PHP Exam #2 Midterm (copy)

What is it meant by the delivery system? What is it meant by delivery? what is it meant by system?

Delivery System 

• Delivery: anything and everything related to the delivery of any type of medical care or service 

  • Hospitals 

  • Doctors 

  • Nurses of all kinds 

  • All other health professionals (e.g.,) pharmacists, chiropractors, physical therapists, home health aids, etc.)

  • Complementary and alternative medicine (CAM) providers 

  • Many other things 

• System: as you know well by know, there is no system-ness, nothing system-like, about health care delivery in the US 

What are some trends about the numbers of hospitals both in general and then in focus of rural areas? 

1. the total number of hospitals is falling 

2. the reduction is due to closures of rural hospitals 

what is the total trend of inpatient hospital utilization admissions? inpatient hospital utilization days? emergency departments?

• number of admissions went down

• inpatient days dropped increasingly

• number of emergency departments is goign down but now going back up

what is the trend of outpatient visits?

• there are a lot of care outside of hospitals so increase in outpatient visits

Around how many percentages of healthcare expenditures is part of our total GDP? What is the breakdown of the health care expenditures usage?

~17.3 —> 17-18 percent of healthcare expenditures is part of our total GDP

What are some overall trends when looking at hospital numbers, inpatient utilization, redeployment, economies, medicaid expansions?

Take Home Messages

• Inpatient utilization is falling, and in response, hospital outpatient utilization is rising

• Redeployment: hospitals are shifting outpatient care

  • Something called a facility fee which increase their reimbursement when they really aren’t doing additional work within the facility 

• Hospitals are very important to local economies and the US economy (and, not surprisingly, they have a very strong lobby)

• Medicaid expansions helps struggling hospital (urban and rural)

• More later: Hospital mergers and consolidation, impact trend

what is the physician gender ratio?

physician workforce gender is 60:40 male : female

however, female is increasing

International Medical Graduates (IMGs) make up what percentage of practicing physicians in the US?

24%

What are the take home messages for physicians? Think back to distributions of MDs by states and urban/rural groups. Think about the workforce? what are the trends? What about challenges? What percentage of IMGs make up the MD workforce?

Take Home Messages

• Supply/demand mismatch; likely shortages, especially in primary care

• Uneven geographic distribution of MDs

  • By state

  • Also (data not shown), by urban/rural (rural shortages) 

• MD workforce is aging (men especially)

• Serious workforce diversity challenges, that are worsening

•  ~24% of MD workforce are international medical graduates (IMGs)

What is the training hierarchy for LPN, RNs and Advanced Practice Nurse?

• LPN: Licensed Practical Nurse (1 year training)

• RN: Registered Nurse (2 years training)

• Advanced Practice Nurse (usually MA degree)

What are some take home points for other providers other than doctors? think PA, NP, APRNs

• there are many important types of providers other than MDs 

• NPs, PAs, and others such as pharmacists will play an increasingly important role in the future 

• APRNS and PAs make good salaries 

• As always, there is state to state in nursing salaries 

Primary care focuses on …

• primary care focuses on complex individuals in the context in which they live and function 

What is the definition of primary care? 

• The Definition 

  • 1996 Institute of Medicine (IOM) Report 

  • Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community 

  • Definition is in terms of the functions that primary provides, not who performs those functions 

  • Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community 

What is the dilemma of primary care? what is one of the main reasons? how does it compare to other nations? 

The Dilemma

• We have a high cost, and often low quality, health care system 

• The “value” of the health care we get is, relative to other developed nations, low (lecture 1)

• Assertion: part of the reason we have this dilemma is that health care in the US is specialty dominated, and specialty driven; not primary care driven 

• Today’s goal: understand the reason for this assertion

what are the the three C’s and what do they mean in terms of integrated care?

• Comprehensive: any health problem at any stage of the life cycle 

• Coordinated: the combination of services that meets patient’s needs, and the connection between and rational ordering of those services 

• Continuous: care over time by an individual or team, and timely communication of health information (e.g., events, risks, advice, patient preferences)

what are healthcare services? where can they be held ? physicians and the systems they work in are responsible to patients, families, and communities for the delivery of? 

• The full array of services performed to promote, maintain and restore health 

• Those services should be provided where the patient is 

  • Office 

  • Skilled nursing facilities 

  • Nursing home 

  • Hospitals 

  • Schools and homes 

• Physicians and the systems they work in are responsible to patients, families and communities for the delivery of 

  • Qualify care 

  • Patient satisfaction 

  • Efficient use of resources 

  • Ethical behavior 

an essential characteristic of primary care is that…?

