Healthcare Policy & Delivery Exam 1

Flexner Report (1910)

• required medical schools to be part of universities, to have at least 4 years of training, and to have 2 years in laboratory science

• quality of medical education and medicine improved

• caused hospitals to become a place for healing and research

Affordable Care Act (2010)

• extended Medicare coverage to more than 10 million people living in or near poverty that were previously ineligible

• provided health insurance to an additional 11 million formerly uninsured people with low to moderate incomes through a combination of regulated insurance exchanges and tax subsidies for the cost of insurance

• made a series of changes to regulations affecting companies that provide health insurance to make it more affordable

• made a series of changes in the Medicare program to reduce costs and improve benefits

• created a series of new sources of tax revenues to support these programs

Horizontal Integration

• similar hospitals

• form affiliations with other hospitals to increase efficiency

• share equipment, supplies, management, services

• usually between large urban and smaller rural community hospitals

• make more money by doing this

• Ex: Baystate

Vertical Integration

• different types of facilities beyond hospitals

• develop newer markets to provide a continuum of services

• focus on transferring inpatients to outpatient services

• ambulatory care, home health, rehabilitation, hospice, nursing homes

• save money by doing this

• Ex: Baystate

general hospitals

• treat a variety of medical conditions

• may have specialty areas/floors (cardiac, maternity, etc)

specialty hospitals

treat a specific medical condition or population (cancer, cardiac, children, veteran, psychiatric, etc)

short-term hospitals

average LOS <30 days; majority of hospitals (84.1%, 5,157 hospitals)

long-term hospitals

average LOS >30 days

privately owned hospitals

• 80% of hospitals

• nonprofit hospitals (58%)

• for-profit hospitals (24%)

• Owned by groups of physicians, HMOs, corporations (most common)

• profit typically goes to shareholders or investors

• usually offer more expensive services

nonprofit hospitals

• owned by voluntary groups (often church affiliated)

• profit typically goes back to the institution

• offer more family planning, emergency, and psychiatric services

• criticized for not providing enough charity care

• Ex: Mercy

government owned hospitals (public)

• 19% of hospitals

• Federal

• State

• Local

Federal Hospitals

• military- active and inactive members

• Indian health service

• prisons

state hospitals

• long-term psychiatric hospitals

• prisons

• state university teaching hospitals

local (city/country) hospitals

• Metropolitan areas- lots of staff and residents, private physicians

• non-metropolitan areas (rural)- private physicians

teaching hospitals

• 7% of hospitals

• work with medical schools to provide training for health care practitioners

• larger and located in urban areas

• more specialized services

• more employees and patients

• more uncompensated care

• more expensive to run

rural hospitals

• needed so everyone has access to a hospital

• not appealing for healthcare workers due to low pay and lower quality of technology

The Joint Commission

• inspects health care facilities at least every 3 years

• no legal requirement to be JCAHO accredited

• non-government, non-profit

• evaluates and inspects the credentials of the staff, quality of work, safety and sanitation, program and procedures

distributive services

• provide dispensing services (medication)

• overseeing technicians

• filling of unit dose medication carts

• preparation of sterile products

• monitoring drug storage

• providing and maintaining crash carts

non-distributive services

• medication management

• medication reconciliation (ACA)

• monitoring/adjusting drug therapy

• providing specialized pharmacy services

• providing drug information

Activities of daily living (ADLs)

eating, using the bathroom, grooming, bathing, walking

Instrumental activities of daily living (IADLs)

shopping, preparing meals, managing finances, managing medications

skilled nursing facilities (SNFs)

• require 24-hour skilled nursing care

• risk factors: age, gender, ethnicity, medical conditions, marital status, poverty, low social support, mental status, problems with ADLS and IADLS

• Medicaid is primary payer (62%)

• Medicare (13%)

• Private/other (25%)

intermediate care facilities

provide temporary care for individuals who need recuperation time after a hospitalization (surgery, illness)

Medication Regimen Review (2016)

medication management

• monitor psychotropic drug use (drug that affects brain activities associated with mental processes and behavior)

• must be necessary to treat a specific condition

• must monitor and employ gradual dose reductions and behavioral interventions

• discourage PRN use; but if given limit to 14 days

Home Health Care (HHC)

provisions of health care services in the home; Factors:

