BSN). • Specialists—Physicians who also hold certification in a specialty area. Specialty certification requires additional years of advanced residency training followed by several years of practice in the specialty. A specialty board examination is often required as the final step for becoming a board-certified specialist. Common specialties include anesthesiology, cardiology, dermatology, family medicine, internal medicine, neurology, obstetrics and gynecology, ophthalmology, pathology, pediatrics, psychiatry, radiology, and surgery. • Specialty care—Tends to be limited to illness episodes, the organ system, or the disease process involved. Specialty care, if needed, generally follows primary care. End Week 4 WEEK 5 Start Week 5 Objectives: Chapter 5 1) Understand the broad term and use of technology in health related environments 2) Discuss the categories of technology in health and medicine
  • 41. 3) Understand and discuss the diffusion of technology in healthcare delivery services 4) Discuss and apply a technology assessment model or structure 5) Discuss and compare the types and uses of information systems in health related environments. Reading Assignments: a) Chapter 5, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) Read (in Web Course): Straight Talk: Medical Technology Rising Costs, July 2003 d) Read (in Web Course): Chapter 5 HIT Paper, may 2006 Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) The next quiz is in week 7, Quiz # 2 Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 6 and the topic for you to analyze is: Increased Utilization of Customized Medical Products (such as Pharmaceuticals, Implants, Prosthetics, etc…). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 29 points) 1. Medical technology encompasses more than just sophisticated equipment. Discuss. (Comprehension: 2 points)
  • 42. 2. Discuss the role of information technology in the delivery and management of healthcare services. (Application: 3 points) 3. Generally speaking, why is medical technology more readily available in the United States than in other countries? (Comprehension: 2 points) 4. How do perverse financial incentives in a fee-for-service payment system and in cost-based reimbursement incur greater use of expensive services? (Comprehension: 2 points). 5. How does competition lead to greater levels of technology diffusion? How does technological diffusion, in turn, lead to greater competition? (Comprehension: 2 points). 6. Discuss the demand-side and supply-side factors that influence technology diffusion and its use. (Knowledge: 1 point). 7. Discuss the government’s role in technology diffusion. (Comprehension: 2 points). 8. Discuss how technology influences the quality of medical care and quality of life. (Application: 3 points). 9. Discuss the relationship between technological innovation and healthcare expenditures. (Comprehension: 2 points). 10. What impact has technology had on access to medical care? (Application: 3 points). 11. Which factors have been responsible for the low diffusion and low use of telemedicine? (Synthesis: 4 points). 12. Discuss the policy and management implications of technology assessment. (Application: 3 points). ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. How does competition lead to greater levels of technology diffusion and how does technology diffusion lead to greater competition? 2. What is the government’s role in technology diffusion? 3. You are a member of a human genome project. A federal task force has been formed to discuss this revolutionary science and how it can and should be used. You are asked by
  • 43. the task force to come to its next meeting to help the members learn more about how patient confidentiality can be protected in the human genome project. List and describe measures you would want to include in your presentation to the member of the task force. 4. Your grandmother is 79 years old. She just learned from her primary care physician after numerous and elaborate tests that she has a confirmed diagnosis of breast cancer. It has metastasized to her bone and lungs. She is in considerable and frequent pain, and is experiencing difficulty in breathing. Her prognosis is terminal. As a group, discuss the differences in what each member of the group would do in his or her own family's situation. Why are there differences? What are some important factors you used when making this decision? Discuss the implications of the costs to society to prolong her life for one month. How did you define costs and why? Summary of Week: CHAPTER 5 Medical Technology MEDICALTECHNOLOGY INCLUDES THREE ELEMENTS: 1. Application of biomedical discoveries to provide more effective medical care 2. Adaptation of discoveries in other scientific fields (physics, chemistry, engineering, computer science) to the delivery of medical care 3. Application of technologies to improve the structural elements of healthcare delivery • Information systems • Facilities and settings • Organizational arrangements INFORMATION TECHNOLOGY • Considered medical technology when it is used to support healthcare delivery functions • Application of computer technology in organizations falls into four main areas: 1. Clinical information systems, for example, electronic patient charts 2. Administrative information systems, for example, financial management systems 3. Decision support systems, for example, analytical tools for advanced decision making 4. The Internet—both physicians and patients are increasingly relying on the Internet for clinical information. There are some immediate benefits, but concerns also remain. Benefits: • Increased patient empowerment as patients become more actively involved in their own health care • Better efficiency in medical practice by using the Web to register patients, transmit medical results, and order pharmaceuticals and other products;
  • 44. access patient information from physicians’ homes or hospital lounges to get a head start on hospital rounds; and transmit medical records Concerns: • Privacy issues—the Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires protective measures against illegal access to personal medical information. However, public skepticism remains. • Little oversight to ensure validity of clinical information; can result in misinformation • Potential of conflict between patient and physician DIFFUSION AND UTILIZATION OF TECHNOLOGY Diffusion (spread, availability) and utilization (aggregate use) go hand in hand. Both are important factors in medical cost escalation. Technology is a two-edged sword. It can provide tremendous health benefits, but it also increases costs. Once technology becomes available, its use is almost guaranteed unless deliberately controlled. Why don’t we control technology diffusion? Because people want it, and physicians want to use it. Insurance coverage implies a right to access all available technology. Our belief and value system leads to a continuous search for technological advancements. We are driven by the technological imperative—the desire to use technology regardless of its cost. Managed care has been criticized for its efforts to control usage because overt supply-side rationing is not acceptable to the American public. Currently, price rationing under the market justice system is the only constraining force against over-utilization. Other factors contributing to the growth of technology in the US: • Specialization, specialty maldistribution, specialty training. • Payment for services, when payment mechanisms insulate patients against the cost (moral hazard) or contain loopholes for provider-induced demand. • Competition among hospitals based on acquisition of technology has led to duplication. • Defensive medicine. • Absence of supply-side rationing—national healthcare programs in other countries use health planning and global budgets to contain technology dissemination. The government’s role in technology diffusion: • Regulation of drugs and devices. Role of the FDA. • Certificate of need to control the growth of new construction and acquisition of costly equipment. The program had failed to demonstrate its effectiveness in cost containment. It was criticized for stifling competition. CON was abandoned by some states. • Research on technology—role of the Agency for Healthcare Research and Quality (AHRQ).
  • 45. • Research funding. IMPACT OF MEDICALTECHNOLOGY • Quality of care—our notion of quality is often associated with high technology. Technology has improved diagnosis and treatment—more effective, less invasive, safer procedures—resulting in greater life expectancy and decreased morbidity and disability. • Quality of life—technology enables people to live more normal lives than would otherwise be possible. Examples include relief of pain and suffering, improved mobility, and compensation for disabilities. • Costs—generally, technology increases costs, but some technology has reduced costs. Technology has enabled the delivery of care in less costly, alternative settings (home health, subacute care), and a reduction in hospital average length of stay. Technology has contributed to economic growth by reducing disability, prolonging life, and allowing a quicker return to work. • Access—portable technology can be used in small towns and rural areas. • Telemedicine—application of computer technology combined with advanced interactive telecommunications • Access to specialist consultations (radiology, dermatology, pathology, cardiology; tele- presence surgery) • Structure and processes—growth in home health, outpatient, subacute care. Clinical applications include lithotripsy, MRI, total parenteral nutrition (TPN), outpatient surgery, and home kidney dialyzers. • Information systems applications—bedside computers that review and update clinical information; access to medical data, research; teleconferencing, continuing education, organizational networks, managed care organizations (MCOs). • Global practice of medicine—adoption by other countries of technology developed in the US. • Bioethics—artificial prolongation of life without the capacity to live. Genetic research and its implications: Creation of life outside the womb. Example: What to do with frozen embryos? TECHNOLOGYASSESSMENT Technology assessment deals with the assessment of efficacy, safety, and cost- effectiveness. Together they define how “appropriate” the technology is. Assessment serves as a guide for the adoption and diffusion of new technology. • Efficacy (effectiveness)—determination of health benefits (outcomes), more accurate diagnosis, better treatment, quicker recovery • Safety—not causing undue harm; evaluation of risk (negative side effects) • Cost-effectiveness—evaluation of benefits in relation to costs • Implications of technology assessment—technology assessment determines whether care delivered is appropriate. In current practice, it is mostly governed by efficacy and safety considerations. Cost- effectiveness criteria have been slow to enter into the delivery of health care. This is
  • 46. because patients generally are not satisfied until all possible technology is used. The providers now have a financial incentive to limit the indiscriminate use of technology, but conflicts are created between what patients demand and what providers and insurers may consider appropriate based on cost-effectiveness criteria. Such tensions can best be resolved through public policy initiatives. TERMINOLOGY • Administrative information systems—Designed to assist in carrying out financial and administrative support activities such as payroll, patient accounting, materials management, and office automation. • Clinical information systems—Involve the organized processing, storage, and retrieval of information to support patient care processes. • Clinical trial—A research study, generally based on random assignments, designed to study the effectiveness of a new drug, device, or treatment. • Cost benefit analysis—Used to evaluate benefits in relation to costs when both are expressed in dollar terms. Hence, cost benefit analysis is subject to a more rigorous quantitative analysis compared to cost-effectiveness analysis. • Cost-effectiveness (or cost-efficiency)—A step beyond the determination of efficacy. Whereas efficacy is concerned only with the benefit to be derived from the use of technology, cost-effectiveness evaluates the additional (marginal) benefits to be derived in relation to the additional (marginal) costs to be incurred. • Cost-efficiency—See cost-effectiveness. • Decision support systems—Computer-based information and analytical tools to support managerial decision making in healthcare organizations. • Effectiveness—See efficacy. • Efficacy—In a general sense, efficacy refers to the effectiveness of a medical procedure or intervention. If a product or service actually produces some health benefits, it can be considered efficacious or effective. • Flat of the curve—A point in the health production function where the potential health benefits from additional delivery of medical care approach zero. Traditionally, much of the medical care delivered in America has been at the flat of the curve, which represents a waste of healthcare resources. • Medical practice guidelines—Systematically developed statements to assist practitioners in delivering appropriate health care for specific clinical circumstances. These benchmark practice patterns are being regarded as norms governing what is appropriate and what is not appropriate in clinical practice. • Provider-induced demand—Refers to the ability of providers to increase utilization, thus increasing their revenues (incomes). Self-referrals occur when physicians who have an ownership interest in facilities refer their patients to those facilities to obtain medical services. Self-referral is prohibited by law. • Quality-adjusted life year (QALY)—A measure of health benefit, QALY is defined as the value of one year of high quality life, which in recent years has been assigned a value of $100,000. • Self-referrals—Referral of patients to a facility in which the physician has an ownership interest. Self-referral is illegal.
  • 47. • Technological imperative—Implies the use of technology without cost considerations, especially when the benefits to be derived from the use of technology are small compared to the costs. • Technology assessment—Refers to any process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use; cost and cost-effectiveness; as well as social, economic, and ethical consequences, whether intended or unintended. Technology assessment is concerned with the appropriateness of medical technology. • Technology diffusion—The proliferation of technology once it is developed. • Telemedicine—Encompasses the use of advanced telecommunications, such as videoconferencing, and computer technology to provide health care at a distance. • Value—Means greater benefits or higher quality at the same or lower price levels (costs). • Xenografting—Refers to the transplantation of animal organs into humans. End Week 5 WEEK 6 Start Week 6 Objectives: Chapter 6 1) Understand and discuss the role of health care financing and its impact on delivery 2) Understand and discuss the basics of insurance and its terminology 3) Differentiate between group, self, individual insurance and managed care vehicles 4) Comprehend, examine and discuss the financial features of public programs 5) Understand methods of reimbursement 6) Discuss the general model and issues in health care finance 7) Discuss current trends in health care finance Reading Assignments: a) Chapter 6, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’)
  • 48. c) Read (in WebCT): Chapter 6 Calc_0605_rvu.pdf d) Review/Read (in WebCT): Chapter 6 Revised CHS Pay Schedule RBRVS 2004 for…pdf e) Review/Read (in WebCT): Chapter 6 Relative Value Units.doc Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) The next quiz is in week 7, Quiz # 2 Thought Worksheet Assignment: a) Thought Worksheet # 2 is s due this week. b) Due this week: Thought Worksheet Assignment # 2 and the topic for you to analyze is: Increased Utilization of Customized Medical Products (such as Pharmaceuticals, Implants, Prosthetics, etc…). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 25 points) 1. What is meant by healthcare financing in its broad sense? What impact does financing have on the healthcare delivery system? (Comprehension: 2 points). 2. Discuss the general concepts of insurance. Describe the various types of private health insurance options, pointing out the differences among them. (Application: 3 points). 3. Discuss how the concepts of premium, covered services, and cost sharing apply to health insurance. (Comprehension: 2 points). 4. What is the difference between experience rating and community rating? (Knowledge: 1 point).
  • 49. 5. What is Medicare Part A? Discuss the financing and cost-sharing features of Medicare Part A. What benefits does Part A cover? What benefits are not covered? (Comprehension: 2 points). 6. What is Medicare Part B? Discuss the financing and cost-sharing features of Medicare Part B. What benefits are covered under Part B? What benefits are not covered? (Comprehension: 2 points). 7. Discuss the financing, eligibility, and covered benefits for the Medicaid program. (Comprehension: 2 points). 8. What provisions has the federal government made for providing health care to military personnel and to veterans of the US armed forces? (Comprehension: 2 points). 9. Using appropriate examples from the public and private sectors, discuss the functions of financing, insurance, delivery, and payment. (Application: 3 points). 10. What are the major methods of reimbursement for outpatient services? (Comprehension: 2 points). 11. What are the differences between the retrospective and prospective methods of reimbursement? (Comprehension: 2 points). 12. Discuss the prospective payment system under DRGs. (Knowledge: 1 point). 13. Distinguish between national health expenditures and personal health expenditures. (Knowledge: 1 point). ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. List and discuss three financing strategies used to reduce or control health services utilization. How long have they been in effect and to what extent have these measures helped to control health care use? 2. Medicare pays for physician services under Section 1848 of Title XVIII of the Social Security Act. The Act requires that payments under the fee schedule be based on the values assigned to each physician service. These values represent the relative resources involved in providing a service. The scale of values is the Resource Based Relative Value Scale (RBRVS) developed by researchers from Harvard University for the Health Care Financing Administration, now called CMS. (1) What have been the results of this method of financing to both physicians and to Medicare? (2) What impact does this reimbursement system have on those with private health insurance (e.g., to what extent are private insurers adopting this payment method?), and (3) has it changed the distribution of physician specialties or the distribution of physicians geographically?