• Primary Care Physicians (PCPs) receive all the problems patients bring 

• Have the skills to manage most of them 

• Know when to appropriately involve specialist 

personal health care needs often include

• physical, mental, emotional, and social concerns related to individual functioning 

what is the sustained partnership between the provider and patient?

• Patient-centered care 

• Shared decision making 

  • Providers (generally) have more knowledge about medicine 

  • But patients/families are the only ones who can provide information about values, goals, priorities, preferences 

  • We can make grave mistakes when we assume we know what a patient or family might want, and do not ask (and listen)

• Patients’ values should (almost) always trump providers’ values 

within the context of family and community, primary care understands…? community is defined as? our population is increasingly …

• living conditions 

• family dynamics 

• cultural background 

• Community is broadly defined and can mean a physical community like a neighborhood, or people who share values, experiences, language, etc. (e.g., gay community, Hispanic community, breast cancer community)

• In the context of our poor “value” health care system, arguable this is the kind of care that is needed, particularly given that our population is increasingly 

  • Older 

  • Chronically ill 

  • Obese

  • Diverse: racially, ethnically, religiously, culturally, linguistically 

what is the secondary care? tertiary care? and quaternary care?

• Primary care 

• Secondary care: short term, can be outpatient, may have technological focus 

• Tertiary care: complex, institution based, highly specialized 

• Quaternary care (not in the book): pediatric heart surgery or pediatric bone marrow transplantation (e.g., for a leukemia)

what is the relationship between physician connected patients and practice connected patients in context of prevention? 

• Physician vs. practice connectedness 

• Large MA study of primary care (n=92,315)

• Physician connected patients more likely than practice connected patients to get: mammography, cervical cancer screening, colorectal cancer screening, recommended diabetes care, and recommended coronary disease care 

having more primary care providers is associated with? having more specialty providers is associated with ? think quality and costs

• Counter intuitive findings 

  • Having more primary care providers is associated with higher quality and lower costs 

  • Having more specialty providers is associated with lower quality and higher costs 

primary care is associated with … (positive impacts)

• Primary care associated with

  • Greater use of preventive services

  • Less use of Emergency Departments

  • Higher care quality using Medicare data

  • Lower care costs using Medicare data

  • Other data show equal quality of care for diabetes, hypertension, and back pain

  • Higher overall satisfaction with care

  • Population-level mortality

what does the simon paper cover?

• evidence about attributes of high value primary care 

• definition of high value: low cost AND high quality 

• data: claims data from commercial insurance 

• blinded interviews of high and average value practices 

what are attributes seen in higher value practices?

• Decision support for evidence-based medicine → usually integrated into your medical record, is the ability to get quickly get access to definitions of high quality evidence based care

• Risk-stratified care management → map the intensity of the various types of care to different patients and problems 

• Careful selection of specialists 

• Coordinated care 

• Standing orders and protocols → you might not have to see a doctor and can instead see a nurse, being more efficient and ensuring timely care ← example

• Balanced compensation → do people actually want to work as a team and do work as a team 

what are simon paper’s three themes? 

• risk stratified care management 

• careful selection of specialists 

• coordination of care 

teamwork is essential for high value care 

primary care: ideally positioned to provide essential leadership 

primary care only receives around X % of funding but receives X % of health care patient visits

• primary care only receives 5% of primary care funding but helps and receives 35% of health care patient visits 

what is desktop medicine? 

consists of activities such as communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results 

what are some take home messages about primary care? think how often people see them, funding received, who they work with, what the pandemic did, what their job entails? 

over past three years, gender pay gap has widened among doctors by how much for PCP gap and specialist gap? 

PCP gap: 39k (15%)

Specialist gap: $108k (32%)

what is the RUC? who is it sponsored by? who is on the RUC? what is the discrepancy between the RUC members and primary care? 

• Resource-Based Relative Value Scale (RBRVS) Update Committee (RUC)

  • An association of doctors that is in charge of how much doctors get paid

• Sponsored and run by American Medical Association 

• Recommends RVUs for each of >7000 medical services 

• Who is on the RUC? 

