Goals of Health Care

Delivery System

(comparing them)

• cost: health care spending per capita, adjusted for cost of living)(total expenditures on health as percent of GDP
• access: percentage of population with health insurance coverage
• quality: deaths of specified disease per 1k population and disease admission rates per 1k population

The 5 W's and 1 H of Health Care

• Who uses health care system?
• Where is health care used the most?
• what are the causes for the most encounters?
• What are the top causes of death?
• Who is in charge of health care systems?
• Who or what is more important in health care? individual or population

Greatest Public health Achievments

• fluoride
• immunizations
• sewer systems
• motor-vehicle safety
• infectious disease control
• decline in heart disease
• healthier moms and babies
• safe and healthier foods
• family planning
• tobacco

Types of Health Care Systems

• preventive care
• primary care
• specialized care
• chronic care
• long and short term care
• acute care
• rehabilitative care
• end of life care

Preventive Care

• public health programs
• community programs
• personal lifestyle

Primary Care

• physician office/clinic
• self-care
• alternative medicine

Specialized Care

• specialist clinics

Chronic Care

• primary care settings
• specialist provider clinics
• home health
• long-term care facilities
• self -care
• alternative medicine

Long term care

• home health 
• long term care facilities

Sub-acute care

• sub specialty hospitals
• home health
• outpatient surgical centers

Acute Care

• hospitals

Rehabilitative Care

• rehabilitation departments
• home health
• outpatient rehabilitation centers

End-of-Life Care

• hospice centers

Types of Hospitals

• public (government, federal, VA, State, local, prison)
• private (not-for-profit, secular, religious)
• for-profit (private corparation, hospital corporation of america)
• physician owned (often singular specialty)

Organization for Economic

Cooperation and Development

• Abr. OECD
• consists of 34 industrialized nations 
• used to compare countries healthcare
• some countries include Australia, Canada, Denmark, France, Germany, US, Netherlands, Norway....

US Health System compared to

World and OECD

• US spends the most of any other country in both catagories
• Spend 2 and a half times OECD average (has a lot more private expenditure)
• at 17.6% of GDP spend 1.5 as much as any other country and twice the OECD average
• the US is very far of the line of best fit
• this is due to higher prices and higher service provision

US Healthcare Service Prices

• US Services are 60% higher than average of 12 OECD countries (Itally is second highest)
• US has significantly higher prices for the same procedures (double for some of them)

US MRI Machine Statistics

• greatest supply of MRI machines
• highest utilization
• highest scan and imaging fees

Procedures and Products US does

More than other countries

• 2nd in MRI units and Exams
• 3rd in CT scanners and Exams
• 1st in tonsillectomy and knee replacements
• 3rd in coronary bypass
• 6th in caesarean sections

True or False: US has higher hospital admission rates and average lenght of stay (LOS)

False

Catagories the US does

less then other countries

• 26th in practicing physicians and hospital discharges
• 29th in doctor consultations
• 28th in hospital beds 
• 29th in average length of stay in hospitals
• most based on on per capita or per 1k popultaion

True or False:

Prescription Utilization, Prices and spending are all highest in the US

• true
• next highest country on drug prices is 75 percent of US price(canada)
• UK sits at half and New Zeland at 34%
• US double the pharmaceutical spending per capita as the OECD average

US Quality Outcomes

• US ranks 6th of 7 in terms of quality but is variable
• cancer care in US i particulary high based on 5year survival rates but have high rates of chronic disease admissions 
• has average performance on effectiveness and patient centeredness
• low performance on safety and coordination
• primary care sector is not performing well
• netherlands seems to be the best

OECD Life expectancy 

• US has below average Life expectancy (80.4 female and 75.3 male)
• also has the lowest of major countries in increase in life expectancy since 1988

Bismarck Model

• multi-payer; private providers (Germany)
• decentralized national health program (sickness fund)
• Uses insurance system funded by employer and -ees
• health insurance has to cover everybody; multi-payer does not make a profit 
• physicians and hopsitals tend to be private; tight regulation gives government cost control power that single-payer provides

National Health Insurance Model

• single payer; private providers
• socialized insurance model (national health insurance)
• uses private sector providers with negotiated reimbursement
• payment comes from a single, government run insurance program that every citizen pays into
• example is canada, taiwan and south korea

Beveridge Model

• single payer; government providers (socialized med.)
• health care provided and finacned by government thorugh tax payments
• government employs most health care practitioners, owns most facilities and administers health care systems
• british people never get a doctor bill
• tend to have low costs per capita because government is sole payer and controls physicians price
• example england, spain, and N. Zealand