  • 50. 3. You are Beth, the vice president for outpatient services of a major teaching hospital located in the center of a metropolitan city. You have been collecting information on the types of presenting problems in your emergency department and learn that the number of emergency department visits has increased by 100 percent over the last year. You discover through analysis of the data collected that children under 13 years old are coming to the emergency department for basic primary care services and account for 65 percent of emergency department visits. These children are Medicaid eligible and have multiple physical and developmental disabilities. The state health department has been trying to address access issues for these children for some time, but has been unsuccessful. You hold a meeting with the head of the health department, and the vice president of the medical school. You work out a plan to set up a primary care clinic for these children. The clinic will be partially staffed by the residents rotating through Pediatrics and will be overseen by the chairman of the pediatric department. The hospital will provide the nursing and administrative staff to run the clinic as well as donate the space in one of its outpatient offices. The health department will provide a nurse case manager to set up appointments, help the children and families get to the appointments, and help facilitate follow-up services once seen. In addition, the health department is providing a pediatric nurse practitioner to provide the basic health care screening exams and the majority of the primary care services. The results have been outstanding. Emergency department visits for this group of children have decreased 50 percent and hospital admissions have decreased 75 percent in the first year of the program's operations. The project is now in its second year. The head of the health department was replaced at election year by the new governor. 'It is now coming up on budget time and the health department's new director did not include continuation of funding for this project as his board of directors wants him to address childhood immunizations. As the vice president of outpatient services, you set up a meeting with the new director. What are you going to discuss with him to ensure that funding continues? What data can you share with him? Can you mention any benefits the health department may realize? Summary of Week: CHAPTER 6 Health Services Financing HEALTHCARE DELIVERY FUNCTIONS • Financing—by employers, government, or self, to purchase health insurance • Insurance—commercial insurance, managed care, self-insurance (government and large companies) • Payment—reimbursement methods and disbursement of funds to providers for services rendered
  • 51. • Delivery—provision of services In this chapter, the term financing is used in a broad sense to include the functions of financing, insurance, and payment. The concept of insurance: • Risk—possibility of a substantial financial loss from some event • Probability that the event will occur is small • Predictability of loss • For individuals—unpredictable • For a large group—predictable (group insurance) • Pooling of resources (premiums) • Sharing of losses by the group • During the 1950s and 1960s • Catastrophic coverage to cover hospitalization, surgery • Major medical to cover physician expenses • Now, major medical means comprehensive coverage (includes basic and routine services). • Health insurance, as used today, is an anomaly to the insurance principle because coverage is not restricted to catastrophic events. TYPES OF FINANCING AND INSURANCE Private • Employer-sponsored—employer/employee cost-sharing to purchase group health insurance. One-third of the premium costs are now borne by the employees. Premiums are commonly based on experience rating. • Self-insurance—eliminates the insurance company (the middleman). ERISA 1974— exemption from having to provide certain mandatory benefits. Also, premiums are not taxed because they do not constitute revenue as they would for an insurer. • Individually purchased insurance—for those not covered under an employer’s plan, and can afford to purchase privately—self-employed, farmers, and others. Public • Medicare—covers the elderly, disabled on Social Security, and people with end-stage renal disease. • Medicare Part A—premiums are financed by the government through a special payroll tax. • Medicare Part B—voluntary. Premium cost sharing between the government and beneficiary. Premiums are subsidized by the government. • Medicaid—covers the poor who meet certain income and asset requirements (means test). Financed by states with federal matching based on per capita income for the state. Publicly-financed programs are also referred to as categorical programs because they are designed to benefit specified categories of people who meet the required eligibility criteria. EFFECTS OF HEALTH INSURANCE
  • 52. Three factors have led to a rise in national healthcare expenditures (share of GDP spent on health care): • Increase in the demand for health care; higher utilization; moral hazard • Creation of demand for health care by providers; provider-(supplier-) induced demand • Technology diffusion and utilization are higher when covered by insurance MEDICARE Also known as Title 18 of the Social Security Act. It is administered by the Centers for Medicare and Medicaid Services (CMS), US Department of Health and Human Services Part A • Hospital Insurance (HI)—entitlement for those who meet Medicare enrollment criteria. • Financed by payroll taxes on total income. Both employers and employees are taxed equally. • Hospital Insurance Trust Fund—pays for current beneficiaries, and retains some surpluses. • Part A covers hospital inpatient, limited SNF, home health, and hospice care. Part B • Supplementary medical insurance (SMI)—voluntary program. • Financed by required premiums ($58.70 per month in 2003), which is subsidized from general taxes. • Covers outpatient services, medical equipment and supplies. Medicare is not a comprehensive program. It pays for only about 40% to 45% of personal healthcare expenses. The gaps are filled by Medicaid for those who are eligible, employer retiree insurance benefits under Medicare+Choice, if entitled, or a private Medigap policy. Medicare+Choice Created in 1998 under the Balanced Budget Act (BBA) of 1997, it does not consist of a new layer of benefits under existing Parts A and B, but merely offers additional managed care choices. However, enrollees have the option to remain under the traditional fee-for- service program. The program mainly enrolls lower income Medicare beneficiaries who are enticed by additional benefits such as prescription drug coverage. However, participation has been declining as many managed care plans no longer participate in Medicare. To encourage managed care plans to stay in the program, increased financing has been authorized under the Balanced Budget Refinement Act of 1999 and the Benefits Improvement and Protection Act of 2000. MEDICAID Also known as Title 19 of the Social Security Act. Joint financing by the state and federal governments (50% to 83% of total medical costs).
  • 53. • Eligibility and covered services are determined by each state, but certain services are federally mandated. Automatic coverage for: 1. SSI recipients 2. TANF (temporary assistance to needy families) recipients • Medicaid is a comprehensive program • Dual coverage—Medicaid pays Medicare premiums, and other costs not covered by Medicare PACE Program of All-inclusive Care for the Elderly • Enacted under the Balanced Budget Act of 1997 • Spans both Medicare and Medicaid • Provides community-based care for persons aged 55 or over who already qualify for placement in a nursing home • A PACE team coordinates all medical and social services • The program is financed through funds pooled from Medicare, Medicaid, and private insurance • Services are delivered by non-profit organizations who receive a fixed monthly fee for each participant (capitation). SCHIP State Children’s Health Insurance Program, Title XXI of the Social Security Act. • Enacted under the Balanced Budget Act of 1997 • Covers children from low-income families who are not covered under a private plan or Medicaid • Requires that applicants be first screened for and enrolled in Medicaid if eligible • Three options for administering the program: 1. Expansion of Medicaid 2. Establishment of a special child health assistance program 3. Combination of 1 and 2 WORKERS’COMPENSATION • Not a regular health insurance program • Covers those injured (or killed) on the job • Includes diagnosis and treatment of occupational diseases contracted on the job • Covers: • lost wages • medical expenses • indemnification for loss of occupational capacity • survivor’s death benefits THE PAYMENT FUNCTION Includes reimbursement and disbursement
  • 54. • Reimbursement—determination of the method and amount of reimbursement to be paid to providers • Disbursement—actual payment after services have been delivered • Service cost-sharing—amount that the insured must pay when receiving services; also known as out-of-pocket costs. • Deductible—yearly amount the insured must first pay before insurance will pay anything. • Co-payment—proportion of total costs each time services are used after the deductible has been paid. • The ratio of cost-sharing (such as 80 –20) is called coinsurance. • Stop loss—maximum limit on out-of-pocket costs per year. • Medicare beneficiaries can incur substantial out-of-pocket costs. • Medicaid has minimum out-of-pocket requirements. • Private insurance varies. • Methods of reimbursement 1. Fee-for-service • Fees (charges or prices) are set by providers • Each service is separately billed • Variations a. Fee-for-service limited to a usual, customary, and reasonable (UCR) charge—balance bill for the remaining portion b. Discounted fee-for-service under some managed care arrangements, notably preferred provider organizations • Main drawback—provider-induced demand 2. Bundled charges or package pricing. Reduces provider-induced demand because the fee is inclusive of all bundled services. 3. Resource Based Relative Value Scale (RBRVS) • Relative values determined by time, skill, and intensity required to provide a service. • Relative values are used by the payers to set reimbursement rates— Medicare Fee Schedule (MFS). 4. Managed care approaches a. Preferred provider approach. Discounted fee schedule. Fee-for-service charges are discounted b. Capitation—PMPM fee to cover all needed services Creates incentive to provide only medically necessary services; minimizes provider-induced demand; drawback—incentive to limit services can result in underutilization (when necessary services are withheld) 5. Reimbursement for inpatient services a. Cost-plus (retrospective)—per diem rate based on historical costs, no longer in use b. Prospective—based on pre-established criteria • Diagnosis-Related Groups (DRGs)—used for hospitals. Fixed rate per discharge (a bundled charge) based on principal diagnosis at the time of admission. Adjustments—prevailing wages, rural vs. urban
  • 55. location, teaching hospital, uncompensated care, outliers, DAF (discretionary adjustment factor—for new technology and productivity) • Ambulatory Payment Classification (APC)—for hospital outpatient departments. All outpatient services are classified into more than 300 procedural groups based on clinical similarity and resource use. Each APC is assigned a relative payment weight based on the median cost of services within the APC. A bundled reimbursement rate, which includes services such as anesthesia, certain drugs, supplies, and recovery room charges, is established for each APC. • Resource Utilization Groups (RUGs)—for Skilled Nursing Facilities (SNFs).Acase-mix method is used to determine the composite level of clinical intensity by classifying each Medicare patient in a RUG category based on individual assessment of each patient on admission. A per diem rate is established based on the case-mix. • Home Health Resource Groups (HHRGs)—the PPS for home health pays a fixed, predetermined rate for each 60-day episode of care based on case-mix. All services provided by a home health agency are bundled under one payment made on a per patient basis. • Disbursement • Internal claims departments—insurance companies, MCOs • Self-insured employers—TPAs • Medicare and Medicaid—fiscal intermediaries • National Health Expenditures: Also called health care spending, and more loosely, healthcare costs. Four main components: 1. Personal health expenditures 2. Administrative costs 3. Expenditures for public health programs 4. Research and construction Proportion of GDP in 2001—14.1%; 55% private, 45% public of the total public spending, approximately 70% is federal and 30% is state and local Distribution of Medicare and Medicaid Expenditures—most of the Medicare dollars are spent on inpatient hospital care under Part A. Most of the Medicaid dollars are spent on nursing home care. • Cost containment • Demand-side rationing (price rationing—based on ability to pay) • Supply-side rationing (planned rationing—based on availability of services). Has not been successful in the US • Reimbursement (price of healthcare services) • Utilization (quantity of healthcare services consumed)—MCOs manage utilization • Managed Care • MCO assumes risk—the employer or government transfers risk to MCO • MCO manages the premium dollars—offers lower premiums than traditional insurance
  • 56. • MCO arranges to provide services to the enrollees • MCO implements utilization controls • MCO sets reimbursement rates—capitation, discounted fee-for-service TERMINOLOGY • Adverse selection—Occurs when high-risk individuals enroll in comprehensive plans and, as the cost of premiums goes up, healthy individuals start dropping out. Eventually, the plan is left with a disproportionate number of high-risk people. • Balance bill—The amount a provider bills to the patient for the portion not paid by insurance. • Beneficiary—Refers to the insured, especially a person insured through a public program such as Medicare or Medicaid. • Benefit period—Determined by a spell of illness beginning with hospitalization and ending when a beneficiary has not been an inpatient in a hospital or a skilled nursing facility for 60 consecutive days. Medicare inpatient benefits are based on benefit periods. • Benefits—Services covered by an insurance plan. • Carriers—Private claims processors for Medicare Part B services. • Case-mix—Refers to the overall intensity of medical conditions requiring medical and nursing intervention. It is determined by an assessment of each patient’s condition and an estimate of the amount of resources the patient will need. • Catastrophic plan—High-deductible insurance plan that is not designed to cover routine and inexpensive services. • Categorical programs—Public health insurance programs, each designed to benefit a certain category of people. Examples are Medicare for the elderly and certain disabled individuals, Medicaid for the indigent, the Defense Department’s programs for active service people, and VA for former armed forces personnel. • Charge—The fee (price) for a service generally set by the provider. • Claim—Refers to a billing for services the provider has to file with the insurer in order to receive payment. • Coinsurance—The ratio of cost sharing between the insurance plan and the insured. For example, an 80–20 coinsurance means that insurance will pay 80%, and the patient will pay 20% of an approved charge. • Community rating—A method for the determination of health insurance premiums that spreads the risk among members of a large community and establishes premiums based on the utilization experience of the whole community. For a set of benefits, the same rate applies to everyone regardless of age, gender, occupation, or any other indicator of health risk. • Co-payment—The portion of total medical costs that the insured has to pay out of pocket each time health services are received. • Cost-plus—A method of reimbursement in which total operating costs and certain allowable capital costs are included in arriving at the per diem rate. • Cost shifting—The practice whereby providers charge extra to payers who do not exercise strict cost controls to make up for inadequate reimbursement from other sources, or to make up for uncompensated care rendered.
  • 57. • Deductible—The amount the insured must first pay before benefits by the plan are payable. A deductible is commonly required to be paid on an annual basis. • Defined contribution—A health insurance program in which employers pay a fixed amount toward their employees’ healthcare benefits. Employees can use the cash to buy any plan of their choice. • Entitlement program—People are “entitled” to the benefits provided by the program because they have contributed toward it. For example, the elderly are entitled to Medicare benefits regardless of the amount of income and assets they may have. • Experience rating—A method for the determination of health insurance premiums that is based on a group’s own medical claims experience. Under this method, premiums differ from group to group because different groups have different risks. • Fee schedule—A list showing individual fees for each type of service. • First-dollar coverage plans—Health insurance plans without deductibles and copayments. Such plans are now quite rare. • Fiscal intermediaries—Private sector insurers, such as Blue Cross/Blue Shield and commercial insurance companies, who process provider claims under contract from Medicare and Medicaid. • GDP, or gross domestic product—The total value of goods and services produced in a country. It is an indicator of total economic production. • Group insurance—A policy obtained through an entity, such as an employer, a union, or a professional organization, that anticipates that a substantial number of people in the group will participate in purchasing insurance through that entity. • Indemnity plan—Provides reimbursement to the insured without regard to the expenses actually incurred. The term is often used for traditional health insurance plans that are not managed care plans. • Insurance—A mechanism for protection against risk. • The insured—The individual who is covered for risk by insurance. • The insurer—Or underwriter is the insuring agency that assumes risk. • Job lock—Refers to the inability of a person to change jobs for fear of losing health insurance with his or her current employer. • Major medical insurance—Originally designed to cover catastrophic situations that could subject the insured to substantial financial hardships, such as hospitalization, extended illness, and expensive surgery. Now, major medical coverage is all-inclusive comprehensive coverage. It is no longer limited to a single type of expense but applies broadly to almost all types of medical care. • Means-tested program—Any government insurance program in which eligibility is determined by the person’s assets and income. • Medical loss ratio—The ratio of benefit payments to premiums, which indicates the proportion of the premiums spent on medical expenses. • Medigap—A private insurance policy purchased by many of the elderly to pay for expenses not covered by Medicare. • Moral hazard—Refers to consumer behavior that leads to a higher utilization of healthcare services when people are covered by insurance. • An MSA—A tax-free savings account coupled with a high-deductible catastrophic health insurance plan.
  • 58. • National health expenditures—Refers to an estimate of the amount spent for all health services and supplies and health-related research and construction activities consumed in the United States during a calendar year. • Outliers—Unusual cases that call for additional reimbursement under the DRG methodology. These are atypical cases requiring an exceptionally long inpatient stay or exceptionally high costs compared to the overall distribution of cases in the same DRG. • Personal health expenditures—The expenditures remaining after expenditures for research and construction, administrative expenses incurred in health insurance programs, and costs of government public health activities have been subtracted from national health expenditures. These expenditures are for services and goods related directly to patient care. • Preexisting condition—A health problem that an insured had prior to obtaining health insurance coverage. • Premium—The amount charged by the insurer to insure against specified risks. • Prospective reimbursement—Uses certain pre-established criteria to determine in advance the amount of reimbursement. • Rate—The price for a healthcare service generally set by a third-party payer, whereas a charge is the price set by the provider. • Reinsurance—A mechanism whereby an insurer can cover high-risk losses through insurance from another insurer. For example, self-insured employers generally protect themselves against the risk of high losses by purchasing reinsurance from a private insurance company. • Retrospective reimbursement—A reimbursement methodology in which rates are set on the basis of costs already incurred. • Risk—The insurance context refers to the possibility of a substantial financial loss from an event of which the probability of occurrence is relatively small. • Risk rating—Means that high-risk individuals will pay more than the average premium price, and low-risk individuals will pay less than the average price. • Risk selection—The skimming of healthy people by a health plan to enroll into the plan. • A service plan—Provides specified services to the insured. The plan pays the hospital or physician directly, except for the deductible and copayments for which the insured is responsible. • Stop-loss—The maximum out-of-pocket liability an insured incurs in a given year. The plan pays 100% of expenses beyond the stop-loss limit. • Third-party administrators (TPAs)—Process and pay claims on behalf of self-insured employers. The TPA may also monitor utilization and perform other oversight functions. • Third-party payers—Insurance companies, Blue Cross/Blue Shield, and the government (for Medicare and Medicaid) who make payment for claims on behalf of the insured. • Underutilization—When providers withhold necessary services due to cost constraints. • Underwriting—A systematic technique for evaluating, selecting (or rejecting), classifying, and rating risks. • Uninsured—People who are not covered by either private or government-sponsored health insurance programs. End Week 6
  • 59. WEEK 7 Start Week 7 Objectives: Chapter 7 1. Know the difference between outpatient, ambulatory, primary, secondary and tertiary care 2. Identify why there is growth in outpatient care services 3. Identify various outpatient settings and services Reading Assignments: a) Chapter 7, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) Complete Quiz 2 on the WebCT Course Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 9 and the topic for you to analyze is: Nurse personnel/staff shortage and the maldistribution of physicians (do both items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 26 points)
  • 60. 1. Describe how some of the changes in the health services delivery system have led to a decline in hospital inpatient days and a growth in ambulatory services. (Comprehension: 2 points) 2. What implications has the decline in hospital occupancy rates had for hospital management? (Comprehension: 2 points) 3. All primary care is ambulatory, but not all ambulatory services represent primary care. Discuss. (Comprehension: 2 points) 4. What are the main characteristics of primary care? (Knowledge: 1 point) 5. Discuss the gatekeeping role of primary care. (Comprehension: 2 points) 6. What is community-oriented primary care? Explain. (Application: 3 points) 7. Discuss the two main factors that determine what should be an adequate mix between generalists and specialists. (Comprehension: 2 points) 8. What are some of the reasons solo practitioners are joining group practices? (Application: 3 points) 9. Why is it important for hospital administrators to regard outpatient care as a key component of their overall business strategy? (Application: 3 points) 10. Discuss the main hospital-based outpatient services. NOT USED IN REVIEW QUESTIONS , CAN BE USED IN ONLINE CHAT AND DISCUSSION BOARD 11. What are some of the social changes that led to the creation of specialized health centers for women? (Comprehension: 2 points) 12. Why is the hospital emergency department sometimes used for nonurgent conditions? What are the consequences? (Synthesis: 4 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. Discuss the main hospital-based outpatient services. (Same as Number 10 above) 2. What are mobile healthcare services? Discuss the various types of mobile services. 3. What is the basic philosophy of home health care? Describe the services provided through home health care.