  • 32 voting members, most appointed by specialty societies 

• Primary care

  • 35% of visits 

  • Only 1 guaranteed seat for primary care

RVU stands for Relative Value Units. They are a metric used in healthcare to measure the complexity, time, and resources required to provide medical services. 

How does the RUC determine RVUs? think relationship to CMS and the percentage of recommendations CMS has implemented from RUC. what is the trend in compensation gap? 

• Proceedings are private and proprietary, with secret ballots 

• In a zero-sum redistribution game, decisions are political 

• The RUC is the primary advisor to CMS for RVUs 

  • CMS has implemented 95% of the RUC’s recommendations 

• No surprise when you understand the RUC process: growing compensation gap between cognitive and proceduralist specialties

what is the take home messages for primary care physicians in terms of pay, policies in terms of prices, and then reimbursement differences? 

• primary care physicians get paid significantly less than specialists 

• payment policies are complex, and the process of setting prices is dominated by specialists

• these reimbursement differences between generalists and specialists are hard to change and have important implications 

what is the summary from the 2025 scorecard report —> thinking financing, workforce/access, training, and research? 

Summary 

1. Financing: Declining investment and fee-for-service payment are hindering primary care clinicians’ ability to meet growing patient needs

2. Workforce/Access: Insufficient funding is diminishing the primary care workforce and access to care

3. Training: Misdirected graduate medical education funding is not producing enough new primary care physicians, exacerbating access issues for patients

4. Research: The lack of research dollars to study the practice of primary care is limiting evidence-based improvements in care

what are some general take home messages about primary care workforce in terms of the workforce make up of it? what are some reasons? 

• Primary care workforce not growing fast enough 

• Too few trainees enter and stay on primary care paths 

• The government underinvests in primary care 

• Technology has become a burden 

• Research on novel solutions is lacking

which providers are PCPs?

• Primary care practitioners are usually 

  • Family physicians 

  • General internists 

  • Geriatricians 

  • General pediatricians 

  • Nurse practitioners 

  • Physician assistants 

• Sometimes included: nurses, pharmacists, health educations, medical assistants 

what are hospitals and hospital healthcare practices doing to primary care practices?

• hospitals and hospital healthcare practices are buying primary care practices and bringing them into their systems 

what is the distinction between primary care physians and primary care providers?

 A primary care physician (PCP) is a medical doctor (\(MD\) or \(DO\)) who provides comprehensive primary care, while a primary care provider is a broader term that includes physicians as well as other qualified healthcare professionals like nurse practitioners and physician assistants. All primary care physicians are providers, but not all primary care providers are physicians.

how many million americans live in primary care health professional shortage areas? `

101 M americans

what role do IMGs play in primary care?

IMGs play an important role in providing access to primary care

64% of foreign trained physicians were practicing in medically underserved areas or health professional shortage areas with almost 46% of these physicians practicing in rural areas 

what are the definitions of brand name drug, generic drug, biologic drug, biosimilar drug, and a specialty drug? what are examples of them ?

what are some trends with how much the US pays for pharmaceuticals?

• the us pays significantly more on pharmaceuticals compared to other countries 

• in the 90s US spending on pharmaceuticals increases 

what was the average annual costs of widely used prescription drugs? for generic? for brand name? for specialty drugs? 

• The average annual cost of therapy for widely used generic drug products was $679 in 2020 

• The average annual cost of therapy for widely used brand name drug products was $6,604 in 2020 

• The average annual cost of therapy for wiley used specialty drug products was $84,442 in 2020 

TRUE or FALSE: specialty drug growth outpaces traditional drugs

TRUE

what are some take home messages about prescription drug costs? think about US vs worldwide, for patients and the impact, and the cost of various types of drugs? 

Take Away Messages

• Prescription drug costs are increasing worldwide but much faster in the US 

• Out of pocket costs impact patients’ ability to take their drugs as prescribed by their physicians 

• The cost of specialty drugs are the most expensive category of prescription drugs and continues to increase in sales 

what is the US drug approval process? how long does it take for each step? what does each step entail? 