Undeveloped Countries

(out of pocket Model)

• plan used by most nations because are too poor and disorganized to provide any government sponsered or private health care system
• basic rule is rich get medical care and poor stay sick and die
• some may barter goods for care
• in developed countries this includes uncovered services and amenities

US. All four basic models of Health Care

• Bismark = employer insurance
• Beveridge = VA
• Nat Health insurance = Medicare
• Out of pocket = 15% uninsured and electives

US Forces driving Health Care Spending 

• administrative overhead and complexity
• lack of coordinated care
• pract of defensive medicine (overtreatment)
• use of technologically advanced equipment
• health disparities 
• price increases
• loose government regulation

Urgent Aims for Ambulatory Care

Improvements

• safe
• effective
• patient-centered
• timely
• efficient
• equitable

2011 Patient Centered Medical Home Standards

• enhance Access and continuity
• identify and manage patient populations
• plan and manage care
• provide self-care and community support
• track and coordinate care
• measure and improve performance

Enhance Access and Continuity

• Patient Centered Medical Home Standard
• patients have access to culturally and linguistically appropriate routine/urgent care clinical advice during and after office hours
• the practice provides electronic access
• the focus is on team-based care with trained staff

Identify and Manage Patient Populations

Plan and Manage Care

• patient centered medical home standard
• identifies patients with specific conditions, including high risk or complex care needs
• care management emphasizes assesing patient progress toward treatment goals and adressing patient barriers to treatment goals
• reconciles patient medications at visits and post hospitalization - uses e-prescribing

Provide Self Care and Community Support

• patient centered medical home standard
• practice assesses patient/family self management abilities
• practice works with patient family to develop a self-care plan and provide tools and resources
• practice clinicians counsel patients on healthy behaviors and medications

Track and Coordinate Care

• patient centered medical home standard
• practice tracks, follows-up on and coordinates tests, referrals and care at other facilities
• practice follows up with discharged patients

Measure and Improve Performance

• patient centered medical home standard
• practice uses performance and patient experience data to continuously improve
• tracks utilization and measures such rates of hospitalizations and ER visits
• identifies vulnerable patient populations 
• practice demonstrates improved performance

Core Function of Accountable Care Organization

• facilitate provider partnerships with patients, families and communities
• redesign primary care medicine and advance the medical home concept
• integrate the health care system across the continuum of care
• provide tools and resources to health care providers
• population health management

Hospitals acount for how much of US health care expenses?

• they acount for 1/3
• centerpiece of health care delivery system
• most complex health care entity
• 5,700 hospitals in the US

Flexner Report

• filled out in 1910
• recomended reducting number of medical schools from 150 to 31, change admission requirements to baccalaureate degree and incorporate scientific method as foundation
• some were adopted by AMA
• hospitals became teaching and research centers for medicine and center for tech innovations

Advent of Health Insurance

• provided financial stability for hospitals
• increased demand for health care
• initially covered only inpatient care (financial incentive to admit patients resulted in unneccesary admis.)
• increased the demand for hospital beds, hospital services and health care in US

Hill-Burton Act

• 1946
• created federal funding to: build hospitals, expand and renovate, increase bed capacity and add emerging tech
• resulted in increase in number of beds and addition of new technology

Diagnosis-Related Groups (DRG's)

• 1983
• instituted to control increases in medicare spending
• reimbursement moves from historical fee-for-service to reimbursement independent of services provided or Lenght of stay
• new hospital incentives: LOS, # of procedures, Efficiency, evaluation of Dx procedures for appropriateness
• Results on hospital: inpatient acuity, unbundled pre-op and post op Services, utilization review, financial support for uncompensated hospital care

Horizontal Integration

• affliations between hospitals 
• affiliation vs ownership
• improve efficiency-combine services
• secure better contracts-supples and equipment
• avoid duplication of patient care services
• frequently, a partnership btw a small community hospital and  a tertiary care hospital

Vertical Integration

• organization provides a continuum of care
• examples of services in addition to acute care
• hospitals less dependent on declining revenues from acute care
• hospitals can provide MCO's with a variety of services
• integrated delivery systems emerged

Economic Recession

• decline in revenues, charitable donations, value of financial reserves
• as unemployment increased, hospitals say decline in elective procedures increase in patients covered by medicaid and uncompensated care
• responded by cutting administrative expenses and reducing staff and services