  • 61. 4. What are the conditions of eligibility for receiving home health services under Medicare? 5. Explain the concept of hospice care and describe the types of services provided by hospices. What are some of the main requirements for Medicare certification of a hospice program? 6. Describe the scope of public health ambulatory services in the United States. 7. Describe the main public and voluntary outpatient clinics, and the main problems they face. 8. What is alternative medicine? What role does it play in the delivery of health care? 9. Briefly explain how a telephone triage system functions. Summary of Week: CHAPTER 7 Outpatient and Primary Care Services OUTPATIENT SERVICES Reasons for growth 1. Changes in reimbursement constraining inpatient services and favoring outpatient services. • Few payment restrictions in outpatient services: surgeries, chemotherapy, dialysis—paid as fee-for-service Two main agents of change: • Medicare—PPS reimbursement based on DRGs; fixed rate per admission; “quicker and sicker” discharges; coverage of home health • Managed care—capitation 2. Development of new technology. • Less invasive procedures enable quicker recuperation from surgery. Patients often do not need to be hospitalized for routine surgery 3. Utilization controls—managed care. • Restrictions on utilization • Quicker discharge • Prior authorization (precertification) • Utilization review 4. Social factors.
  • 62. • Preference for obtaining services at home or in community-based settings— especially true for long-term care HOSPITAL OUTPATIENT DEPARTMENTS Hospitals have been in a competitive position to develop outpatient services. 1. Financial ability to adopt new technology 2. Physical ability to provide appropriate facilities • operating rooms • recuperation rooms 3. Best equipped to provide emergency care 4. Excess (unutilized) capacity Advantages: • Significant contribution to profits • Continuum of services: “One-stop shopping” for managed care • Cross-referrals within a hospital’s own network OUTPATIENT CARE SETTINGS • Private practice—shift from independent solo practice to group practice, institutional employment; Advantages to physicians: • Lower operating costs (startup, sharing of overhead, equipment, diagnostics) • Greater opportunities to contract with managed care • Advantages to patients: • Most routine services available at one place • Cross-referrals • Hospital-based: Five main types of hospital outpatient services: 1. Clinical services—specialist consultations 2. Surgical services 3. Emergency services for acute conditions • Emergent—require immediate attention • Urgent—attention within a few hours • Non-urgent, non-emergency—misuse of emergency departments, but used mainly by the uninsured as a substitute for primary care 4. Home health care 5. Women’s health centers • Women are the major users of health care • Greater proportion of women in the population • Unique healthcare needs that were previously ignored • Freestanding facilities—walk-in clinics, urgi-centers, surgi-centers • Mobile medical services—ambulance, EMT, and paramedics • Diagnostic vans—X-ray, MRI Service vans, eye and dental care TERMINOLOGY
  • 63. • Adult day care—Complements informal care provided at home by family members with professional services available in adult day care centers during the day. • Alternative medicine—Refers to nontraditional approaches and includes the broad domain of all health care resources—other than those intrinsic to biomedicine—to which people have recourse. Examples include homeopathy, herbal formulas, use of other natural products as preventive and treatment agents, and acupuncture. • Ambulatory care—Refers to outpatient services. It includes (1) care rendered to patients who come to physicians’ offices, outpatient departments of hospitals, and health centers to receive care; (2) outpatient services intended to serve the surrounding community (community medicine); and (3) certain services that are transported to the patient. • Case management—Provides coordination and referral among a variety of healthcare services. The objective is to find the most appropriate setting to meet a patient’s healthcare needs. • Categorical programs—Public health programs specifically designed to address certain categories of disease or serve specific categories of persons. • Community-oriented primary care (COPC)—Incorporates the elements of good primary care delivery and adds to this a population-based approach to identifying and addressing community health problems. • Durable medical equipment (DME)—Includes certain medical supplies and equipment, such as ostomy supplies, hospital beds, oxygen tanks, walkers, and wheelchairs. • Emergent conditions—Require immediate medical attention; time delay is harmful to patient; and the disorder is acute and potentially threatening to life or function. • A free clinic—A general ambulatory care center serving primarily the poor and the homeless who may live next to affluent neighborhoods. Free clinics are staffed predominantly by trained volunteers, and care is given free or at a nominal charge. • Gatekeeping—The care coordination role of a primary care practitioner. It implies that patients do not visit specialists without referral from the primary care physician, who functions as the gatekeeper. It is not designed to be a controlling mechanism to deny people necessary care. It is designed to protect patients from unnecessary procedures and over-treatment. • Home health care—Includes various types of services that are brought to the patients in their own homes. Such patients are generally unable to leave their homes safely to get the care they need. • Hospice—Refers to a cluster of comprehensive services that address the special needs of dying persons and their families. It blends medical, spiritual, legal, financial, and family-support services. Services are taken to patients and their families wherever they happen to be located. • Iatrogenic—Illness or injury is any complication that is caused by the process of health care. • Medically underserved—A designation determined by the federal government. It indicates a dearth of primary care providers and delivery settings, as well as poor health indicators of the populace. The majority of this population group are Medicaid recipients. • Non-urgent conditions—Do not require the resources of an emergency service, and disorder is nonacute or minor in severity.
  • 64. • Outpatient services—Include any healthcare services that are not provided on the basis of an overnight stay in which room and board costs are incurred. The term is synonymous with “ambulatory care.” • A phone care system—Provides telephone access to bring expert opinion and advice to the patient, especially during the hours when physicians’ offices are generally closed. • Primary health care—Essential health care that constitutes the first level of contact by a patient with the health delivery system and the first element of a continuing healthcare process. • Secondary care—Includes routine hospitalization, routine surgery, and specialized outpatient care, such as consultation with specialists. Compared to primary care, these services are usually short-term in nature and more complex, involving advanced diagnostic and therapeutic procedures. • Surgi-centers—Freestanding ambulatory surgery centers independent of hospitals. They usually provide a full range of services for the types of surgery that can be performed on an outpatient basis and that do not require overnight hospitalization. • Telephone triage—Refers to a telephone call-in system staffed by specially trained nurses who receive patients’ calls. Using a computer system, they can access a patient’s medical history and view the most recent radiology and laboratory test results. The nurses use standardized protocols to guide them in dealing with the patient’s problem and consult with primary care physicians when necessary. If necessary, the staff can direct patients to appropriate medical services such as an ED or a physician’s office. • Tertiary care—Constitutes the most complex level of care. Typically, tertiary care is institution-based, highly specialized, and highly technological. Examples include burn treatment, transplantation, and coronary artery bypass surgery. • Urgent care centers—Community-based freestanding clinics open 24 hours a day, 7 days a week. These emergency centers, however, generally are not equipped to serve truly emergent patients or to receive ambulance cases. • Urgent conditions—Require medical attention within a few hours; a longer delay presents possible danger to the patient; and the disorder is acute but not necessarily severe. • Walk-in clinics—Proprietary, community-based freestanding clinics that provide ambulatory services ranging from basic primary care to urgent care. They are generally used on a non-routine, episodic basis. The main advantage of these clinics is convenience of location, evening and weekend hours, and availability of services on a “walk-in,” no- appointment basis. End Week 7 WEEK 8 Start Week 8 Objectives: Chapter 8 1. Recognize the factors contributing to the evolution of hospitals
  • 65. 2. Survey the growth of hospitals 3. Understand reasons for hospital declines 4. Measure hospital operations and utilization 5. Differentiate between types of hospitals 6. Differentiate between for profit and nonprofits 7. Comprehend hospital governance 8. Identify ethical issues and the future of hospitals Reading Assignments: a) Chapter 8, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 9 and the topic for you to analyze is: Nurse personnel/staff shortage and the maldistribution of physicians (do both items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions:
  • 66. REVIEW QUESTIONS (total of 25 points) 1. What is the difference between inpatient and outpatient services? (Comprehension: 2 points) 2. As hospitals evolved from rudimentary custodial and quarantine facilities to their current state, how did they change in their purpose and function? (Comprehension: 2 points) 3. What were the main factors responsible for the growth of hospitals until the latter part of the 20th century? (Knowledge: 1 point) 4. Name the three main forces that have been responsible for hospital downsizing. How has each of these forces been responsible for the decline in inpatient hospital utilization? (Synthesis: 4 points) 5. What is a voluntary hospital? Explain. How did voluntary hospitals evolve in the United States? (Comprehension: 2 points) 6. Discuss the role of government in the growth, as well as the decline, of hospitals in the United States. (Comprehension: 2 points) 7. What are inpatient days? What is the significance of this measure? How do inpatient days vary by patient demographic characteristics? (Comprehension: 2 points) 8. Discuss the different types of public hospitals and the roles they play in the delivery of healthcare services in the United States. (Comprehension: 2 points) 9. What are some of the differences between voluntary and investor-owned hospitals? (Knowledge: 1 point) 10. What are long-term hospitals? Why has the number of these hospitals declined in the United States? (Comprehension: 2 points) 11. Do you think Roemer’s Law is still applicable today? Please explain. (Application: 3 points) 12. The table below gives some operational statistics for two hospitals located in the same community. Answer the questions following the table. NOT USED IN REVIEW QUESTIONS 13. Is it true that a specialty hospital provides higher quality of care than a general hospital? Please explain. (Comprehension: 2 points)
  • 67. ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. Discuss the three types of specialty hospitals described in this chapter. 2. How do you differentiate between a community hospital and a general hospital? 3. What are some of the operating challenges faced by urban and rural hospitals? 4. Discuss some of the issues relative to the tax-exempt status of nonprofit hospitals. If you were a member of the board of trustees of a nonprofit hospital, what would you recommend such a hospital do to justify its nonprofit status? 5. Why are hospitals among the most complex organizations to manage? 6. Discuss the governance of a modern hospital. 7. In the context of hospitals, what is the difference between licensure, certification, and accreditation? 8. What can a hospital do to address some of the difficult ethical problems relative to end-of-life treatment? Summary of Week: CHAPTER 8 Inpatient Facilities and Services HOSPITAL Legal description: • Minimum 6 beds • Provides diagnosis and treatment • Licensed by state • Organized physician staff • Nursing care under the supervision of RNs Other appellations used today • Medical Center—offers a wide array of specialized services • Health System—covers a large geographic area with a variety of facilities such as satellite hospitals, physician clinics, rehab centers, long-term care facilities, home health care, etc. EVOLUTION OF HOSPITALS
  • 68. Five stages: 1. Institutions of social welfare • almshouses and pesthouses • public (government) institutions • charity function • more a custodial or isolation function—rudimentary medical function 2. Hospitals built specifically to care for the sick • Initially, an extension of the above public institutions, although almshouses often continued to exist side by side • Subsequently, hospitals built to serve the general public were voluntary (nongovernment), financed by rich philanthropists • Hospitals opened in Philadelphia, New York, and Boston were the most prominent • Control in the hands of the boards • Many of the early hospitals were unsanitary, unventilated, had unskilled staff, and were dreaded as “houses of death” • Europe—started by religious orders, later converted to public 3. Institutions of medical practice • Science and technology—anesthesia, germ theory of disease (antiseptic, sterilization), X-ray • Inpatient treatment began to be restricted to the acute phase of illness • Physicians started many of the first proprietary hospitals, generally required financing from private donors 4. Institutions of medical training • Hospital experience became necessary for physicians • Affiliations between medical schools and teaching hospitals • Many training programs for nurses were hospital-based • Research—variety of cases with similar medical conditions were found in one place 5. Institutions of health service consolidation • Diversification into nonacute services—outpatient departments, physician clinics, home health, long term care, etc. HOSPITAL EXPANSION • Hospitals grew once they became institutions of medical practice • Reasons for growth: • Advances in medical science • Development of specialized technology • Advances in medical education • Development of professional nursing • Growth of health insurance—created demand, generous reimbursement • Role of government: • Hill-Burton Act in 1946 provided federal construction grants to states • Medicare and Medicaid extended coverage to the elderly and the indigent
  • 69. • Between 1965 and 1980, hospital beds increased by roughly one third HOSPITAL DOWNSIZING Reasons—some of the same factors created the growth for outpatient services, which were addressed in Chapter 7. 1. Reimbursement—financial incentives to reduce length of inpatient stay 2. Economic constraints—led to the closure of many small rural hospitals 3. Technology—enabled procedures to be performed in outpatient settings 4. Utilization controls 5. Social factors TYPES OF HOSPITALS Community hospital: • Nonfederal, short-stay (< 30 days, acute) • Services available to the general public • Examples of non-community hospitals—federal, long term, prison, or university hospitals General hospital: • Provides a variety of services to meet the general medical needs of the community such as general and specialized medicine, general and specialized surgery, obstetrics, etc. Specialty hospital: • Admits only certain types of patients (women, children) or only patients with certain types of conditions (TB, psychiatric, rehabilitation, cardiac care) Hospitals can be distinguished by: 1. Ownership a. Public—Government ownership • Federal—do not serve the common public; serve special groups— military, VA • State—mostly mental and TB hospitals • Local—county and city governments • Mostly community hospitals • Serve mainly the inner city (urban), indigent, minority groups • The majority are small- to mid-sized, located in small towns • Some large ones in urban areas often are operated as teaching hospitals b. Private • Voluntary—non-profit (tax-exempt), assets belong to the community, they make a profit but it cannot be distributed to any individuals. Among all private hospitals in the US, 80% are nonprofit. • Proprietary (investor-owned), for-profit; owned by individuals, partners, or corporations; operated for the financial benefit of the stockholders • First started by physicians
  • 70. 2. Affiliation a. Independent b. Multi-unit hospital chains (hospital systems) Advantages of belonging to a chain: • Reduced administrative overhead • Ability to provide a wide spectrum of services • Ability to reach a variety of markets • Access to capital • Access to management resources, expertise Other hospital types Teaching hospital—have AMA-approved residency programs for physicians Osteopathic hospital—community general hospitals operated according to osteopathic principles Nonprofit hospitals—main characteristics, three major distinguishing features: Exist primarily for some public good; social function—community health, charity care, teaching, research. Profits are not distributed to any individuals (they do not have shareholders). Exempt from income, sales, and property taxes—receive a subsidy from taxpayers. Do they deliver benefits to society that equal or exceed the tax subsidies? HOSPITAL GOVERNANCE Tripartite structure: • Board of trustees (governing body)—define the mission, set long-term direction, establish relationship with the community, establish broad operational policies, carry legal responsibility for the operations, appoint and evaluate the CEO, approve appointment of physicians to the medical staff • CEO—responsible for day-to-day operations to accomplish the mission and objectives in accordance with established policies, reports to the board • Medical director—chief medical officer (chief of staff) • Responsible for clinical oversight • Medical staff—chiefs of service (head specialty departments) • Medical staff committees LICENSURE, CERTIFICATION, ACCREDITATION • Licensure—state function, mandatory • Condition—compliance with state laws, building codes, fire safety, sanitation standards • Certification—federal function, eligibility for participation in Medicaid and Medicare • Condition—satisfy the conditions of participation; compliance with standards • Accreditation—private function (JCAHO), voluntary • Condition—satisfy Joint Commission standards ETHICS PRINCIPLES • Respect for others
  • 71. • Autonomy • Truth-telling • Confidentiality • Fidelity • Beneficence • Nonmaleficence • Justice LEGALRIGHTS, PATIENT BILLOFRIGHTS • Informed consent • Advance directives • Do not resuscitate orders • Living will • Durable power of attorney TERMINOLOGY • Advance directives—A patient’s wishes regarding continuation or withdrawal of treatment when the patient lacks decision-making capacity. • Average daily census—Refers to the average number of hospital beds occupied daily over a given period of time. This measure provides an estimate of the number of inpatients receiving care each day at a hospital. • Average length of stay (ALOS)—The average number of days each patient stays in the hospital. For individual or specific categories of patients, this measure indicates severity of illness and resource use. • Bill of rights—A document that reflects the law concerning the rights a patient has while confined to an institution such as a hospital. Some common issues addressed in the bill of rights include confidentiality, consent, and the right to make decisions regarding medical care, to be informed about diagnosis and treatment, to refuse treatment, and to formulate advance directives. • Board of trustees— The governing body of a hospital. It consists of influential business and community leaders, and is responsible for defining the mission and long-term direction of the hospital. • Chief of service—A physician who is in charge of a specific medical specialty in a hospital, such as cardiology. • Chief of staff (medical director)—A physician who supervises the medical staff in a hospital. • Community hospital—A nonfederal short-stay hospital whose facilities and services are available to the general public. It can be a private or a public (city or county) hospital. • Conditions of participation—Standards developed by the Department of Health and Human Services (DHHS) with which a facility must comply in order to participate in the Medicare and Medicaid programs. • The credentials committee—Reviews qualifications of clinicians for admitting privileges.