FDA Phases 

Discovery and Development 

• Find a selection of potential compounds through results from separate studies, extensive testing, or new scientific or technological knowledge 

• Narrow down the field by examining the chemical and biological properties of the compounds to find one that may interact favorably with a given condition 

Pre-Clinical Trials

• Both in vitro (i.e. in a petri dish) and in vivo (i.e. animal studies) to determine any major effects of the drug, specifically efficacy, toxicity, and dosing 

• If results are promising, submit an investigational new drug proposal to the FDA outlining preclinical results and plans for clinical trials 

FDA Phases: Clinical Trials 

Phase 1 

• 20-100 healthy participants (except for cancer, in which case testing done on cancer patients) 

• Testing for metabolism, dosing, efficacy and side effects 

• Several months 

• ~70% move to Stage 2 

Phase 2

• Several hundred participants with the target condition 

• Testing for safety and efficacy 

• Several months ~2 years 

• ~ 33% move to Stage 3 

Phase 3 

• 300-3000 participants with the target condition 

• Testing for efficacy and larger range of side effects (due to large sample) 

• 1-4 years 

• Once filed 

  • ~92% approved 

Phase 4 

• Post-marketing surveillance 

• Several thousand participants with the target condition 

• Continued safety and efficacy testing – look at long-term side effects 

Phase 5 

• Drugs that have been approved by the FDA and available to be prescribed by physicians 

• May involve thousands of people 

• Typically the safest type of trial as it has been studied in detail and many instances for a long time 

• May gather data on long-term side effects, recurrence or survival 

• Outcomes may include quality of life or cost-effectiveness

what is the federal drug administration : new drug approval? what is the to be licensed portion entail ? what does it mean? 

To be licensed: “safe and effect under conditions of intended use” (statutory standard) 

• Risks are considered acceptable for the potential benefits for a given indication 

what is the costs of development for the DiMasi study?

• Sample of 106 drugs from 10 firms 

  • Financial and development information submitted by the companies via a surgery - no way to publicly verify information 

  • These 10 firms are from the top 50 pharmaceutical companies, so no perspectives from smaller firms 

• Similar cost calculations as Wouters 

• Time costs (different between out-of-pocket and capitalized costs) make up about 45% of total cost 

  • $1.163 billion of the $2.6 billion figure are due to this calculation of opportunity costs into the model 

what was the wouters study about? what did it result and produce?

• Sample of 63 FDA approved pharmaceuticals between 2009-2018 (the amount of approved drugs with publicly available R&D)

• Found mean development cost of $1.336 billion and median of $985 million (calculated costs for Dupixent were a large outlier)

• The study accounted for direct and indirect yearly R&D spending, average numbers of failed trials, and the cost of capital rate (10.5%) – basically the opportunity cost of developing the drug 

What are some take home messages about costs of developing medicines, phases, the probability of starting phases, and the R&D pipeline? 

Take Home Messages

• The cost to develop a new medicine is significant 

• There are multiple phases for evaluating the safety and efficacy of a new product 

• The probability of a product starting phase 1 and progressing to FDA approval is low 

• The R&D drug pipeline is crowded with likely high-cost specialty drugs 

what is the history of PBMs/ pharmacy benefit managers?

• During the 1970s and 1980s, PBMs evolved the system of discounted mail-delivered pharmaceuticals and networks of bricks and mortar pharmacies 

• Starting in 1987, PBMs introduced real-time electronic processing of drug claims, moving the management of insurance based pharmaceutical therapy to a completely paperless system 

  • Predominantly serving the private sector during the 1970s and 1980s 

  • PBMs expanded services to Medicaid programs in the 1990s 

PBMs are hired by health plans/employers/ Unions/ government to…

• Design formularies 

• Negotiate rebates 

• Set up pharmacy networks 

• Process claims 

what are PBMs or pharmacy benefit managers? 

• PBMs, or Pharmacy Benefit Managers, are third-party companies that act as intermediaries in the prescription drug supply chain, managing drug benefits for health insurers, large employers, and other payers. Their main functions include negotiating drug prices and rebates with manufacturers, creating drug formularies, processing claims, and managing pharmacy networks. PBMs were created to help control prescription drug spending but have become complex entities that generate revenue through various means, including fees and the spread between what they charge insurers and what they pay pharmacies. 

PBMs reduce drug costs by…

• Offering home delivery of medications and created select networks of more affordable pharmacies; 

• Encouraging the use of genetics and more affordable brand medications; 

• Negotiating rebates from drug manufacturers and discounts from drugstores; 

• Managing high cost specialty medications 

• Reducing waste and improving adherence 

what is a prescription drug formulary? what is it also called? 

• A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list  

what is the formulary development process? 

what is the pharmacy and therapeutics committee (P&T)? who is on it? who do they do? 