• correct answer is community hospital

A hospital is classified as critical access when:

• it has less then 25 beds

Hospital Management

• board of trustees/directors(ultimate authorities)
• hospital administration(health-system adm)
• medical staff(most physicians are not hospital employees)
• alignment of medical staff with the health-system

Hospital Committees

• medical staff committees: pharmacy and therapeutics comittee, credentialing committee, infection control committee, medical staff executive committee
• hospital committees: patient safety committee, various quality committees, various operations committees

Hospital Accreditation

• The Joint Commission: sets standards and accredits hospitals against those standards; accredits hospitals, behavioral health facilities, LTC facilities, office-based surgery org, home care organization, ect
• based on voluntary compliance with standards
• standards focused on clinical processes and outcomes of care

Medicaid Defined

• nations publically financed health and long term care coverage for low income people
• most beneficiaries lack access to private insurance
• dominant source of LTC coverage
• financed thru federal-state partnership
• each state designs and operates own program thru broad federal guidelines

The State and Federal Medicaid Partnership

• states must cover mandatory services specified in federal law in order to recieve federal matching funds 
• they are permited to cover many services that federal law designates as optional

Whos is covered by Medicaid

• 62 million Americans (1 in 5)
• pregnant women (40% of births)
• 39 million children
• some parents in both working and jobless low income families
• low income elderly with many complex health care needs
• non elderly adults w/0 dependent children are generally excluded
• ACA will significantly expand coverage

Medicaids Role in US Health Care System

• Fills large gaps in our health insurance system
• expands to cover more people during economic downturns
• main source of LTC coverage in US (31% of total medicaid expenditures are for nursing facility
• supports safety net institutions that provide halth care to low income and uninsured people

Medicaid is largest Coverage for Certain Groups

Medicaid Cost

• about 414 billion in 2011
• 16% of total national spending (2.3 trillion)
• aggregate costs high and adm costs low
• acute care spending has been rising
• beneficiaries are not proportional to spending (more schildren but account for less of spending)
• 5% of the medicaid patients account for 54% of the spend

Medicaid Federal Match Rate

• normally it is 50% but may be higher in poorer states (highest is 73%)
• overall the federal share of spending is 57%

Medicaid Access to Care Problems

• low provider rates (31% of surveyed physicians wont accept new medicaid patients
• administrative burden to providers
• access to specialist and dental care is a major concern
• providers often do not locate in low-income neighborhoods

Medicare Defined

• the federal health insurance program for people 65 and older
• also covers younger adults with permanent disabilities and medical conditions
• it + medicaid is 960billion in health care expenditur

Medicare Advantage is:

• part a
• part b
• part c
• part d

• it is part C

Medicare Part A eligibility requirement

• age 66
• US green card
• Hx paying into medicare program
• pay premium

• the correct answer is Hx paying into the medicare program

Medicare Eligibility: Part A

• work history > 10 years
• us citizen or perm resident > 5 years
• age 65
• no montly premium
• disability benefits > 24 mo
• have als and receive disability 
• ESRD  

MEdicare Eligibility Part B

• standard montly prem of 105/mo in 2013
• hold harmless provision prohibits states from increasing premiums in amount > SS cost of living adj
• higher income beneficiaries pay higher premium (capped)

Medicare Part C and Part D

• part C is medicare advantage option to participate in private health plans (HMOS and PPOs) about 26% of medicare beneficiaries participate
• part D is prescription drug benefit (about 30million enrolled)

Not A medicare Funding Source:

• state governments
• payroll taxes
• beneficiaries
• general federal government funds

Medicare Administration

• HHS responsible for adm of medicare program through SS admin (eligibility and enrollment)
• CMS develop operational policies, formulate conditions of participation, maintain review utilization, oversee general financing of the program, contract with claims and work with state gov agencies

Medicare Part A inpatient hospital care

• 60 consecutive days or 90 days per benefit period
• 60 lifetime reserve days 
• $1,156 deductible per benefit period
• co-insurance 61-90 289 per day and 91-150 578 per day

Medicare Part A: Hospice Care

• must have life expectancy < 6 months
• voluntarily waive right to traditional treatment
• cost sharing involved
• services covered are pain relief, physician services, nursing care, counseling

Medicare Part B does not cover

• physician care
• physician assistant care
• hospice care
• outpatient radiology

• hospice care

Physician accepts medicare approved charge

• balance billing
• assignment
• diagnostic related grouping
• fee-for-service model