  • 72. • Critical access hospital—A designation created by the Centers for Medicare and Medicaid Services (CMS) for some very small (15 acute care beds) and isolated rural hospitals. These hospitals offer access in remote locations, and receive cost-based reimbursement from Medicare to keep their operations viable. • Days of care—Constitute the cumulative number of patient days over a given period of time. • Discharge—A patient who has received inpatient services. Total number of discharges indicate access to hospital inpatient services as well as the extent of utilization. • Do-not-resuscitate orders (DNR orders)—Advance directives by individual patients who do not wish to be resuscitated via cardiopulmonary resuscitation (CPR). Such wishes are based on the premise that a patient may prefer to die than live when the quality of life available after resuscitation is likely to be worse than before. • A durable power of attorney—A written legal document in which the patient appoints another individual to act as the patient’s agent for purposes of healthcare decision-making in the event that the patient is unable or unwilling to make such decisions. • An ethics committee—An interdisciplinary committee responsible for developing guidelines and standards for ethical decision-making in the provision of health care and for resolving issues related to medical ethics. • The executive committee—Continuing monitoring responsibility and authority over the hospital. Usually it receives reports from other committees, monitors policy implementation, and provides direction. • A general hospital—Provides a variety of services, including general medicine, specialized medicine, general surgery, specialized surgery, and obstetrics, to meet the general medical needs of the community it serves. It provides diagnostic, treatment, and surgical services for patients with a variety of medical conditions. • A hospital—A licensed institution with at least six beds, whose primary function is to deliver diagnostic and therapeutic patient services for various medical conditions. A hospital must have an organized physician staff, and it must provide continuous nursing services under the supervision of registered nurses. • The infection control committee—Responsible for reviewing policies and procedures for minimizing infections in the hospital. • Informed consent—A fundamental patient right. A patient, who has the capacity to understand information being given, must give a written consent before any treatment or procedure is performed, or medication is given. • Inpatient—A patient who incurs an overnight stay in a healthcare facility. The term is also used in reference to an overnight stay, such as inpatient care, inpatient procedure, inpatient day, etc. • Inpatient day (also referred to as a patient day or a hospital day)—A night spent in the hospital by a person admitted as an inpatient. • Investor-owned hospital—See proprietary hospital. • A living will—An advance directive given by a competent adult in the form of an explicit written statement that he or she does not wish life-sustaining measures to be used in the event of hopeless illness. • A long-term hospital—One in which the average length of stay (ALOS) is more than 30 days.
  • 73. • The medical records committee—Responsible for certifying complete and clinically accurate documentation of the care given to each patient. • The medical staff committee—Charged with medical staff relations in a hospital. For example, it reviews admitting privileges and the performance of the medical staff. • Moral agent—A person, such as a healthcare executive, who has the moral responsibility to ensure that the best interest of patients takes precedence over fiduciary responsibility toward the organization. • Occupancy rate—The percentage of a hospital’s total inpatient capacity that is actually utilized. • Osteopathic medicine—A holistic approach to medical practice that involves correction of the position of the joints or tissues and also emphasizes diet and environment as factors that determine natural resistance to disease. • Proprietary hospital—Or investor-owned hospital, is a for-profit hospital owned by individuals, a partnership, or a corporation. • A public hospital—Owned by an agency of the federal, state, or local government. • The quality improvement committee—Responsible for overseeing the program for continuous quality improvement. • A rehabilitation hospital—Specializes in providing restorative services to rehabilitate chronically ill and disabled individuals to a maximum level of functioning. • A rural hospital—Located in a county that is not part of a metropolitan statistical area. • A short-stay hospital—One in which the average length of stay is less than 30 days. • A specialty hospital—Admits only certain types of patients or those with specified illnesses or conditions. Examples include psychiatric hospitals, rehabilitation hospitals, tuberculosis hospitals, and children’s hospitals. • Swing beds—Beds in rural hospitals that have been authorized under the Omnibus Reconciliation Act of 1980 to be used either as acute care beds or long-term care skilled nursing facility (SNF) beds according to need. • A teaching hospital—A hospital with an approved residency program for physicians. • An urban hospital—Defined as one located in a county that is part of a metropolitan statistical area. • The utilization review committee—Evaluates the appropriateness of admissions and length of stay and reviews the various resources used in providing care. • A voluntary hospital—A private nonprofit hospital owned and operated by community associations or other non-government organizations for the benefit of the community. End Week 8 WEEK 9 Start Week 9 Objectives: Chapter 9 1. Define managed care.
  • 74. 2. Describe the financial, reimbursement and contract scenarios associated with managed care. 3. Describe the insurance implications associated with a managed care environment. 4. Describe an integrated delivery system noting vertically and horizontally integration. 5. Describe the utilization controls used in managed care environments. 6. Discuss the political, regulatory, social, and economic forces that have shapes the managed care environment. 7. Describe the perceptions of key healthcare stakeholders with regard to managed care environments. 8. Discuss the impact of managed care on cost, quality and access to healthcare services. Reading Assignments: a) Chapter 9, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) Read Chapter 9 Hammurabi Managed Care article Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) Thought Worksheet # 3 is due this week. b) Your next Thought Worksheet Assignment is due in week 12 and the topic for you to analyze is: Telemedicine expansion, Electronic Medical Record Utilization and Computerized Physician Order Entry System Utilization (do all three items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file
  • 75. c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 23 points) 1. What are some of the key differences between traditional health insurance and managed care? (Comprehension: 2 points) 2. Explain how the fee-for-service practice of medicine led to increased healthcare costs. (Knowledge: 1 point) 3. Despite a recognition of increasing healthcare costs, why did the Health Maintenance Organization Act of 1973 fail to achieve its objectives? (Synthesis: 4 points) 4. What are the three main payment mechanisms managed care uses? In each mechanism, who bears the risk? (Comprehension: 2 points) 5. Generally speaking, what are the three main a venues of cost control in MCOs? In which areas have managed care not performed as well as it has in controlling costs? (Comprehension: 2 points) 6. Discuss the concept of utilization monitoring and control. (Knowledge: 1 point) 7. What are the various mechanisms used by MCOs to monitor and control utilization? Briefly discuss each mechanism. (Comprehension: 2 points) 8. Describe the three utilization review methods, giving appropriate examples. Discuss the benefits of each type of utilization review. (Comprehension: 2 points) 9. Describe the factors that led to the development of different types of managed care plans and HMO models. (Comprehension: 2 points) 10. What is an HMO? How does it differ from a PPO? (Knowledge: 1 point) 11. Briefly explain the four main models for organizing an HMO. Discuss the advantages and disadvantages of each model. NOT USED AS REVIEW QUESTION 12. What is a point-of-service plan? Why did it grow in popularity? What caused its recent decline? (Comprehension: 2 points)
  • 76. 13. Discuss the concept of risk contracting for Medicare beneficiaries. (Comprehension: 2 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1 What are the outcomes of managed care in the areas of cost containment, access, and quality of health care? 2. Which forces in the healthcare delivery system have led to the formation of integrated delivery systems? 3. Explain how managed care has contributed to the development of integrated delivery systems. 4. State the main strategic objectives of horizontal and vertical integration. 5. What is antitrust policy? Which business practices does antitrust law prohibit? Why do antitrust laws exist? Summary of Week: CHAPTER 9 Managed Care and Integrated Organizations Managed care versus indemnity insurance and fee-for-service prepaid plans: Integration of the quad functions is not a feature of indemnity plans in which there is open access to any provider, and the provider’s charges are reimbursed on a fee-for-service basis. Both managed care and prepaid plans make contractual arrangements with selected providers Utilization control measures are lacking in both indemnity and fee-for-service prepaid plans Both managed care and prepaid plans put providers at risk to the extent that providers may deliver services in excess of what the capitated or prepaid rates cover Health Maintenance Organization Act, 1973—federal funds for the development of HMOs as an alternative to fee for-service to stimulate competition to contain the growth of healthcare expenditures. At the time, HMOs did not become popular because the insured preferred open access and minimal controls over utilization. REASONS FOR GROWTH OF MANAGED CARE IN THE 1990S: • Failed attempts toward a national healthcare system reform proposed by Clinton • Growth of healthcare costs MAIN CHARACTERISTICS OF MANAGED CARE: • Defined group of enrollees
  • 77. • Comprehensive services • Capitation or discounted fees as payment methods • Risk sharing with providers • Limits on choice of providers • Utilization controls • Financial incentives to providers for efficiency • Accountability for plan performance (quality) INTEGRATION OF HEALTH CARE DELIVERY FUNCTIONS • Financing—assist employers to manage financing • Insurance—MCO assumes risk; an estimated 17–20% of premium is retained for insurance costs • Delivery—80–83% medical loss ratio; healthcare delivery is arranged through employed physicians or contracts • Payment—risk sharing in varying degrees with providers: • Capitation (PMPM)—most risk sharing • Discounted fees, fee schedule—minimum risk sharing • Salaries—coupled with bonuses and withdrawals tied to utilization patterns allows some risk sharing INEFFICIENCIES IN THE CONVENTIONAL INSURANCE SYSTEM: Due to fragmentation of health delivery functions: • Premiums were adjusted based on utilization and charges set by providers • Payment by item-by-item claim (fee-for-service) without questions asked • No controls over utilization (Q) and charges (P); hence, little control over expenditures (E): E = P _ Q • Insured were free to go to any providers; moral hazard and provider-induced demand also led to unbridled utilization • Sickness coverage—no wellness (prevention) coverage COST CONTROL IN MANAGED CARE: • Elimination of insurance and payer intermediaries • Risk sharing with providers to minimize provider induced demand—indirectly controls utilization • Limiting the choice of providers—indirectly controls utilization • Open panel (open access, out-of-network) • Accompanies higher cost sharing to discourage open access • Closed panel (closed access, in-network) • Offers better utilization control • Gatekeeping • Primary care provider • Point of entry • Coordination of care
  • 78. • Higher level services covered only on referral • Drug formularies (list of approved drugs) are used to contain rising prescription costs • Case management is found particularly valuable in three types of situations: 1. When conditions require secondary and tertiary care more often than primary care; 2. When appropriate community-based long-term care services can be provided instead of costly nursing home placement; 3. When complex problems require a variety of services along the continuum of care over an extended period of time: • Utilization review (UR)—process for evaluating the appropriateness of health services utilization • Commonly applies to inpatient stay: Review each case, Determine the most appropriate level of services, Determine the most appropriate setting; planning of subsequent care • Discharge planning: Expected inpatient stay, Anticipated outcomes, Next appropriate setting Special requirements • Utilization review falls into three categories: 1. Prospective—prior authorization (precertification), second opinions; 2. Concurrent—length of stay and discharge planning; 3. Retrospective—review of medical records, claims review • Practice profiling—evaluation of individual practice patterns by comparing them to a norm DISADVANTAGES OF MANAGED CARE: 1. Numerous health plans add to complexity and system-wide administrative costs Determination of coverage, prior approvals, cost sharing, billing; 2. Lengthy appeals for denied services; 3. Possibility of underutilization TYPES OF MCOS HMOs • Emphasize preventive services • Use capitation to pay providers—maximum risk sharing • Closed panel • Control over utilization and accountability for quality • May employ physicians on salary—some risk sharing Types of HMOs 1. Staff model 2. Group model—large group 3. Network model—more than one medical group 4. Independent practice association—intermediary between HMO and providers; risk bearing entity; paid a capitated fee PPOs • Contracts with preferred providers
  • 79. • Discounted fee arrangements • Allows use of open panel • Little or no risk sharing • Little control over utilization Point of service (POS) plans • Combine features of HMOs (capitation, gatekeeping) and PPOs (open panel at a higher cost sharing) ORGANIZATIONAL INTEGRATION • Phenomenon has accompanied the growth of managed care • A response by providers to a fear of dominance by managed care Advantages of integration • Greater efficiencies and cost-containment • Ability to offer a continuum of services sought by managed care Disadvantages of integration • Complex to manage • Confusing to patients Three general models of integration 1. Consolidation—control over organizations by consolidating existing assets, for example, acquisitions, mergers, alliances (existing facilities) 2. Expansion—expanding existing or new services through building expansion (new facilities) 3. Diversification—entering into new services through consolidation, expansion, or utilization of existing resources INTEGRATED DELIVERY SYSTEM • Also called organized delivery systems or integrated service (delivery, provider) networks • A network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population serviced. • Major participants are physicians and hospitals, who sometimes also join hands with insurance companies or MCOs: MSOs—management services organizations (because most physician groups are small); PSOs—provider-sponsored organizations (function as MCOs); risk-bearing entities; PHOs—physician hospital organization; contract with MCOs or direct contract with employers
  • 80. SERVICE CONSOLIDATION • Horizontal integration—a mode of geographic expansion, not diversification • Vertical integration—to add services along the continuum (diversification) TERMINOLOGY • Acquisition—Refers to the purchase of one organization by another. • An alliance—A joint agreement between two organizations to share their resources without joint ownership of assets. • Antitrust—Refers to federal and state laws that make it illegal to form an integrated delivery system (IDS) for the purpose of stifling competition. Business practices prohibited or regulated by antitrust laws include price fixing, price discrimination, exclusive contracting arrangements, and mergers among competitors. • Any willing provider laws (AWP)—Prevent deliberate exclusion of a physician from participation in a managed care plan when the physician meets the criteria for participation. • Capitation—Payment of a fixed amount per enrollee (per member per month) to cover all services the enrollee may need. • Carve out—A special contract to cover specialized services that are funded by a managed care organization separately from regular capitation. • Case management—The coordination and management of care over a period of time by an experienced healthcare professional. In consultation with primary and secondary care providers, case managers determine what care is necessary. Patients are channeled through the health delivery system to receive services in the most appropriate and cost- effective settings. • Closed panel (or closed-access)—Refers to a plan that does not allow enrollees to use providers outside the panel. • Consolidation—Refers to a concentration of control by a few organizations over other existing organizations through a consolidation of facility assets that already exist. Acquisitions, mergers, alliances, and formation of contractual networks are examples of consolidation. • Discharge planning—Includes an estimate of how long the patient will be in the hospital, what the expected outcome is likely to be, whether there will be any special requirements at discharge, and what needs to be facilitated. • Diversification—Refers to the addition of new services that the organization has not offered before. • Expansion—A growth strategy in which an organization builds new facilities to add new services or services similar to those it has offered before. • Fee schedule—A list of prenegotiated fees for each type of service. • Gag rules—Clauses in managed care contracts that prohibit providers from speaking to patients about coverage, treatment options, and treatment determinations made by the plan.