• P&T Committee consists of non-employee physician members and pharmacists from active community and academic based practices and represents a broad range of medical specialties 

• P&T Recommendations 

  • Must add/Include 

  • May add / Optional

  • Must not add / Exclude 

what are three different formulary types? 

• Open - the plan sponsor pays a portion of the cost for all drugs, regardless of formulary status. Although, a plan sponsor may choose to exclude certain products, such as “lifestyle” drugs, from coverage 

• Restricted- the plan sponsor will only cover drugs listed on the formulary. Non formulary drugs are not covered unless approved through a formulary override process 

• Tiered - plan sponsored offer different copays or other financial incentives to encourage participants to use preferred formulary drugs but will still pay a portion of the cost of the non-preferred design, it may cover non-preferred, nonformulary products on its third tier with a higher copay 

the more covered lives (insured customers) represented by a PBM…

the more likely that manufacturers will offer rebates in return for formulary placement

what are PBMs rebates? why do manufacturers pay for rebates? rebates can only occur in a competitive drug class? 

• Rebates are retroactive discounts negotiated with manufacturers by PBMs and health plans for brand name drugs 

  • Manufacturers pay rebates in exchange for improved access, preferred formulary position or exclusive status or to lock out the competition 

  • Rebates can only occur in competitive drug classes 

what is PBM scrutiny? 

• In the past few years PBMs have gotten greater visibility and public attention 

• Increases in consolidation (with the three leadings PBMs – CVS Caremark, Cigna–Express Scripts, and UHS OptumRX – controlling 80 percent of the market), power, and secrecy have swung the needle in the opposite direction 

• As the PBMs have consolidated, prices have risen. Manufactures that wish to have their dugs covered on PBM formularies pay significant rebates and fees to PBMs, often paid for by raising the price tag 

what is the inflation reduction act and the impact it had on prescription drug provisions?

• Require the federal government to negotiate prices for some drugs covered under Medicare Part B and Part D with the highest total spending, beginning in 2026 

• Require drug companies to pay rebates to medicare if prices rise faster than inflation for dugs used by Medicare beneficiaries, beginning in 2023 

• Cap-out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024 

• Limit monthly cost sharing for insulin to $35 for people with MEdicare, beginning in 2023 

• Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023 

• Expand eligibility for full benefits under the Medicare Part D Low Income Subsidy Program, beginning in 2024 

• Further delay implementation of the Trump Administration's drug rebate rule, beginning in 2027 

What are some certain categories of drugs that are excluded from the negotiation process?

• Drugs that have a generic or biosimilar available 

• Drugs that are less than 9 years (for small-molecule drugs) or 13 years (for biological products) from their FDA approval or licensure date 

• “Small biotech drugs“ (until 2029), defined as those which account for 1% or less of Part D or Part B spending and account for 80% or more of spending under each part on that manufacturer’s drugs 

• Drugs with Medicare spending of less than $200 million in 2021 (increased by the CPI-U for subsequent years)

• Drugs with an orphan designation as their only FDA approved indication 

• All plasma-derived products 

what is the IRA estimated impact? on medicare D enrollees? on medicare? on out of pocket costs? 

IRA Estimated Impact 

• Medicare Part D enrollees expected to save $1.5 billion from the 2026 negotiations 

• Price negotiations finalized on August 1, 2024 

• If the negotiated prices for the 10 2026 drugs had been implemented in 2024, Medicare would have saved $6 billion, or about 22% 

• Insulin caps and free vaccines alleged saved $400 million in out-of-pocket costs 

what are some drugs qualified for negotiations for 2027? 

• 15 drugs include the popular diabetes and obesity drugs Ozempic and Wegovy

• Other drugs used to treat asthma and chronic obstructive pulmonary disease, type 2 diabetes, prostate and breast cancer, and other conditions 

• Total spending on these 15 drugs between November 2023 and October 22024 was $40.7 billion, with 5.3 Medicare beneficiaries using these medications during that time 

what is the cost of the IRA for medicare part D drug benefits?

• The dressing of the Medicare Part D drug benefit will cost $10 billion to $20 billion more next year than the Congressional Budget Office initially projected 

what is inpatient care?

• at least one overnight stay

what is ambulatory care?

“ambul“ : walking

• ambulatory care is a medical treatment provided in an outpatient setting, meaning patients do not stay overnight 

what are three interrelated trends? think within the context of inpatient care, hospital based out patient care, and non hospital based outpatient care

• 3 interrelated trends 

  • Because inpatient care is so expensive, payers won’t pay for an overnight stay if it isn’t medically necessary 

  • Hospital-based outpatient care is more expensive that non hospital-based outpatient care 

  • Busy people demand convenient care 

what is the trend of why hospitals must maintain all the expensive services and technology?