• assignment

Coverage Gap in Medicare Prescription drug benefit

• deductible
• catastrophic threshold
• donut hole
• co-pay

• donut hole coverage gap above $2970 to $4700 in out of pocket spending

Medicare Part D: Standard Benefit

• pay first 325$ (deductible)
• then pay 25% of cost from 325-2970
• donut hole is 2970-6734 and you pay 47.5% on brand names and 79% on generic
• pay 5% of catastrophic coverage

Mechanisms by Which IT Improves Safety

• improving communication
• making knowledge more readily accessible
• prompting for key pieces of information
• assisting with calculations
• monitoring and checking in real time
• providing decision support
• patient access to health records

Potential Impact of EHR Adoption

• net savings from increased savings and operational efficiencies (371 billion for hospitals and 142 billion for physician practices)
• management of chronic diseases
• prevention opportunities 

Computerized Provider Order Entry (CPOE)

• eliminates illegible handwriting
• reduces medical errors and adverse drug events through access to information
• reduces medication errors through structured orders
• improves patient care through standardization
• allows remote access
• simplifies billing process/justification
• new types of errors
• high cost
• mixed reviews on effectiveness

Surescripts

• company that provides connectivity between prescribers, insurance companies and pharmacies

Clinical Decision Support Systems (CDS)

• provides clinicians, patients or individuals with knowledge and person specific or population information, intelligently filtered or presented at appropriate times to foster better health process, better individual patient care and better population health
• makes it easy to do right thing and hard to do wrong 
• provides alerts, however important ones might be lost if there are too many in total (alert fatigue)

Population Aging Trends

• in 2010 1:8 us citezens are over 65+
• by 2030 1:4 us citezens over 65
• 4 million seniors over 85 in 2010 will go to 9 million by 2030

Ultimate Objectives of the Afordable Care Act

(ACA)

• morality
• acountability 
• transperancy 

Supreme Court Ruling on

Affordable Care Act

• individual mandate is constitutional (penalty vs tax)
• expansion of medicaid is constitutional
• expansion decision made by each state
• rest of ACA is constitutional

Affordable Care Act

Coordination of Care

• ACO: groups of doctors, hospitals, and other health care providers to give coordinated high quality care to their medicare patients
• Patient Centered Medical Homes (PCMH) is a transition away from a model of symptom and illness based episodic care to a system of comprehensive coordinated primary care
• tiered networks/narrow networks: tiered assign physicians into tto or more seperate tiers and narrow is a small or select network of physicians within a larger physician network

Top Reasons for Calling the

Clinical Communications Centerz

• urinary symptons
• post op symptoms and questions
• blood sugar
• abdominal pain
• trauma

Patient-Centered Medical Home 

• redesign of primary care: delivered in a team-base approach that care is highly coordinated
• delivers high quality, cost efficient care with concurrent increases in patient and provider satisfaction
• 55% increase in patient satisfaction and 35% increase in provider satisfaction

Racial Disparity vs medical advances

• 1991 -2000: 176,633 lives were saved through medical advances
• if we could have resolved racial disparities 886,202 deaths could have been avoided
• could save more lives through resolving racial disparities but spends more money on medical advances

Why are transitions in long

Term care important?

• $225 billion spent in 2012 on LTC services
• will escalate with demographic changes
• major impact on national and state budgets
• major impact on individuals: -cause of catastrophic expenses and 20% elders average 25,000/yr out of pocket

Cost of poor Coordination of Care

• acounts for 25-45 billion in wasteful spending
• unnecessary hospital readmissions
• inadequate management of care transitions

Discharge Function

• activities of daily living (ADL)-dressing, bathing, toileting, transferring, eating and continence
• instrumental activities of daily living (IADL) managing medications, housework, finances, shopping, telephone, transportation
• cognitive abilities: dementia and inellectual disability

Assisted Living

• less restrictive, less expensive, more home-like setting
• wide variability but most offer meals, housekeeping, laundry, transportation, personal support
• cost range from 2k-4k/month
• may be paid for by medicaid waiver for dual eligible individuals, but mostly covered by private pay

Hospice Care

• accepts death as the final stage of life
• affirms life and neither hastens nor postpones death
• offers a holistic team-based approach to patient adn family care
• palliative rather than curative care
• terminal illness with 6 months or less to live
• quality of life

Errors Across Transitions

• 49% of adults experience a medical error after hospital discharge
• 19-23% suffer adverse consequences
• most commonly a medicatin error
• breakdown in communication btw hospital team and or patient and primary provider