  • 81. • A group model HMO—Contracts with a multispecialty group practice, and separately with one or more hospitals, to provide comprehensive services to its members. • An HMO (health maintenance organization)—A managed care organization (MCO) that provides comprehensive medical services for a predetermined annual fee per enrollee. • Horizontal integration—A growth strategy in which a health delivery organization extends its core product or service. • An independent practice association (IPA)—A legal entity representing a large number of physicians that is organized for the purpose of establishing contracts with HMOs. • An integrated delivery system—May be defined as a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population within its geographic service area. • Integration—A broad expression that may refer to certain types of consolidations, expansions, or diversifications that generally involve new products or services. • The IPA model—An organizational arrangement in which an HMO contracts with an independent practice association for the delivery of physician services. • A joint venture—Results when two or more institutions share resources to create a new organization to pursue a common purpose. • A merger—Involves the unification of two or more organizations into a single entity through mutual agreement. • A mixed model—An organizational arrangement in which an HMO cannot be categorized neatly into a single model type because it features some combination of large medical group practices, small medical group practices, and independent practitioners, most of whom have contracts with a number of managed care organizations (MCOs). • MSO—Stands for management services organization. An MSO is an organization that brings management expertise and, in some instances, capital for expansion to physician groups. • A network model—An organizational arrangement in which an HMO contracts with more than one medical group practice. • Open panel (or open-access)—Refers to a plan that allows access to providers outside the panel, but some conditions apply, such as higher out-of-pocket costs. A panel is composed of physicians who have formal affiliations with an MCO. • Panel—Providers selected by an MCO to render services to the MCO’s enrollees. • APHO (physician-hospital organization)—A legal entity that allows a hospital and its physicians to negotiate with MCOs or, if a PHO is large enough, to contract directly with employers. • Point-of-service plans—Combine features of classic HMOs with some of the characteristics of patient choice found in PPOs. • APPO—A type of managed care organization that has a panel of preferred providers who are paid according to a discounted fee schedule. The enrollees do have the option to go to out-of-network providers at a higher level of cost sharing. • Practice profiling—Refers to the development of provider-specific practice patterns and comparing individual practice patterns to some norm. • Primary care case management (PCCM)—A variation of the managed care arrangement in which a state contracts directly with primary care providers who agree to
  • 82. be responsible for the delivery and/or coordination of medical services for Medicare recipients under their care. Payment is on a fee-for-service instead of capitation basis. PCCM programs are authorized by section 1915(b) of the Social Security Act. • A PSO (provider-sponsored organization, sometimes called provider service organization)—A quasi-managed care organization; that is, it is a risk-bearing entity sponsored by physicians, hospitals, or jointly by physicians and hospitals to compete with regular MCOs. • Risk adjustment—The adjustment of premiums to reflect health status and thus the potential utilization of medical care. • A risk contract—Categorizes beneficiaries in risk categories such as age, sex, and disease/disability status, and establishes separate premiums for each category to reflect higher or lower risks. • A staff model HMO—Employs its own salaried physicians. • Utilization review (UR)—Sometimes also referred to as utilization management (UM), is the process of evaluating the appropriateness of services provided. • Vertical integration—Links services that are at different stages in the production process of health care, for example, organization of preventive services, primary care, acute care, and postacute service delivery around a hospital. • Virtual integration—The formation of networks based on contractual arrangements. End Week 9 WEEK 10 Start Week 10 Objectives: Chapter 10 1. Comprehend the concept of long-term care (LTC) 2. Identify who needs LTC and why 3. Identify the different types of community-based LTC 4. Name the types of LTC institutions and levels of service 5. Understand the demographics of nursing homes and residents 6. Observe industry trends in LTC 7. Learn about sources of LTC financing
  • 83. Reading Assignments: a) Chapter 10, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 12 and the topic for you to analyze is: Telemedicine expansion, Electronic Medical Record Utilization and Computerized Physician Order Entry System Utilization (do all three items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 29 points) 1. Long-term care services must be individualized, integrated, and coordinated. Elaborate on this statement, pointing out why these elements are essential in the delivery of long-term care. (Comprehension: 2 points) 2. Age is not the primary determinant for long-term care. Comment on this statement, explaining why this is or is not true. (Application: 3 points) 3. Long-term care is generally needed over an extended period of time. Comment on this statement. What do some of the recent trends suggest in this regard? (Comprehension: 2 points)
  • 84. 4. Long-term care services are an amalgam of health care and social services. Comment on this statement, providing appropriate examples. (Application: 3 points) 5. Discuss the preventive and therapeutic aspects of long-term care. (Comprehension: 2 points) 6. What is meant by “quality of life”? Discuss the quality-of-life features as they pertain to (1) long-term care delivered in LTC facilities and (2) hospice care. (Comprehension: 2 points) 7. What responsibilities does a long-term care facility have toward meeting the acute care needs of patients? (Comprehension: 2 points) 8. What is the difference between mental illness and mental retardation? (Comprehension: 2 points) 9. What implications does an aging population have for long-term care services? (Synthesis: 4 points) 10. What are the main objectives of community-based long-term care? (Comprehension: 2 points) 11. Give a profile of the person most likely to use home health care. What are the requirements for receiving Medicare coverage for skilled nursing care provided in the home? (Comprehension: 2 points) 12. Discuss the three different models of adult day care. Which services are common to all three models? (Application: 3 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. Enumerate the main functions of long-term care case management. 2. What is an S/HMO? Who is served by S/HMOs? What services do they provide? What are the funding sources? What are the similarities and differences between the S/HMO and PACE models? 3. Briefly discuss the continuum of institutional long term care services. 4. What is the difference between licensure and certification? What are the two types of certifications? What purpose does each serve from (1) a clinical standpoint, and (2) a financial standpoint?
  • 85. 5. Why is subacute care of interest to MCOs? What are some of the advantages hospitals have in operating subacute care units? What are some of the disadvantages skilled nursing facilities face in operating similar types of units? 6. Even though the elderly are the primary users of nursing homes and, generally speaking, Medicare is the primary source of payment for healthcare services provided to the elderly, why does Medicare pay only a small fraction of the cost of nursing home care? 7. Even though the Medicaid program is for the poor, it has been used more and more by middle-class elderly to finance institutional long-term care. Explain. 8. Despite the availability of private long-term care insurance, why does the future of long-term care financing pose some critical problems? Summary of Week: CHAPTER 10 Long-Term Care Long-term care (LTC) is, and will remain, a growing sector. Main reason—aging of the population. Chronic conditions often result in disability. But, LTC is not confined to the elderly. Also, the majority of the elderly do not require LTC although the odds of LTC utilization increase with age. Chronic condition—a persistent negative health condition that continues over a long period of time. • Generally irreversible. Cure is not possible. • Can cause decreased independent functioning. • Calls for assistance and monitoring. The goal of LTC is to promote independent functioning to the greatest possible extent. WHAT IS LONG-TERM CARE? • LTC is much more than care provided in nursing homes. • LTC is often needed for assistance due to functional impairment, post-acute convalescence, and rehabilitation. • Functional impairment—inability to perform certain basic functions necessary for daily living. A key determinant of need for LTC. • Functional assessment—measurement or evaluation of independent functioning. 1. ADL scale—activities of daily living, 6 areas of personal care: a. Eating b. Bathing c. Dressing d. Toileting e. Transfer
  • 86. f. Maintaining continence 2. IADL scale—Instrumental activities of daily living—necessary for independent living—can be more easily supplemented than ADLs: a. Cooking b. Shopping c. Housekeeping d. Money management KEY CHARACTERISTICS OF LONGTERM CARE • Range of services—continuum (spectrum). Include: 1. Health care Management of chronic conditions Assistance with functional impairments Coordination of other needed services 2. Mental health Psychological/psychiatric Behavioral (wandering, combativeness) Mental retardation 3. Social support Social interaction Recreation Spiritual needs Money management, will, estate planning 4. Housing Assistive Comfort/cleanliness Safety Privacy Meals/laundry (hotel services) may be needed • Duration of care Extended period of time compared to acute services Short-term LTC—90 days or less • Integration of care—LTC services must be rationally integrated (linked) with the rest of the health delivery system —primary care, acute care, mental health. LTC takes responsibility for these services for patients under its care. LEVELS OF INTENSITY • Personal care—basic ADL assistance; informal care or care provided by paraprofessionals • Custodial care—maintenance of functioning • Personal care + basic functional maintenance (range of motion, ambulation, etc.)—care provided by paraprofessionals • Restorative care—professional therapies + basic functional maintenance • Skilled nursing care—clinical care is provided and directed by licensed nurses
  • 87. • Subacute care—postacute THE NATURE OF LTC Preventive and therapeutic; holistic approach • Preventive—prevent or delay institutionalization • Preventive medical services • Nutrition • Social support—a variety of supplementary services (homemaker, errands, repairs) • Other community-based services • Therapeutic • Medical history, physical, and needs assessment • Nursing care • Medications • Rehabilitation therapies • Recreational activities • Special diets • Spiritual pursuits Informal or formal • Informal—unpaid, rendered by family or friends Mostly lighter assistance with IADLs • Formal—paid Community-based or institutional services Respite care to offer caregivers some relief from stress and burnout Community-based services • Home health care • Patients’ eligibility for home health (Medicare) 1. Three-day prior hospitalization 2. Must be homebound 3. Physician must certify the need for care 4. Must need Skilled Nursing Care and/or rehab therapies • Adult day care • Supplementary service to informal care • A type of respite care • Adult foster care • Family run group homes • Senior centers • Provide congregate meals and socialization • May also provide health-related educational programs • Home-delivered meals (meals-on-wheels) • Funded through Title VII of the Older Americans Act • Homemaker services
  • 88. • Limited availability of services • Emergency response/telephone reassurance • Also known as PERS (personal emergency response systems) Case management • Coordinate the varied and changing needs within the continuum of long-term care services • Four key elements: 1. Assessment and care planning 2. Referral to services that are most appropriate and cost effective 3. Financing arrangements 4. Follow up • Three models: 1. Preadmission screening—to determine whether institutionalization is most appropriate 2. Brokered model—referral, to arrange for services based on assessed needs 3. Consolidated model—managed care; actual delivery of LTC services based on assessed needs • Examples of consolidated model: • S/HMO—services to Medicare enrollees • On-Lok, San Francisco—enrollment after a person has been certified for nursing home admission • PACE—replication of the On-Lok project Hospice care • End-of-life care for the terminally ill • A range of services (holistic in nature): • medical—palliative (to provide relief) • comfort—counseling • spiritual • legal • bereavement support for the family INSTITUTIONAL LTC Integration of key services in an institutional setting: • Health care • Mental health • Social support • Housing The extent of integration depends on the level of care CONTINUUM OF INSTITUTIONAL CARE
  • 89. 1. Retirement living (independent living facility) • Emphasizes independence, housing, and social support • Private funds, some subsidized by the government (HUD—funding under Section 202 of the National Affordable Housing Act of 1990). 2. Residential care (includes personal care facilities, board-and-care homes) • Emphasizes housing and social support • Minimal health care: supervision, personal care (drug use management, help with light ADLs) • Private-pay, SSI payment 3. Assisted living—level of services are somewhere in between independent living and the traditional nursing home • Basic assistance with ADLs, some custodial nursing care • Mostly private-pay, Medicaid coverage in some states (which also require licensing of such facilities) For the above three types, intermittent healthcare services can be arranged through a home health agency. Discharge is mainly due to the need for higher level services. 4. Nursing facilities • All facilities are licensed by state • Federal certification is optional: Certified by the Centers for Medicare and Medicaid Services (a federal agency under the Department of Health and Human Services). Certification allows a facility to receive Medicare and/or Medicaid funding • Noncertified—does not qualify for federal or state funding; can admit only private paying or private insurance patients • JCAHO accreditation is voluntary • Federal certifications: For Title 18 (Medicare)—SNF, freestanding or distinct part For Title 19 (Medicaid)—NF Dual certification—SNF and NF 5. Subacute care facilities—require SNF certification • Distinct parts in nursing homes • TCUs or ECUs in hospitals to utilize excess capacity • Clinically complex post-acute monitoring and treatment—higher level of health care than SNFs • Emphasize health care over social support and housing • Particularly attractive to managed care because costs are lower than acute care in hospitals 6. Specialized facilities ICF/MR (separate federal certification)—financed by Medicaid Alzheimer’s facilities—specialized environment and security are emphasized CCRC (Continuing Care Retirement Community) • Provides the full range of institutional services on one campus
  • 90. • Facilitates the changing healthcare needs of older adults • Independent living cottages or apartments • Require entrance fee + monthly maintenance fee • Assisted living • SNF—Medicare certification • Private financing except SNF TERMINOLOGY • Adult day care—A daytime program of nursing care, rehabilitation therapies, supervision, and socialization that enables frail elderly people to remain in the community. Services are generally provided on weekdays, usually between 7:00 A.M. and 5:30 P.M. Participants come in the morning and return home in the evening. • Adult foster care—Provided in small, family-operated homes, located in residential communities, which provide room, board, and varying levels of supervision, oversight, and personal care to nonrelated adults. • Affiliation—A term used to categorize long-term care (LTC) facilities into multi-facility chain and independent facilities, and hospital-based and nonhospital-based facilities. • Alzheimer’s disease—A progressive degenerative disease of the brain producing loss of memory, confusion, irritability, and severe loss of functioning. The disease becomes progressively worse and eventually results in death. • An assisted living facility—Can be described as a residential setting that provides personal care services, 24-hour supervision, scheduled and unscheduled assistance, social activities, and some healthcare services. • Brokered model—An approach to long-term care case management in which case managers arrange services through other providers once needs have been independently assessed. • Case management—The method of linking, managing, and coordinating services to meet the varied and changing healthcare needs of clients needing formal long-term care services. • CCRC—Stands for continuing care retirement community. A CCRC integrates and coordinates the independent living and other institution-based components of the long term care continuum. Different levels of services are generally housed in separate buildings, all located on one campus. • Chronic condition—A persistent, recurring, and often irreversible health problem lasting over a period of time. Examples include arthritis, diabetes, hypertension, heart disease, and dementia. • Consolidated model—An approach to long-term care case management in which a multidisciplinary team of health professionals assesses individual needs. The team also plans, organizes, and delivers most of the care. Certain services, such as hospital, diagnostics, and home healthcare, are provided under contract, but care provided by other organizations is closely monitored and managed. • Custodial care—Emphasizes functional maintenance through ADL assistance and routine functional exercises such as range of motion and ambulation. Services are typically provided by paraprofessionals rather than licensed nurses.
  • 91. • A developmental disability—A physical incapacity that generally accompanies mental retardation. It often arises at birth or in early childhood. • A distinct part—A section of a nursing home that is distinctly certified from the rest of the facility. It generally refers to an SNF distinct part. • Dual certification—Means that a facility, or section of a facility, has both SNF and NF certifications. Dual certification allows a facility to admit both Medicaid and Medicare patients. • Facility size—Indicated by the number of beds in a nursing home. • Long-term care—Provides a range of health care, mental health, social support, and housing services to temporarily or chronically impaired persons with the goal of enabling them to maintain as high a level of independent functioning as possible. • Meals-on-wheels—A program of home-delivered meals for the elderly. The program is administered by Area Agencies on Aging under Title VII of the Older Americans Act. • Mental retardation—Refers to significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior. It is manifested during the developmental period. • NF—The federal certification of a skilled nursing facility that enables a facility to admit Medicaid but not Medicare patients. • A non-certified nursing facility —Licensed but does not have either SNF or NF certification, and therefore cannot admit Medicaid or Medicare patients. • Ownership—Refers to whether the facility is proprietary, private nonprofit, or government-owned (public). • PACE—Stands for Program of All-inclusive Care for the Elderly. PACE is an example of the consolidated model of long-term care case management for clients who have been certified as eligible for nursing home placement. It has had a high success rate in keeping clients in the community. • Paraprofessionals—Personnel, such as certified nursing assistants and therapy aides, who provide basic ADL functions and/or assist licensed and professional staff. • PERS—Stands for personal emergency response system. It provides at-risk elderly persons effective and convenient means to summon help when an emergency occurs. A transmitter unit enables the individual to activate an alarm that sends a medical alert to a local 24-hour response center. • Personal care—Assistance with basic ADLs. • Preadmission screening—The assessment of an individual’s functional status by a trained health professional prior to institutional placement to determine whether alternative community services would be more appropriate. • Private-pay patients—Patients not covered by either Medicare or Medicaid. • Quality of life—Refers to the integration of social, environmental, and personal factors into the delivery of care. Examples include safety, comfort, dignity, interpersonal relations, privacy, and attention to personal preferences. • Respite care—Either community- or institution-based long-term care service that takes over the care of a patient temporarily so that informal caregivers can have some time off. For example, adult day care is a type of respite care since it allows family members to work during the day. Temporary placement of the patient in a nursing home can allow a family to take a vacation.
  • 92. • Restorative care—Provides typical rehabilitative therapies such as physical therapy, occupational therapy, and speech therapy, and/or it integrates restoration of functioning into the daily care routine. • Senior centers—Local community centers for older adults that provide opportunities to congregate and socialize. Many centers offer subsidized meals, wellness programs, health education, counseling, and referral services. • S/HMO—Stands for social health maintenance organization. S/HMO is an example of the consolidated model of long-term care case management that coordinates both long- term care and acute care services for Medicare beneficiaries who are voluntarily enrolled in the program. • Skilled nursing care—Medically oriented care provided by a licensed nurse, including monitoring of acute and unstable chronic conditions, evaluation of the patient’s care needs, injections, care of wounds and bed sores, tube feedings, and clearing of air passages. Rehabilitation therapies often form an important component of skilled nursing care. • SNF—The federal certification of a skilled nursing facility that enables the facility to admit Medicare patients. • Spend-down—The depletion of personal assets and income to the medically needy level established by a state as a requirement for Medicaid eligibility. • Subacute care—Provides postacute services that are above and beyond traditional skilled nursing care. This type of care is indicated for patients who remain critically ill during the postacute phase of illness or injury. • Transitional care units—Hospital-based long-term care units certified as SNF. End Week 10 WEEK 11 Start Week 11 Objectives: Chapter 11 1) Learn the population groups facing greater challenges and barriers in health care access 2) Understand racial and ethnic disparities in health status 3) Be acquainted with the health concerns of America’s women 4) Appreciate the challenges faced by rural health and the homeless 5) Understand the nation’s mental health system.