• Hospitals must maintain all the expensive services and technology in order to: 

  • Be properly accredited and licensed 

  • Attract various insurers, patients AND good physicians 

• This high overhead puts them at a competitive cost disadvantage relative to free-standing, single focus ambulatory facilities, including even surgical centers or imaging centers 

what are ambulatory care setting examples?

• Hospital emergency departments (EDs)

• Hospital-based outpatient departments (OPDs)

• Outpatient offices; physician private practices

• Community Health Centers

• Free-standing specialty care settings

  • Ambulatory surgery centers (ASCs)

  • Imaging centers

• Urgent Care Centers

• Retail clinics

• Concierge medicine

• Complimentary and Alternative Medicine

what did the chau et al conclude in context of acute care?

• Chau et al., Conclusions

  • Large decline in acute care visits to primary care offices 

  • No corresponding, balancing increase in acute visits to EDs 

  • The rapid rise of alternative acute care sites such as retail clinics, urgent care centers, and telemedicine likely also plays a part in the reduction in rates of acute primary care visits 

what are the take home messages for visits for PCPS, specialists, and visits to NPs and PAs? 

• Take Home Messages

  • Visits to primary care physicians for acute care and care more generally are decreasing 

  • Visits to specialist are mostly flat 

  • Visits to NPs and PAs in medicare are increasing (and probably in non-Medicare settings also)

  
  

what is EMTALA (1986)? what does it require of hospitals? it functions as a safety net? it was a response to ? 

• Emergency Medical Treatment and Labor Act (S&S, page 316)

  • Requires hospitals and ambulances to provide emergency care to anyone needing it regardless of ability to pay, citizenship, and legal status 

  • Functional “safety net”

  • Provides no money to accomplish this; classic “unfunded mandate”

  • Counteract “dumping” of uninsured or unprofitable patients 

everyone wishes that EDs weren’t ? EDs are essential for?

Place of EDs in US system of Care 

• Everyone wishes ED weren’t so important 

  • Essential for “real emergencies”

  • A complex, inefficient and expensive way to provide non-emergent care 

• Article is an ED-centric view, arguing that given that EDs do so much that they need to be better paid 

• Article referring to RAND - strategies for sustaining emergency care in the United States 

What is the general take home message for ED care? think EMTALA — what does EMTALA cover / what doesn’t it cover? think about trends of ED utilization. think about acute care trends in context of primary care doctor’s officers. 

• Know what EMTALA is (and isn’t)

  • You may get a bill for being seen 

  • They wont pay for medicines, follow up care, if you get diagnosed with heart disease or cancer → they won’t provide follow up care, they just need to stabilize you 

• Pre-pandemic, ED utilization appeared to be decreasing slightly; post-panemic visits are trending up again 

• There are pretty dramatic decreases in the amount of acute care that is done in primary care doctor’s offices 

• Use of EDs is a difficult habit to break, but will continue to receive attention because it is an expensive and efficient palace to provide nonemergency care 

what are urgent care centers? how does it differ than a primary care practice? compared to an emergency room — what is the difference in cost, wait times? what is the caveat for children though? how do urgent care centers operate in terms of patients coming in? what are the hours like?

• Treat patients who have illness/injury that requires immediate care but do not require ED level care 

  • Should be treated within 24 hours 

  • Unscheduled, walk in abscess 

  • Extended hours 

    • Fills in the gap after private offices are closed 

• More services than primary care practice 

• X-ray defibrillator, oxygen, lab capabilities 

• Can be free standing or within hospitals 

• Compared to emergency room

  • Less expensive source of care (3-4 x cheaper)

  • Often shorter wait times 

• Often lower copay for insurance than ER 

• Perhaps inappropriate for children under 2 if not pediatric expertise 

• But, access to regular physicians?

what is the percentage of growth in urgent care centers from 2016-2024?

~67% growth over 8 years

what are the take home messages for urgent care centers? what do they try to fill? their growth is a testament that? what is the trend of the utilization of urgent care centers?

