Ch 7 & 8 Organization and A &M text

Primary, Secondary, Tertiary levels of care-examples-which is most costly

Primary 

• Common health problems that account for 80- 90% visits to providers

• ex. immunizations, colds, physicals, ear infections

Secondary 

• Problems that require more specialized clinical expertise 

• ex. OB/GYN, ENT, Surgery, Cancer treatment 

Tertiary 

• Rare + complex problems 

• ex. Organ transplant, congenital malformations

Most costly: Tertiary

Regionalized model-dispersed model- features,

1. Regionalized model

• Highly structured

• Base is primary care, organization
  works upward as needed

• General physician practitioners (GPs)
  practice exclusively at the primary care
  level

• Relies on resources coordinated in a
  geographic region

2. Dispersed model

• More fluid model- allows patients to go
  where they wish, tertiary expertise
  emphasized

• Primary care is spread among
  specialists, total supply of generalists

Why dispersed model has grown in the U.S.

Biomedical Model

• Flexner report 1906- Medical training was reformed with an
  emphasis on

  • Academically oriented training

  • Technology and basic science

  • Specialist training

• Financial Incentives

  • Medicare/Medicaid paid more for procedures

  • Blue Shield- Reimbursement for procedures- fees remained
    high despite the physician time needed for procedures
    declined

• Hill Burton Hospital Construction Act 1946- hospital expansion

• Professionalism

  • Physicians have been sovereign, American Medical
    Association (AMA) has supported physician independence.

  • System has been weighted toward hospital and specialty care

Arguments for and against a dispersed model

For

• Pluralism enables providers and facilities
  to be more available

• Americans value choice of providers,
  access to specialists and technology

Against

• It lacks coordination

• Quality of care can be maintained with use of fewer
  resources

  • Research shows comparable outcomes for patients treated by
    General practitioners and Nurse practitioners

• It is not consistent with the health needs of the
  majority of the population “Common disorders
  commonly occur and rare ones rarely occur”

  • e.g. (URI, skin disorders, emotional disorders, preventive care
    needs)

• Is costly

  • Research shows that generalists in contrast to specialists
    practice a less resource intensive style of medicine

  • Costs are lower for patients treated by generalists vs.
    specialists after controlling for severity of illness.

    
    

Supply of U.S. generalist physicians- why this is a problem

Vertical integration- First generation HMOs- Kaiser

• A vertical integration model: consolidates all
  levels of care, staff, and facilities under one
  organizational ownership

• Does not cover an entire population but
  responsible for delivering all services to a
  population of enrollees

• Physician group practice provides care to
  members under a capitated plan.

• Enables a more population based model of
  health

Virtual integration- Independent Practice Associations (IPAs) and Integrated Medical Groups

Benefits of vertical/benefits of virtual integration

Virtual integration:

• Hospitals and insurers recruit office
  based fee for service community physicians into an IPA
  creating a basis for an HMO and negotiate contracts
  with the physicians to provide care.

IPA model:

• Allows insurers, etc. to respond to market changes by
  renegotiating contract bargains with providers

• Has the advantage of low capital costs because the HMO
  does not have to own buildings

Integrated medical group model:

• Physicians do not own their practices but the medical group
  organization employs them

(IMGs)- Value of virtual integration, disadvantages

IMG Value/Disadvantages: 

• Encourages cooperation w/o consolidation

• Limited control + potential inconsistency across independent entities 

Importance of HMO act 1973

Purpose:

• encouraged the development of Health Maintenance Organizations 

Importance:

• marked a shift towards managed care, cost containment, & preventative focus 

Differences between old and new primary care models

Old Model:

• solo or small-group practice; fee-for-service payment; limited coordination; reactive care 

New Model:

• team-based, integrated sys, use of electronic health records, pop health management, + preventive focus 

Role hospitalists have in health care

Patient care medical homes

Accountable Care Organizations

• Networks of physicians and other providers that are held accountable for the cost and quality of the continuum of care delivered to a group of Medicare patients.

Medical Neighborhoods

• Services are functionally integrated similar to traditional HMOs. PCP coordinates care. Patients are informed and involved. Coordinated care contributes to the health of a population.

• High performing health care requires excellent medical homes and medical neighborhoods.

• Are based on “Patient Centered Medical Homes” where the primary care physician is in charge of care provided by all people and places where care is provided including specialists, pharmacies, hospice, home health, nutritionists, etc.