  • 93. 6) Understand the AIDS epidemic in America, a. the groups affected by it, and b. the services available to HIV/AIDS patients Reading Assignments: a) Chapter 11, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) There are no quizzes this week Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. b) Your next Thought Worksheet Assignment is due in week 12 and the topic for you to analyze is: Telemedicine expansion, Electronic Medical Record Utilization and Computerized Physician Order Entry System Utilization (do all three items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 20 points) 1. What are the racial/ethnic minority categories in the United States? (Knowledge: 1 point) 2. Compared with white Americans, what are the health challenges faced by minorities? (Comprehension: 2 points) 3. Who are the AAPIs? (Knowledge: 1 point)
  • 94. 4. What is the Indian Health Service? (Knowledge: 1 point) 5. What are the health concerns of children? (Comprehension: 2 points) 6. Which childhood characteristics have important implications for health system design? (Synthesis: 4 points) 7. Which health services are currently available for children? (Comprehension: 2 points) 8. What are the health concerns of women? (Knowledge: 1 point) 9. What are the roles of the Office on Women’s Health? (Knowledge: 1 point) 10. What are the challenges faced in rural health? (Knowledge: 1 points) 11. What measures are taken to improve access to care in rural areas? (Comprehension: 2 points) 12. What are the characteristics and health concerns of the homeless population? (Comprehension: 2 points) ONLINE CHAT & DISCUSSION BOARD QUESTIONS 1. How is mental health provided in the United States? 2. Who are the major mental health professionals? 3. How does AIDS affect different population groups in the United States? 4. Which services and policies currently combat AIDS in America? Summary of Week: CHAPTER 11 Health Services for Special Populations RACIAL/ETHNIC GROUPS • White (W) Black (B) Hispanic (H) Native American (N) Asian (A) W B H N A • Fair or poor health (self-assessed) 2 4 3 5 1
  • 95. • Death from heart disease 4 5 2 3 1 • Death from cancers 4 5 2 3 1 • Death from diabetes 2 4 3 5 1 • Death from HIV/AIDS 3 5 4 2 1 • Suicide 4 3 1 5 2 • Death from unintentional injuries 3 4 2 5 1 • Homicides 2 5 4 3 1 • The US healthcare system does not have a systematic approach to addressing these variations, particularly the wide variations between blacks and the rest of the population. • The uninsured • Almost one in four working American adults is uninsured. • Those most likely to be uninsured: poor, less educated, part-time workers, those working for small employers, young adults, minorities. • American Indians are covered under the Indian Health Service system, but financial support of the system has been waning. • One third of all Hispanics are uninsured. • 14% of all children (those under age 18) are uninsured. • Main reasons why many working adults are uninsured: 1. Many small employers do not offer health insurance. 2. Many do not qualify because they are part-time or have not been employed long enough with the current employer. 3. Many cannot afford the premium sharing cost. • Children • Private health insurance and regular Medicaid coverage have shrunk. • Children’s health insurance program (CHIP) allocated $24 billion in federal funds to cover 10 million uninsured children. • Unique issues: 1. Developmental vulnerability—illness, injury, family, and other social circumstances have an impact on a child’s life-course trajectory. 2. Dependency—children face special circumstances in that adults generally have to recognize and respond to their healthcare needs. 3. New morbidities—youngsters face challenges related to drug and alcohol abuse, family and neighborhood violence, emotional disorders, learning problems, and other problems such as teenage pregnancies, tobacco use, etc…. These dysfunctions are mostly linked to family and socioeconomic conditions. • Women • Women have a greater life expectancy than men, but face greater morbidity and poorer health outcomes. • Compared to men, women develop more acute and chronic illnesses and resulting disabilities. • Certain mental disorders, especially depression, are more common among women. • Eating disorders, such as bulimia and anorexia nervosa, and dementia, such as Alzheimer’s disease, predominantly occur in women. • Certain disorders, such as alcohol abuse, are increasing among women.
  • 96. • The Office on Women’s Health has initiated numerous programs to address some of the above concerns. • Women are the principal users of healthcare services, and often coordinate health care for their families. However, women under the age of 65 are 11% less likely to be insured than men. • Rural health • Access to health care is one of the major problems in rural areas. Principal reasons include poverty, long distances, lack of personal transportation, geographic maldistribution of healthcare professionals, and closure of rural hospitals. • Initiatives designed to alleviate access problems: 1. The National Health Service Corps (NHSC)—provides scholarships that require professionals to work in underserved areas. 2. Health Manpower Shortage Areas (HMSAs)—classifies areas on a scale of one to four according to severity of physician shortage for the purpose of targeting financial incentives to attract physicians. 3. Medically Underserved Areas (MUAs)—the index of medical underservice has been developed to target the community health center and rural health clinic programs. 4. Community and Migrant Health Centers (C/MHCs)—provide services to low-income populations by establishing sliding-fee scales based on income. Minorities are the highest users of their services. 5. The Rural Health Clinics Act—authorizes Medicaid and Medicare reimbursement for the services of nonphysician providers. Rural clinics can employ physician assistants, nurse practitioners, and certified nurse midwives to practice without the direct supervision of a physician. 6. Managed care has the potential to improve medical care delivery in rural areas because they often possess the needed resources and infrastructure. However, the demographic and geographic characteristics of rural communities pose significant barriers to managed care. • Homeless • As many as 3 million Americans are homeless. • 8% of the homeless are parents with children. • One third of all homeless men are Veterans. • 20% of the homeless adults are women. • High rates of substance dependence, and mental and physical illness among the homeless. • They overuse hospital and inpatient services, but lack access to ambulatory care. • Health care is fragmented • Health care for the homeless (HCH) program provides grants to private organizations serving the homeless. • The Mental Health Services for the Homeless provides block grants. • Homeless Families Program is a national demonstration project. • The Salvation Army is a private charity that provides food and shelter. • Some scattered free clinics are funded by private donors and staffed by volunteer medical students. • Mental Health
  • 97. • 20% of Americans have a mental disorder in any given year. • Burden on health and productivity is only second to heart disease. • They often go untreated. • Mental illness is a risk factor for suicide, cardiovascular disease, and cancer. • David Satcher’s proposal • Continue to build the science base • Overcome stigma • Improve public awareness of treatments • Improve the supply of mental health services • Tailor treatment to age, gender, race, and culture • Facilitate access to treatment • Reduce financial barriers • Access and expenditures: • 40% private—private psychiatric hospitals and ambulatory mental health clinics. • 22% federal government programs—private psychiatric hospitals and ambulatory mental health clinics that accept Medicaid and Medicare reimbursement. • 38% state and local government programs—state and county mental hospitals and community mental health clinics, mainly serving the uninsured. • Managed care is playing an increasing role in the delivery of mental health care. • Psychiatrists and other mental health professionals are contracting with HMOs to serve enrolled populations under capitated arrangements. • Employers often contract out (as a separate carve out from the regular health plan) behavioral health coverage to specialized providers. • The chronically ill and disabled • The US health care system is primarily oriented towards treating acute illness. • A significant number of deaths are attributable to preventable chronic conditions. • Health promotion and disease prevention programs can play a significant role in the prevention of chronic illness. • As chronic disease and disability continue to increase due to an aging population, the healthcare delivery system needs to be refocused. • HIV/AIDS • The incidence of these conditions has continued to increase despite massive public health efforts. • Mortality rates have declined due to new drug treatments • The rate of hospitalization has also declined. • Despite these improvements, HIV/AIDS remains a primary public health concern especially among blacks, Hispanics, and minority women. It remains a leading cause of death among blacks and Hispanics. These racial differences most likely reflect social, economic, behavioral, and other factors associated with HIV transmission. • AIDS has become a global pandemic, especially in under-developed countries.
  • 98. • Infection often goes unreported due to lack of access to health care where it could be diagnosed, lack of diagnostic ability (rapid HIV testing methods now facilitate diagnosis), poor reporting standards, and protection of confidentiality by physicians. • Home health care will play a major role in the care of AIDS patients as institutionalization becomes unnecessary except in the acute phases of illness. • Healthcare providers in rural areas have to deal with an increasing number of infected patients who are mostly young, nonwhite, and female. However, facilities in rural areas have fewer resources. • An infected mother has a 25% chance of passing the infection to the newborn. Testing, counseling, health education, and treatment with the AZT drug are key interventions. • Although the majority of people with AIDS are men, infected women are progressing to the AIDS stage at a much faster rate. Black and Hispanic women have been particularly vulnerable to contracting HIV. TERMINOLOGY • AIDS—Stands for acquired immune deficiency syndrome. It is a fatal disease believed to be caused by the human immunodeficiency virus (HIV). HIV is an unusual type of virus, called a retrovirus, which causes immune system suppression, leading to AIDS. Individuals infected with HIV generally develop antibodies within a short period of time but may exhibit no symptoms for many years. Typically, the immune system weakens gradually and the blood level of CD4 cells (a type of white blood cell known as a T- helper/inducer lymphocyte) declines from a normal level of between 1200 and 1400/mm. The development of AIDS is estimated to occur at 11 years, on average, from the time of HIV infection. • Dependency—Refers to the special circumstances children face in that others often have to recognize and respond to their health needs. Children are dependent on their parents, school officials, caregivers, and sometimes neighbors to recognize and respond to their health needs, seek healthcare services on their behalf, authorize treatment, and comply with recommended treatment regimens. • Developmental vulnerability—Refers to the rapid and cumulative physical and emotional changes that characterize childhood, and the potential impact that illness, injury, or untoward family and social circumstances can have on a child’s life-course trajectory. • Disability—Refers to impairment of bodily functions, and therefore the restrictions of performing activities of daily living. • HIV—Stands for human immunodeficiency virus. See also AIDS (acquired immune deficiency syndrome). • Homophobia—Refers to a prejudice, fear, and/or hatred of gays and lesbians. Homophobia explains the initial slow policy response to the HIV epidemic. Historically, homophobia has been supported by powerful social institutions such as religious institutions, the law, the medical profession, and the media. • The Medicaid waiver program—Enables states to design packages of services targeted at specific populations, such as the elderly, the disabled, and those who test HIV positive. The waiver is an alternative to some form of institutional care.
  • 99. • The mental health system in the United States is composed of two subsystems, one primarily for individuals with insurance coverage or money, and one for those without. Patients without insurance coverage or personal financial resources are primarily treated in state and county mental health hospitals, or in community mental health clinics. Patients with insurance coverage or the personal ability to pay receive care from both inpatient and ambulatory mental healthcare systems. • New morbidities—Include drug and alcohol abuse, family and neighborhood violence, emotional disorders, and learning problems from which older generations do not suffer. These dysfunctions originate in complex family or socioeconomic conditions rather than biological causes exclusively. • HIV weakens the body’s ability to fight disease. People with HIV can get many infections (called opportunistic infections), which are rarely seen in those with normal immune systems. Many of these illnesses are very serious and deadly to those with HIV. • Psychiatrists—Physicians who receive postgraduate specialty training in mental health after completion of medical school. They treat patients with mental disorders, prescribe drugs, and admit patients to hospitals. • Psychologists—Usually hold a PhD, although some hold master’s degrees. They cannot prescribe drugs. They are trained in interpreting and changing the behavior of people. They provide a wide range of services to patients with neurotic and behavioral problems using techniques such as psychotherapy and counseling. End Week 11 WEEK 12 Start Week 12 Objectives: Chapter 12 1) Understand: a. health care costs and their trends b. why some regulatory cost-containment approaches were unsuccessful c. nature, scope and dimensions of quality d. the difference between quality assurance and assessment 2) Be familiar with regulatory and market-oriented approaches to contain costs 3) Appreciate the framework and dimensions of access to care 4) Learn about access indicators, metrics and measurements
  • 100. Reading Assignments: a) Chapter 12, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. b) Complete Quiz 3 on the Web Course Thought Worksheet Assignment: a) Thought Worksheet #4 is due this week. b) Your next Thought Worksheet Assignment #4 is due this week (week 12) and the topic for you to analyze is: Telemedicine expansion, Electronic Medical Record Utilization and Computerized Physician Order Entry System Utilization (do all three items together). Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 25 points) 1. What is meant by the phrase “healthcare costs?” Describe the three different meanings of the term “cost.” (Comprehension: 2 points) 2. Why should the United States control the rising costs of health care? (Synthesis: 4 points) 3. How do findings of the Rand Health Insurance Experiment reinforce the relationship between growth in third-party reimbursement and increase in healthcare costs? Explain. (Comprehension: 2 points) 4. Explain how, under imperfect market conditions, both prices and quantity of health care are higher than they would be in a highly competitive market. (Synthesis: 4 points)
  • 101. 5. What are some of the reasons for increased healthcare costs attributable to the providers of medical care? (Comprehension: 2 points) 6. What are some of the main differences between broad cost-containment approaches used in the United States and those used in countries with national health insurance? (Synthesis: 4 points) 7. Discuss the effectiveness of CON regulation in controlling healthcare expenditures. (Comprehension: 2 points) 8. Discuss price controls and their effectiveness in controlling healthcare expenditures. (Comprehension: 2 points) 9. Discuss the role of PROs (QIOs) in cost containment. (Comprehension: 2 points) 10. What are the four competition-based cost-containment strategies? (Knowledge: 1 point) ONLINE CHAT AND DISCUSSION BOARD QUESTIONS 1. What are the implications of access for health and healthcare delivery? 2. What is the role of enabling and predisposing factors in access to care? 3. Briefly describe the five dimensions of access. 4. What are the four main types of access described by Anderson? 5. Describe the measurement of access at the individual, health plan, and delivery system levels. 6. Discuss the dimensions of quality from the micro- and macro-perspectives. 7. Discuss the two types of health-related quality of life. 8. Differentiate between quality assessment and quality assurance. 9. What are the basic principles of TQM (or CQI)? 10. Give a brief description of the Donabedian model of quality. Summary of Week:
  • 102. CHAPTER 12 Cost, Access, and Quality COST Can have three different meanings: 1. Price of healthcare services—micro-perspective: How much financiers and consumers (patients) have to pay (P). Under managed care, PPS reimbursement, Medicaid rates, and competitive market situations, there is downward pressure on P. 2. National healthcare expenditures—macro-perspective: System-wide healthcare spending (E). 3. Cost of producing health care—provider perspective: An efficiency measure that influences the provider’s profitability. When there is downward pressure on P, control over the cost of production becomes critical. ACCESS • Ability of consumers to obtain health care when it is needed. • Theoretically, the uninsured lack access to health care. • Access governs the volume or quantity (Q) of healthcare services. QUALITY Three key elements: 1. Extent to which desired health outcomes are obtained. 2. Consistency with current professional knowledge in the delivery of care. 3. Quality applies at both individual (micro-perspective) and population (macro- perspective) levels. RELATIONSHIPS BETWEEN COST, ACCESS, AND QUALITY • Since, E = P _ Q, cost containment at the macro level requires limitations on P and Q. Constraining Q (demand side rationing or supply-side rationing) limits access. • In the US, prospects of universal access have been dampened by high costs. In countries that provide universal access, high costs force supply-side rationing, which also limits access. • Universal access generally does not limit basic and routine care, and produces better health outcomes at the population level (life expectancy, infant mortality, etc.). It produces better quality at the macro level. Lack of universal access produces poorer health outcomes, hence poorer quality at the macro level, even when the healthcare delivery system incurs higher costs. The latter holds true in the US. • Cost and quality are not necessarily trade-offs. Quality can be improved while lowering costs by eliminating services that are not cost-efficient. COST OF HEALTH CARE • Medical inflation has generally stayed above the rate of increase in CPI.