• Urgent Care Centers attempt to fill the need for acute care that falls in the gap between office-based outpatient care and ED care 

• Their growth is a testament to the need for a place for these services to be conveniently provided 

• According to the industry and academic data, utilization of urgent care centers continues 

what are retail clinics? what are examples of them? how are they convenient? they are usually staffed by ? how are their hours? 

• Clinics located in retail stores 

  • Grocery stores 

  • Drugstores 

  • “Big box” stores such as wal-mart 

• Convenient, walk-in for minor problems like colds and prevention (e.g., flu shots)

• Usually staffed by non-physicians 

• Nighttime and weekend hours 

what are some take home messages about urgent care centers? 

• urgent care centers and retail clinics both attempt to meet clear need for more timely, more convenient primary care 

• retail clinics continue to grow through pandemic 

• they clearly fill a market niche for convenient care 

• impact remains to be seen: will they increase quality and decrease costs?

what is concierge medicine? how does it work? what are other names for it? what does it include within services? what are some benefits of it? you still need to have what? 

• Other names: boutique medicine, retainer-based medicine, and innovative medical practice design 

• Pay a retainer of $1000-10,000

• Also called “direct care” because patients pay their PCPs directly, rather than charging patients’ insurance 

• For that, you get increased access to your PCP 

  •  The extra revenue allows PCP to have fewer patients 

  • 600 patients rather than the usual 2,000 to 4,000 for someone in full time practice 

• Get a variety of additional services such as 

  • Cell phone access to MD 24/7 

  • Same day visits 

  • Longer visits 

  • PCP accompanies you to specialty visits 

• You still need to have health insurance 

  • The retainer only covers outpatient care through that practice

  • For lab testing, specialty visits, and hospitalizations, you still need insurance 

• Generally, those who use concierge services have both employer based insurance AND also pay a retainer for concierge services 

• a retainer is an advance payment for services, typically made to a professional like a lawyer or a service provider

  • it secures the provider’s time and expertise, and the fee is often held in a trust account and deducted as work is completed 

What is the concierge medicine controversy? what are the pros? what are the cons? how many are in the country?

Concierge Controversy 

• PROS 

  • Why not allow people to pay more to get more? 

  • Physicians argue that it allows them to practice the kind of medicine that they think is right 

• CONS 

  • 2 tier medicine; very costly 

  • Better care for the wealth 

  • Takes physicians away from those who need them 

• Probably only 1000 or so in the country; probably don’t have a huge impact (yet)

what is direct primary care?

• Direct Primary Care 

  • Direct = no insurance between provider and patient 

  • concierge care for the rest of us 

  • Concept: pay a monthly retainer (say $50/m), and get all the office-based primary care you need 

  • Couple with high deductible plan 

  • MD perspective: don’t have the hassle of reimbursement; focus on patient care 

  • PT perspective: better, easier access 

what does the annals of internal medicine - position paper claim about concierge and direct patient contracting practices? 

1. draws attention to the difficulties in routine practice related to the hassles of payment systems that is driving physicians to enter DPCPs 

2. notes that this trend may exacerbate racial, ethnic, and other socioeconomic disparities

what are some take home messages with concierge medicine and direct primary care? what are they symptoms of? what is the trend of ambulatory care? free market context creates? 

Take Home Messages

• Concierge medicine and direct primary care are symptoms of a poorly functioning “system”

  • Patients not getting what they need 

  • Physicians constrained in how they can meet these needs 

• Free market context creates opportunities, niches to be filled 

• Ambulatory care is evolving rapidly 

what is the difference between complementary versus alternative medicine?

• if a non mainstream approach is used together with conventional medicine, it’s considered “complimentary“

• if a non mainstream approach is used in place of conventional medicine, it’s alternative

what are some take home messages for complementary health approaches? what is the trend? 

• Take Home Messages 

  • Americans use a lot of complementary health approaches 

  • And spend a lot of money out of pocket doing so 

what percentage or fraction os healthcare expenditures in the US go to hospital based care?

1/3 ! 

what is the evolution of hospitals?

what was the expansion phase for the late 1800s to mid 1980s? what was the trend for US hospitals? what was roemer’s law? 

• rapid increase in the number of US hospitals 

• Roemer’s Law (1961) : a built bed is a filled bed

what contributed to this massive growth in the expansion of hospitals?

1. advances in medical science

• medicine moved from a field that was dominated by “snake oil salesmen“ to a respected profession

• physician societies, like the AMA, began to be established in the mid 1800s

• surgical advances made complex procedures safer 

2. development of specialized technology 

• germ theory revolutionizes the practice of medicine, leading to an explosion of medical research and scientific discovery 

• specialized tools like X rays and EKGs begin to be developed that make medicine safer and more effective 

• hospital accreditation and inspection developed more robust standards for hospital equipment and wards (American College of Surgeons in 1918 and Joint Commision in 1951)

3. Advances in medical education 

• advances in biomedical knowledge made it necessary to train physicians in hospital settings, which in turn make doctor’s training more rigorous 

• internships and residencies were established as part of the training 

• clinical research associated with hospitals flourished 

4. development of professional nursing 

• florence nightingale transforms nursing into a recognized profession with the founding of the nightingale school of nursing in england in 1860 

• the US followed suit as the benefits of having trained nurses in hospitals became apparent, increasing treatment efficacy and patient care standards 

• the presence of trained nurses improved the image of hospitals 

5. growth of health insurance

• the development of private health insurance in the 1930s allowed people to more easily pay for and access hospital services 

• it also improved the financial stability of hospitals 

• the advent of public insurance plans in 1965 significantly expanded the pool of peple who could access hospital based care 

6. role of government 

• arguable the most important role in hospital expansion in the 20th century came from government funding for hospital construction 

• the US emerged from WWII flush with cash and with a new generation in need of medical care

• the great depression and WWII consecutively had led to a downturn in construction and a hospital bed shortage 

• enter: the hospital survey and construction act of 1946, more commonly called the Hill Burton Act 

what is the hill burton act (1946)?

• Bipartisan law named for a Northern Republican (se. Harold Burton of OH) and a Southern Democrat (Sen. Lister Hill of AL)

• Original wording called for “separate but equal” hospitals with “equitable distribution of hospital beds for each population group”

• Overturned in Simkins v. Moses H. Cone Memorial Hospital (1963) – challenged federal government's use of public funds to maintain segregated hospital care Civil Rights Act of 1964 banned segregation at hospitals 

However, most Southern hospitals were forced to desegregate primarily due to the loss of access to Medicare and Medicaid funding, which began to represent a significant portion of the market

why did 1980 see a hug contraction in hospitals and beds? as well as occupancy?

• change in care patterns 

  • outpatient care is preferred

• changes in reimbursement 

  • prospective payment system and the advent of DRGs 

• impact of managed care 

• hospital closures 

what is the tax equity and fiscal responsibility act (TEFRA) of 1982? what is a DRG payment? what are the incentives for this system?

• the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, established the hospital prospective payment system (PPS) for Medicare reimbursement 

• Under a PPS, hospitals are paid a fixed amount per admission according to the patient’s primary diagnosis 

• flat rate payment tied to a diagnosis related group (DRG)

• DRG payment is consistent regardless of time in the hospital, resources used, or adverse events that occur 

• the prospective payment system provides a predetermined rate, creating incentives for efficiency 

do non profit hospitals actually deliver on their promise?

• non profit hospitals actually DO make a profit, they are just restricted from distributing that profit to any individuals (e.g., no shareholders looking for return on investment)

• to achieve tax exempt status, must provide some defined public good or community benefit 

• in 1983, this language was standardized to include a 24 hr ED, policy guidelines for treating the uninsured and health promotion in the community 

what are the four new community benefit requirements? 

1. written financial assistance and emergency care policies 

2. limit charges for individuals eligible for financial assistance policy 

3. limit billing and collection actions against those who quality for financial assistance

4. conduction a community health needs assessment and an implementation strategy at least every 3 years 

what are the various ways hospitals are classified? most people classify hospitals however based on ? 

• General Hospitals vs Specialty Hospitals 

• Short Stay vs Long-Term Care Hospitals 

• Urban vs Rural vs Critical Access 

• Teaching vs Non-Teaching 

• Physician-Owned Hospitals 

• Psychiatric Hospitals 

• State Mental Health Institutions 

• Rehabilitation Hospitals 

• Children's Hospitals 

most people think of hospitals by ownership type

• 48% private non profit 

• 21% private for profit 

• 16% state and local government 

• 3% federal 

• 10% psychiatric (non federal) 

• other 2% 

what are key takeaways for hospital classifications? how non profit hospitals operate vs for profit hospitals? 

• there are various ways to classify hospitals, but most people primarily consider ownership type 

• non profit hospitals often behave very similarly to “for profit” hospitals

• understand how the concept of community benefit relates to not - for profit tax status