  • 103. • Healthcare spending has generally exceeded growth in GDP. • The healthcare industry has been among the fastest growing sectors of the US economy. • The US spends more on health care (per capita and as a percent of GDP) than any other developed country. • In recent years, there have been some signs of stabilization. Reasons why rising health care costs need to be controlled: • Healthcare costs cut into the consumption of other needed goods and services. • Excessive healthcare services result in waste of economic resources. • In the US, employer-based health insurance adds to the cost of business. To compete in international markets, US corporations must reduce their costs. • Publicly financed health insurance will require tax increases and/or cuts in benefits unless costs are controlled. • Unchecked increases in healthcare costs are likely to increase the number of the uninsured in America as a larger number of employers and employees would not be able to afford health insurance. Reasons for cost escalation: • Third-party payment—contributes to moral hazard and provider-induced demand because it insulates the consumers against the cost of health care. • Imperfect market—both Q and P remain unchecked (E = Q X P). • Growth of technology—research and development are costly, and are included in healthcare expenditures. This is one reason why the cost of pharmaceuticals has increased at an alarming rate in the US. Once developed, new technology often creates its own demand. • Increase in elderly population—they consume more health care than younger people. • Medical model—medical interventions are costlier than prevention and health promotion. • Multi-payer system—administrative costs in a multipayer system are nearly double of what they would be in a single-payer system. • Defensive medicine—additional tests and medical services are used merely as a protection against lawsuits. • Waste and abuse—general waste as well as fraud and abuse of various programs increase costs of health care. • Practice variations—geographic variations in treatment patterns across the country indicate cost-inefficient overtreatment. COST CONTAINMENT Cost-control efforts in the US are characterized by a combination of government regulation and market-based approaches: Regulatory approaches
  • 104. • Health planning—supply-side controls, such as CON. • Price controls—Medicaid rates, PPS reimbursement under Medicare, RBRVS. We may see price controls for pharmaceuticals unless the industry takes voluntary steps. • Peer review—PROs determine whether care delivered to Medicare beneficiaries is reasonable, necessary, and appropriate. • APGs are being developed to restrict reimbursement for ambulatory services. Competitive approaches • Cost-sharing by patients. • Antitrust provisions regulate competitiveness by prohibiting practices such as price fixing, exclusive contracting, and mergers that may create monopolies. • Payer-driven competition—employers shop for the best value in health insurance premiums, and MCOs try to obtain the best value from providers. This is referred to as the “bottom-up” approach. • Utilization controls implemented by a managed care “top-down” approach is used in national healthcare programs to control healthcare expenditures. Allocation of resources and expenditures within the system are constrained by global budgets. This approach is more effective in controlling total healthcare costs. ACCESS TO HEALTH CARE Implications: • Access to health care is a key determinant of health status (Blum’s model, Chapter 2). • Access is a key benchmark for the effectiveness of a healthcare delivery system. • Access reflects whether the delivery of health care is equitable (social justice, Chapter 2). • Access is linked to quality of health care at the macro-level. Framework of access • Predisposing conditions—determine propensity of individuals to use medical care: age, sex, education, race, etc. Healthcare delivery is considered equitable if differences in utilization are attributable to these factors. • Enabling factors—means available for obtaining medical care: income, insurance, price of medical services. • Healthcare delivery is considered inequitable if differences in utilization are attributable to these factors. Dimensions of access • Accessibility—location of provider, convenience for the patient, insurance, transportation • Affordability—cost sharing, price • Accommodation—ease of getting an appointment, timely care
  • 105. • Acceptability—compatibility between patient and provider, communications, race/ethnic issues Types of access • Potential access—distribution (maldistribution) of providers, managed care penetration, size of uninsured population • Realized access—type of service (physician, dentist, pharmacy, etc.), site of utilization (hospital, outpatient clinic, nursing home, etc.), purpose of utilization (reason for service) • Equitable access—delivery of services not based on enabling factors; anyone can access health care according to individual need Measurement of access • Individual level—utilization of medical services relative to enabling and predisposing factors; patient’s assessment of interaction with the provider • Plan level—cost of premiums, cost sharing • Travel time, waiting time, accommodation • Plan quality QUALITY OF HEALTH CARE • Increased interest in quality has accompanied perceived concerns that emphasis on cost- containment and the growth of managed care may lower quality of care. • There is no common consensus among patients, providers, and payers on what quality is. • Main characteristics of quality (IOM) 1. Quality occurs along a continuum ranging from unacceptable to excellent. 2. The focus of quality is on services provided, not on individual lifestyle factors. 3. Quality may be evaluated from the perspective of individuals as well as populations. 4. The emphasis is on services that improve outcomes. 5. Use of scientific evidence or professional consensus in the evaluation of quality. The IOM’s view of quality ignores two key elements: a. The role of cost in the evaluation of quality—higher expenditures do not lead to better population health b. Access is an important factor that determines quality from the population perspective Dimensions of quality • Micro-perspective—performance of individual caregivers and institutions assessed by evaluating: • Clinical aspects of care • Interpersonal aspects of care • Quality of life
  • 106. • Macro-perspective—performance of the entire healthcare delivery system assessed by using measures of population health: • Life expectancy • Mortality rates • Low birth weight deliveries • Incidence and prevalence of disease • Prevalence of chronic conditions • Clinical aspects: • Facilities and equipment • Caregiver qualifications and skills • Cost-efficiency • Individual health outcomes • Interpersonal aspects: • Practitioner’s interest, concern, and demeanor • Communications • Time spent • Interactions between patients and practitioners influence treatment success. • Consumers lack technical expertise, and often evaluate quality by their interactions. • Quality of life—institution-related quality of life • Quality of life during an inpatient stay: • Cleanliness, safety, comfort • Autonomy, privacy, dignity, accommodation of preferences • Health-related quality of life (HRQL)—life satisfaction during or after disease experience; ability to live independently, role performance, access to healthcare resources, sense of well-being • Disease-specific quality of life—HRQL in the context of a specific disease; for example, cancer: anxiety about recurrence, anxiety about death, side effects of chemotherapy, pain management Quality assessment (measurement of quality) • Establish standards • Establish methods of assessment • Evaluate actual performance against standards • Identify specific variables (indicators) • Collect data • Analyze data • Interpret results • Evaluate variances • Take corrective action • Quality Assurance (quality improvement) • Institutionalization of quality through ongoing assessment and using assessments to improve quality (CQI or TQM) • Characteristics of CQI (TQM): 1. Commitment towards continuous improvement of quality 2. Occurs at all levels in the organizations 3. Support from top managers
  • 107. 4. Involvement of all staff 5. Data driven 6. Consumer focused—internal and external consumers 7. Goal is to work toward a zero error rate (100% success rate) Domains of quality assessment • The Donabedian model includes three domains, which are equally important, complementary, and hierarchical: 1. Structure • Micro-perspective—indicates capability of a provider to deliver adequate level of health care • Tools and resources • Physical and organizational settings • Macro-perspective—indicates capability of a healthcare delivery system to provide adequate healthcare to all citizens • Number of physicians and hospitals per 1,000 population • Geographic and specialty distribution of physicians • Technology diffusion • Access • Public health infrastructure 2. Process • The actual delivery of health care • Micro-perspective—manner in which health care is delivered by a provider • Technical aspects • Interpersonal aspects • Macro-perspective—manner in which the system is used • Use of the public health infrastructure 3. Outcome • The final results obtained from utilizing the structure and processes of healthcare delivery • Micro-perspective—individual outcomes • Organizational level: nosocomial infections, iatrogenic illnesses, mortality rates • Individual level: recovery, improvement, satisfaction • Macro-perspective—population outcomes • Population-wide indicators: life expectancy, low birthweight deliveries, incidence and prevalence of disease, etc. Quality improvement initiatives 1. Clinical practice guidelines (medical practice guidelines)—protocols for preferred clinical processes, a plan for addressing a clinical problem • Purpose—to guide physicians’ clinical decisions
  • 108. • Objective—to eliminate inappropriate medical interventions and reduce healthcare costs • Reason—variations in physician practice • Small area variations • Wide variations across the US in treatment patterns for similar conditions 2. Cost-efficiency (cost-effectiveness)—based on the premise that high quality care is also cost effective. • Benefits > cost or risks • Underutilization • Overutilization 3. Critical Pathways • A quality management tool that specifies planned medical interventions and expected patient outcomes for a given case • Goal—to improve the process of healthcare delivery • Characteristics: Unique to the institution Interdisciplinary, facilitates coordination of care among disciplines Specifies who will do what Identifies resources Timeline—specifies when each intervention will occur Variances from the plan are identified • Benefits: Improved efficiency Minimize errors Improved coordination among staff TERMINOLOGY • Access to care—May be defined as the timely use of needed, affordable, convenient, acceptable, and effective personal health services. • Accessibility—Refers to the fit between the location of a provider and the location of patients. • Administrative costs—Costs associated with the management of the financing, insurance, delivery, and payment functions. These costs include management of the enrollment process, setting up contracts with providers, claims processing, utilization monitoring, denials and appeals, and marketing and promotional expenses. • An all-payer system—Requires the participation of all major healthcare payers in a nationwide cost-containment program. APG stands for ambulatory patient groups, which are based on a patient classification and payment system designed to identify and explain the amount and type of resources used in an ambulatory visit. Patients in an APG have similar clinical characteristics, similar resource use, and similar cost. • Certificate-of-need (CON)—Statutes were state-enacted legislation whose primary purpose was to control capital expenditures by health facilities. The CON process required prior approval from a state government agency for new construction of facilities, expansion of existing facilities, and purchase of expensive equipment. Approvals were based on the demonstration of a need for additional services by the community.
  • 109. • Clinical practice guidelines (also called medical practice guidelines)—Explicit descriptions representing preferred clinical processes. They are standardized guidelines in the form of scientifically established protocols designed to guide physicians’ clinical decisions. • Competition—Refers to rivalry among sellers for customers. In healthcare delivery, it means that providers of healthcare services would try to attract patients who have the ability to choose from several different providers. Although competition more commonly refers to price competition, it may also be based on technical quality, amenities, access, or other factors. • Cost-efficiency—Evaluates the relationship between increasing medical expenditures/risks and improvements in health levels. A service is cost-efficient when the benefit received is greater than the cost incurred in providing the service or the potential health risks from additional services. • Cost shifting—Refers to the ability of providers to make up for lost revenues in one area by increasing utilization or charging higher prices in other areas. • Critical pathways—Case-specific plans of medical care that identify, along a time line, who will provide what interventions and what the expected outcomes would be. • Defensive medicine—The practice of medicine that involves prescribing tests and services that are not medically justified but are likely to protect physicians against possible malpractice lawsuits. • Disease-specific quality of life—Associated with the potential quality-of-life impacts of a specific disorder and its treatment. • Fraud—Involves a knowing disregard for the truth. It generally occurs when billing claims or cost reports are intentionally falsified. It includes provision of services that are not medically necessary and billing for services that were not provided. • Health Plan Employer Data and Information Set (HEDIS)—The standard for reporting quality information on managed care health plans. This quality tool is a product of a partnership established in 1989 among health plans, employers, and the National Committee for Quality Assurance (NCQA), which now manages the HEDIS program. HEDIS 2000 contains 56 measures across eight domains of care: effectiveness of care, access and availability of care, satisfaction with care, health plan stability, use of services, cost of care, informed healthcare choices, and health plan descriptive information. • HRQL—Stands for health-related quality of life. In a composite sense, HRQL includes a person’s own perception of health, ability to function, role limitations stemming from physical or emotional problems, and personal happiness during or subsequent to the disease experience. • Institution-related quality of life—Refers to a patient’s quality of life while confined in an institution as an inpatient. Examples include comfort factors (such as cleanliness, safety, noise levels, and environmental temperature) and factors related to emotional well-being (autonomy to make decisions, freedom to air grievances without fear of reprisal, reasonable accommodation of personal likes and dislikes, privacy and confidentiality, treatment from staff in a manner that maintains respect and dignity, and freedom from physical and/or emotional abuse).
  • 110. • Outcome—The end result obtained from utilizing the structure and processes of healthcare delivery. Outcomes are often viewed as the bottom-line measure of the effectiveness of the healthcare delivery system. • Overutilization—Occurs when the costs or risks of treatment outweigh the benefits, and yet additional care is delivered. • Peer review—Refers to the general process of medical review of utilization and quality when it is carried out directly or under the supervision of physicians. • PRO—Stands for peer review organization. PROs are statewide private organizations composed of practicing physicians and other healthcare professionals who are paid by the federal government to review the care provided to Medicare beneficiaries to determine whether care is reasonable, necessary, and provided in the most appropriate setting. • Quality—Defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • Quality assessment—Refers to the measurement of quality against an established standard. • Quality assurance—A step beyond quality assessment and is synonymous with quality improvement. It is the process of institutionalizing quality through ongoing assessment and using the results of assessment for continuous quality improvement (CQI). • Quality Improvement Organizations (QIOs)—Also referred to as PROs (see PROs). • Reliability—Reflects the extent to which the same results occur from repeated applications of a measure. • Risk management—Consists of proactive efforts to prevent adverse events related to clinical care and facilities operations, and is especially focused on avoiding medical malpractice. • Small area variations—Refer to the unexplained variations in the treatment patterns for similar patients and health conditions in different parts of the country. • A top-down control over total health expenditures establishes budgets for entire sectors of the healthcare delivery system. Funds are distributed to providers in accordance with these global budgets. Thus, total spending remains within preestablished budget limits. The downside to this approach is that, under fixed budgets, providers are not as responsive to patient needs, and the system provides little incentive to be efficient in the delivery of services. Once budgets are expended, providers are forced to cut back services, particularly for illnesses that are not life-threatening or do not represent an emergency. • TQM—Stands for total quality management and is synonymous with continuous quality improvement (CQI). It is an integrative management concept of continuously improving the quality of delivered goods and services through the participation of all levels and functions of the organization to meet the needs and expectations of the customer. • Underutilization—Occurs when the benefits of an intervention outweigh the risks or costs, yet the intervention is not used. • The validity of a scale is the extent to which it actually assesses what it purports to measure.
  • 111. End Week 12 WEEK 13 Start Week 13 Objectives: Chapter 13 1) Understand the definition, scope, and role of health policy in the United States. 2) Recognize the principal features of U.S. health policy 3) Comprehend the process of legislative health policy 4) Be familiar with some of the critical health policy issues in the United States Reading Assignments: a) Chapter 13, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling Examinations or Quizzes: a) There are no examinations this week. Your final examination is in week 15. c) There are no quizzes this week. You have taken your final quiz, quiz # 3 last week. Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. Thought Worksheet #4 was due last week and that was your last Thought Worksheet Assignment. Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file
  • 112. c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 11 points) 1. What is health policy? How can health policies be used as regulatory or allocative tools? (Application: 3 points) 2. What are the principal features of US health policy? Why do these features characterize US health policy? (Comprehension: 2 points) 3. Identify healthcare interest groups and their concerns. (Comprehension: 2 points) 4. What is the process of legislative health policy in the United States? How is this process related to the principal features of US health policy? (Synthesis: 4 points) ONLINE CHAT AND DISCUSSION BOARD QUESTIONS 1. Describe the critical policy issues related to access to care, cost of care, and quality of care. 2. What do you think the future of health policy will look like in the United States? Summary of Week: CHAPTER 13 Health Policy Health policy is a type of public policy. It consists of authoritative decisions made in the legislative, executive, or judicial branches of government to influence the distribution of healthcare resources and services. FORMS OF HEALTH POLICY 1. By-product of social policy—for example, Family Independence Act extends health benefits to welfare recipients once they obtain employment. 2. By-product of other public policies—for example, policies supporting biomedical research.
  • 113. 3. Health policies affecting specific categories of individuals, such as physicians, the elderly, or children. 4. Health policies affecting certain types of organizations, such as hospitals, nursing homes, or employers. 5. Private policies are sometimes created to preempt public policies. For example, the pharmaceutical industry may voluntarily decide to restrict price increases in order to avoid price control legislation. USES OF HEALTH POLICY Two primary uses 1. Regulatory tools—health policies often serve a regulatory purpose. For example, drug safety, air pollution control, licensure and certification of facilities. 2. Allocative tools—used to allocate resources. Two main types 1. Distributive policies spread benefits throughout a society. For example, funding of medical research, development of medical personnel. 2. Redistributive policies take money or power from one group and give it to another. For example, use of tax funds to benefit a certain category of people—the poor, the elderly, or children. FEATURES OF US HEALTH POLICY 1. Government as subsidiary to the private sector The private sector plays a dominant role. The government’s role has increased incrementally in areas where the private sector has not been very effective. 2. Fragmented, incremental, and piecemeal Health policy is often fragmented for lack of coordination between federal, state, and local governments. Policy-making involves compromises against competing interests. Hence, it is incremental and piecemeal. Incremental policy may add new benefits to existing programs, such as adding a prescription drug benefit to Medicare. Piecemeal policy may create small new programs, such as CHIP. 3. Pluralistic and interest group politics Power interest groups lobby Congress to protect their own best interests; for example, the AMA aims to protect the interests of physicians, and the AARP lobbies on behalf of senior citizens. 4. Decentralized role of the states Health policy in the US is not concentrated at the federal level. States have a significant role. Examples include administration of the Medicaid and CHIP programs, licensure of facilities and health professionals, certification oversight, and training of health professionals. Fragmentation of the system is exacerbated with states having significant control over policy. 5. Impact of presidential leadership The executive office is often looked to for strong leadership in health policy matters. THE MAKING OF HEALTH POLICY
  • 114. The policy cycle • The policy cycle has five stages: 1. Issue raising—evaluation of a problem requiring policy decision. 2. Policy design—development of a policy proposal. 3. Public support building—public appeals and seeking support from interest groups. 4. Legislative decision making and support building—support of key legislators, hearings. 5. Legislative decision making and policy implementation—vote, president’s signature, public hearings, rulemaking, allocation of resources. • Suppliers of policy a. The legislative branch, senators and congressmen, are often the key suppliers of policy because of the constitutional powers Congress has: • Power to enact laws • Power to tax • Power to spend (allocate resources) b. The executive branch—president, state governors, executives of departments and agencies. c. The judicial branch—courts provide interpretation of statutes and establish judicial precedence. Legislative committees and subcommittees • Most influential House committees: • Ways and Means Committee—deals with tax issues; also holds jurisdiction over Medicare Part A, Social Security, public welfare, and healthcare reform. • Commerce Committee—has jurisdiction over Medicare Part B, Medicaid, public health, mental health, health personnel, managed care, food and drugs, air pollution, product safety, and biomedical research. • Committee on Appropriations—responsible for allocation of funds. • Most influential Senate committees: • Committee on Labor and Human Resources—has jurisdiction over most health bills. • Committee on Finance—has jurisdiction over taxes and revenues. The legislative process • House 1. A bill is introduced in the House of Representatives. 2. The bill is assigned to the appropriate committee. 3. It is assigned to a subcommittee—forwarded to affected agency, hearings and testimonies, amended if needed, decision to recommend, not recommend, or table the bill.
  • 115. 4. If recommended, the bill is presented to the full House, where it may be amended. 5. If approved, the bill is forwarded to the Senate. • Senate 1. The bill goes through the appropriate committee and subcommittee, and goes through similar procedures as in the House. 2. If recommended, the bill is presented to the full Senate, where it may be amended. 3. Changes require the bill to go back to the House for a vote. 4. Controversial changes may trigger review by a Conference Committee (includes committee members from the House and Senate). 5. After the bill has passed both the House and Senate in identical form, it is sent to the president for signature. • President 1. If the president signs the bill, it becomes law. 2. The bill is vetoed if the president does not sign it. 3. The veto may be overturned by a two thirds majority of the Congress, otherwise the bill is dead. • Implementation 1. The agency responsible publishes the proposed regulations in the Federal Register. 2. Hearings are held. 3. Final regulations are drafted. TERMINOLOGY • Allocative tool—Designates a use of health policy in which there is a direct provision of income, services, or goods to groups of individuals who usually reap benefits in receiving them. • Block grants—Consolidate funds from different categorical programs into one lump sum that is distributed to the states on a formula basis. It is a vehicle to allow states to prioritize services and funding. • Distributive policies—Spread benefits throughout society. Examples are funding of medical research through the NIH, the training of medical personnel through the National Health Services Corps, the construction of health facilities under the Hill-Burton program, and the initiation of new institutions (e.g., HMOs). • Health policy—Refers to public policy that pertains to or influences the pursuit of health. • Public policies—Authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others. • Redistributive policies—Take money or power from one group and give it to another. Examples are the Medicaid program, which takes tax revenue and spends it on the poor in the form of health insurance.
  • 116. • Regulatory tool—Designates a use of health policy in which the government prescribes and controls the behavior of a particular target group by monitoring the group and posing sanctions if it fails to comply. End Week 13 WEEK 14 Start Week 14 Objectives: Chapter 14 1) To assess the trends in employer-based health insurance 2) To evaluate the challenges faced by managed care 3) To discuss future financing and insurance options in the current system 4) To discuss various options for a universal access system 5) To understand future challenges in wellness and prevention, chronic care, and infectious disease 6) To foresee the transforming role of public health under new threats 7) To address the future needs for a well-prepared health care workforce 8) To familiar with new trends in the way in which health work is organized 9) To get an overview of new technology frontiers Reading Assignments: a) Chapter 14, Delivering Health Care in America, 3d Edition by Shi and Singh b) Course Pack (Read until you reach “End of Week #’) c) Read “Preparing for Disaster: Philanthropy and Medicine in a Post-9/11, Post- Katrina, Pre-Pandemic World,” in Philanthropy, by Kirk Oberfeld. This article can be found in the Web Course. Lecture Assignments: a) View this Week’s Lecture b) Attend this week’s Live Classroom lecture; check for scheduling
  • 117. Examinations or Quizzes: a) There are no examinations this week. Your final examination is in week 15. b) There are no quizzes this week. You have taken your final quiz, quiz # 3. Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. Thought Worksheet #4 was your last Thought Worksheet Assignment. Review Questions (based on your points selections): a) Complete/Answer Review Questions for this week’s chapter and email to instructor by dates prescribed in file b) Evaluate and score your Answer to Instructor’s Answer for Review Questions for this week’s chapter and email to instructor by date prescribed in file c) Prepare for Online Chat and Discussion Board for week (refer to syllabus online chat schedule) by reviewing questions in this week’s course pack section. Review Questions: REVIEW QUESTIONS (total of 17 points) 1. Discuss the future direction of employer-based health insurance in the United States. (Comprehension: 2 points) 2. What are managed care’s future challenges? How might MCOs address them? (Synthesis: 4 points) 3. What are some of the incremental changes in financing and insurance that the existing healthcare system might see? (Synthesis: 4 points) 4. What proposals might work in a universal access program in the United States, if and when the time comes to debate such proposals? (Application: 3 points) 5. Discuss how the role of public health will change in the future? (Synthesis: 4 points) ONLINE CHAT AND DISCUSSION BOARD QUESTIONS 1. What are some of the workforce-related challenges the United States will face in the future? 2. Discuss some of the changes in the areas of work organization in healthcare delivery.
  • 118. 3. Give an overview of what new technology might achieve in the delivery of health care. Summary of Week: CHAPTER 14 The Future of Health Services Delivery MANAGED CARE To a large extent, the future of healthcare delivery in the US will spring from a new trend in cost escalations after managed care squeezed out some of the inefficiencies from the system. The failure of President Clinton’s proposal to create a national healthcare program was indirectly a major driving force behind the rise of managed care. Despite the backlash of the mid- to late-1990s, managed care has become the primary vehicle of healthcare delivery for the vast majority of privately insured Americans, and to a notable extent, for the Medicaid and Medicare populations as well. However, the backlash also prevented managed care from its full potential to contain cost inefficiencies in the system. Expected future trends in health insurance • As employers face mounting pressures to cut costs, they would be forced to find better value in the purchase of health insurance. • As a mature industry, managed care will have to reinvent itself into delivering better value. • Employers, employees, and providers will have to share in the creation of better value. • If managed care fails to deliver value, employers are likely to engage in direct contracting with large provider organizations. Employers may band together through coalitions and cooperatives to increase their bargaining power. • Employers are inclined to shift to a defined contribution plan for financing employee health insurance. • Medical savings accounts and tax credits for private purchase of health insurance are also likely to remain active proposals. • The CMS and states will make new attempts, through better incentives, to enroll more of the Medicaid and Medicare beneficiaries into managed care plans. • Federal funds have been allocated to create high-risk pools in all states. • The uninsured are likely to remain disenfranchised, as the only viable way to ensure all Americans is to have a national healthcare program, which is not foreseen in the near future. NATIONAL AND GLOBAL CHALLENGES Wellness, prevention, and health promotion
  • 119. • Employers need to take a more proactive approach in identifying high-risk enrollees and obtaining preventive care services for them. • Moving the healthcare delivery system toward a preventive model will require new mindsets (Exhibit 14-2). • Employers, hospitals, and managed care will have to lead the change. • Healthy People 2010 goals and objectives will provide the blueprint. • Implications for medical practice and healthcare professionals • Partnership between communities and the medical establishment Challenge of chronic illnesses • Disease patterns are now characterized by chronic conditions and comorbidities. • The healthcare delivery system of the future will have to be reconfigured by focusing on primary care, home health, special transportation, and affordable long-term care. • Service should also include patient education, training to improve self-coping skills, computerized tracking and reminder systems, and organized approaches to follow-up. • Healthcare professionals need to be trained in the management and coordination of chronic illnesses. • Greater use of nonphysician providers, and direct reimbursement for their services, will be necessary. Infectious diseases are still a challenge • In spite of the growth in chronic conditions, fresh challenges are posed by new types of infections, such as SARS, Lyme disease, West Nile virus, and new influenza viruses. • Increasingly, public health issues must be viewed from a global perspective due to immigration, world trade, and global travel. Bioterrorism • Bioterrorism has brought public health to a new level. • Preparations to deal with the effects of bioterrorism call for central coordination; training personnel at all levels; private and public partnerships; and availability of funds to furnish vaccines, supplies, and equipment. • Safeguarding the nation’s food and water supplies is also a high priority. FUTURE OF HEALTHCARE WORKFORCE • Future workforce will be affected by declining inpatient hospital utilization, an increasing elderly population, and more women and minorities entering the healthcare workforce. • Future healthcare workforce will also be impacted by individual career choices and enrollments in training programs, and immigration of trained foreign workers in areas of high labor demand.
  • 120. • Aggregate physician surpluses along with geographic and specialty maldistribution are expected to continue. • Although an aggregate physician surplus is likely to continue, primary care physicians will be in greater demand as fewer medical students show an interest in primary care. • Forecasts by the Institute for the Future suggest an adequate supply of RNs to meet expected future demands, despite a current nurse shortage. • Future nursing opportunities will be in primary care settings, nursing homes, and other community-based services. • The role of nonphysician providers will continue to expand. • A shortage of geriatrics-prepared healthcare professionals is a critical challenge. • A greater ethnic/racial diversity in the workplace as well as in the populations served will pose some new challenges for healthcare managers. • Cross-training and teamwork in healthcare delivery will receive greater emphasis. ENHANCED FOCUS ON CUSTOMER SERVICE • Increased competition is putting a greater emphasis on patient satisfaction. • Satisfaction ratings are likely to be the best predictors of future success of health delivery organizations. • Healthcare organizations face barriers to service orientation (regulations, lack of incentives for entrepreneurship, paternalism, and the medical model). Managers who can innovate and who make customer orientation a top priority will be successful. TECHNOLOGY • Eight technologies will revolutionize patient care over the next decade: rational drug design, advances in imaging, minimally invasive surgery, genetic mapping and testing, gene therapy, vaccines, artificial blood, and xenotransplantation. • Life-prolonging technologies, gene mapping, and other innovations will add to the ethical challenges. • Information technology and telematics will play an increasing role in healthcare delivery. TERMINOLOGY • A catastrophic plan—A high-deductible health insurance plan that does not cover routine and inexpensive healthcare services. • Cross-training of health service workers may include teaching an employee to assume additional clinical or clerical roles, or training an employee to work in several different areas. The objectives are to improve staff flexibility, realize greater efficiency, and reduce costs. • Cultural competence—Refers to knowledge, skills, attitudes, and behaviors required of a practitioner to provide optimal healthcare services to persons from a wide range of cultural and ethnic backgrounds. • In a defined benefit plan, the employer offers one or more preselected health insurance plans and pays, on a cost sharing basis, the cost of whatever plan the employee chooses.
  • 121. • Under a defined contribution plan, employers commit to a fixed dollar for health benefits. The fixed dollar amount is paid to the employees, who then pay for the healthcare plan they select. • E-health plans—Internet-based health insurance plans. A wide variety of choices allows people to tailor a plan that best fits their needs. • Genometrics—Used for the association of genes with specific disease traits. • High-risk pools—Target population groups that are unable to purchase insurance coverage due to preexisting health conditions. These programs typically require insurers to establish separately administered funds to insure persons who would otherwise be unable to purchase coverage because of their health conditions. • Managed competition—A healthcare reform proposal that would foster competition among integrated networks of insurance companies and health providers. Large businesses and health insurance purchasing cooperatives would represent combined purchasing power to keep costs under control. Certain basic standards, such as universal coverage and minimum benefits, would be set by the government. • Medical savings accounts (MSAs)—Give individuals the responsibility of paying for their utilization of health services. They allow individuals to set aside pretax dollars in a special fund to pay for uncovered (out-of-pocket) healthcare costs, medical insurance premiums (long-term care insurance premiums may be allowable in some accounts), deductibles, and coinsurance payments. The individual pays limited annual contributions into the account. Withdrawals from these accounts, without penalty, are limited to allowable medical expenses only, but these expenses can include both present and future health services. • Under Play-or-pay, employers are required to either provide health insurance for employees or pay into a public health insurance program. • A single-payer health plan—Place the responsibility of financing health care with one entity (most likely the federal government). One major advantage of such a system is that all Americans and lawful residents would be entitled to benefits regardless of individual or family income. • Telematics—The combination of information and communications technologies to meet user needs. • Xenotransplantation—Also called xenografting, is the use of animal tissues for transplants in humans. End Week 14 WEEK 15 Start Week 15 Objectives: Chapter 15 1. Determine how much you have learned by taking the final examination.
  • 122. Reading Assignments: a) Finish all course reading assignments b) Course Pack (Read until you reach “End of Week #’) Lecture Assignments: a) There is no lecture this week; however, view any lectures you may have missed in the course (last 14 weeks). b) Attend this week’s Live Classroom lecture if held (to be determined by instructor); check for scheduling Examinations or Quizzes: a) Final examination is this week. Your final examination is in week 15 and covers all material in the course. The exam will be on the Web Course or as determined by the instructor. b) There are no quizzes this week. You have taken your final quiz, quiz # 3. Thought Worksheet Assignment: a) There are no Thought Worksheets due this week. Thought Worksheet #4 was your last Thought Worksheet Assignment. Review Questions (based on your points selections): a) There are no review or chat or discussion questions this week. End Week 15 END OF COURSE PACK Course Bibliography (in addition to texts, books and documents in course): Alexander, J.A.; Zuckerman H.S.; & Pointer D.D. (1997). The Challenges of Governing Integrated Health Care Systems, Health Care Management Review 22(3), pages 53-63. American Medical Association (1992). Physicians Characteristics and Distribution in the U.S., ed. Chicago : American Medical Association , Table A-29, Update 1992. American Nurses Association (1997). Implementing Nursing’s Report Card: A Study of R N Staffing, Length of Stay, and Patient Outcomes, American Nurses Publication, Washington, DC. Austin, C. J.; & Boxerman S.B. (1995). Quantitative Analysis for Health Services Administration, Health Administration Press, Chicago.
  • 123. Bennett, J.V.; & Brachman, P.S. [eds.] (1998). Hospital Infections, fourth editions, Lippincott-Raven, Philadelphia. Carter, C.C. (1994). Human Resources Management and the Total Quality Imperative, American Management Association, New York. Cejka, S. (1993). The Changing Healthcare Workforce: A call for Managing Diversity, Healthcare Executive 8(2), pages 20-23. Chow, C.W.; Ganulin, D.; Teknika, O.; Haddad, K.; & Williamson, J. (1998). The Balance Scorecare: A Potent Tool for Energizing and Focusing Healthcare Organization Management, Journal of Health Management 43(3), pages 263-280. Coile R.C. Jr. (1994). The New Governance: Strategies for an Era of Health Reform, Health Administration Press, Chicago, pages 27-44. Connors, R.B. [ed.] (1997). Integrating the Practice of Medicine: A Decision-Maker’s Guide to Organizing and Managing Physician Services, American Hospital Publishing, Chicago. Dreachslin, J. (1996). Diversity Leadership, Health Administration Press, Chicago. Duncan, K.A. (1998). Community Health Information Systems: Lessons for the Future, Health Administration Press, Chicago. Gapenski, L.C. (1998). Healthcare Finance: An Introduction to Accounting and Financial Management, Health Administration Press, Chicago. Joint Commission on Accreditation of Healthcare Organization, Accreditation Manual for Hospitals, Chicago. Kotler, P. (1991). Strategic Marketing for Non-Profit Organization, fourth edition, Prentice-Hall, Englewood Cliffs. Krowinski, W.J.; & Steiber S.R. (1996). Measuring and Managing Patient Satisfaction, second edition, American Hospital Publishing, Chicago. Leatt, P.; Shortell S.M.; & Kimberly J.R. (1997). Organization Design, In Essential of Health Care Management, Delmar, New York, pages 256-285. LeTourneau, B.; & Curry, W. [eds.] (1998). In Search of Physician Leadership, Health Administration Press, Chicago. May, L.A. (1999). The Psychological Bases of Health Disease and Care Seeking, Introduction to Health Services, fifth edition, Delmar Publishers, Albany, New York.
  • 124. Melum, M.M.; & Sinorius, M. K. (1992). Total Quality Management: The Health Care Pioneers, American Hospital Association Publishing, Inc., Chicago. Mintzberg, H. (1994). The Rise and Fall of Strategic Planning: Reconceiving Roles for Planning, Plans, Planners, Free Press, New York. Molinari, C.; Morlock, Alexander J.; & Lyles, C.A. (1993). Hospital board Effectiveness: Relationship Between Governing Board Composition and Hospital Financial Viability, Health Services Research 28(3), pages 358-377. Nicholson, L. (1999). The Internet and Healthcare, second edition, Health Administration Press, Chicago. O’Reilly, J.T.; Hagan, P.; De la Cruz, P. [et al.] (1996). Environmental and Workplace Safety: A guide for University, Hospital, and School Managers, Van Nostrand Reinhold, NewYork. Peters, T.J.; & Waterman R.H. Jr. (1992). In Search of Excellence: Lessons from America’s Best-Run Companies, Harper and Row, Inc., New York. Pfeffer J. (1992). Managing with Power: Politics and Influence in Organization, Harvard Business School Press, Boston. Pointer, D.D.; & Sanchez J.P. (1997). Leadership: A Framework for Thinking and Acting, In Essentials of Healthcare Management, Delmar Publications, Albany, New York, pages 99-132. Rosenberg, C. E. (1989). The Care of Strangers: The Rise of America’s Hospital System, Basic Books, New York. Seibert, J.H.; Strohmeyer, J.M.; & Carey, R. G. (1996). Evaluating the Physician Office Visit: In Pursuit of Valid and Reliable Measure of Quality Improvement Efforts, Journal of Ambulatory Care Management 19(1), pages 17-37. Senge, P. (1990). The Fifth Discipline: The Art and Practice of the Learning Organization, Doubleday/ Currency, New York. Silber, M.B. (1992). CEO-ship: Avoiding the Rocks of Self-Malpractice, Healthcare Executive 7(6), pages 26-27. Southwick, A.F. (1988). The Law of Hospital and Health Care Administration, Health Administration Press, Chicago, pages 455-456. Stevens, R. (1989). In Sickness and In Wealth: American Hospitals in the Twentieth Century, Basic Books, New York.
  • 125. Todd, M.K. (1997). IPA, PHO, and MSO Development Strategies: Building Successful Provider Alliances, Healthcare Financial Management Association/McGraw-Hill, New York. Toni, G.; Cesta, H.A.; Tahan, L.; & Fink, F. (1998). The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice, Mosby, St. Louis. Tyler, J.L. (1998). Tyler’s Guide: The Healthcare Executive ‘s Job Search, second edition, Health Administration Press, Chicago. Withrow, S.C. (1999). Managing Healthcare Compliance, Health Administration Press, Chicago.