• increase in number of elderly

• overcrowding of nursing homes

• advanced technologies

• lower cost than hospitals, nursing or assisted living facilities

Medicare Criteria for HHC

• patient is homebound

• patient is under care of a physician

• intermittent need for skilled services from nurse or other care provider

• provider is certified under Medicare

HHC services- Medical

• infusion therapies

• skilling/unskilled nursing services

• home medical equipment

• hospice care

• pharmacy services

HHC services- Nonmedical

• social services

• housekeeping services

• cooking, shopping, home maintenance

• transportation assistance

HHC services- Rehabilitative

• physical

• occupational

• speech

• respiratory

• therapy

HHC services- Pharmacy

• nutrition

• medication

• home medical equipment

• other prescriptions

• medication management

Assisted Living Facilities (ALFs)

• residential care setting for people who can no longer live independently but don’t need full-time nursing care

• address needs of individuals who require help with ADLs and IADLs

• resident autonomy

• max. independence

• respect for patients

• housekeeping

• meals

• laundry

• medication

• socialization

• transportation

Hospice

• provide humane and compassionate management of patients with uncurable disease

• maintain quality of patient’s life rather than cure the disease

• no more than six months to live

• must agree to cease all curative efforts

• must focus on palliative care only

• nursing homes, hospice center, home care

speculative risk

situations where either gain or loss is possible

• stock market

• business investments

risk

uncertainty concerning the occurrence of a loss (event)

pure risk

situations where only loss or no gain is possible

• healthcare

the insurance mechanism

• financial risk is partially or completely transferred from individuals to the insurer

• insured pays a fixed premium to the insurer in exchange for insurance coverage- reduces insured’s risk

adverse selection

inherent in any voluntary system for buying health insurance (death spiral effect) when only sick(er) people are motivated to purchase insurance

insurance effect

the tendency for people with health insurance to use more health care services than people without insurance (even when health status is similar)

moral hazard

use of more tests/healthcare when the patient does not feel the real cost of services (insurance effect)

• copays

deductible

the specific amount you must pay out of pocket before insurance starts to pay; patient must pay for the fixed-dollar amount of services or products consumed during a specific period; strong incentive to control utilization early in plan year unless person is a high utilizer

premium

the regular fee (monthly/yearly) paid to an insurance company to keep insurance policy active

copay

a set amount you pay out of pocket for certain covered services or prescriptions when you receive the service; specified fixed-dollar amount paid per service unit consumed

co-insurance

the percentage of a medical bill you pay after reaching your annual deductible; fixed percentage of charges per service unit or product unit consumed

cost sharing

part of the cost of covered healthcare products and services is paid by the patient, and the rest is paid by the insurer; reduces moral hazard

• reduces utilization of (demand for) healthcare services

• control overall costs of the plan

• control premiums

formulary

a list of medications covered by a health insurance plan

maximum insurance payment

patient must pay out-of-pocket for expenses incurred above the maximum; no longer allowed for health insurance (ACA)

Maximum Out-of-Pocket expense

patient must pay for incurred out-of-pocket expenses up to the maximum OOP expense, then insurance covers expenses above that; does not include premiums

indemnity benefit plans

• reimburse patients instead of healthcare providers

• patient pays for products/services and sends a receipt or claim to insurer, then insurer reimburses patient

• some form of cost sharing is usually used

• patients receive monetary benefits directly

service benefit plans

• healthcare provider files a claim for products or services used by a covered patient

• payer reimburses the provider and the patient is responsible for any cost-sharing charges

• patient receives healthcare services (instead of money) as the benefit

• more common because more convenient

private health insurance

• employer-sponsored

• individual

public (government) health insurance

• medicare

• medicaid

• VA and DoD

• indian health service

Exclusive Provider Organization (EPO)

a managed care plan where services are covered only if you use the doctor’s, specialists, or hospitals in the plan’s network (except in an emergency)

Health Maintenance Organization (HMO)

a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO; generally won’t cover out0of0network care except in an emergency; may require you to live or work in its service area to be eligible for coverage; often provide integrated care and focus on prevention and wellness

Point of Service (POS)

type of plan where you pay less if you use doctors, hospitals, and other healthcare providers that belong to the plan’s network; require you to get a referral from your primary care doctor in order to see a specialist

Catastrophic Insurance

• under the age of 30

• low monthly premiums but very high deductibles

• cover 3 primary visits and some preventative services

High Deductible Health Plan

• higher deductible than traditional insurance plan

• monthly premium is usually lower but you pay more health care costs yourself before the insurance company starts to pay its share

director of pharmacy (hospital)

• Personnel

• Budgets (Medication costs)

• Multidisciplinary committees (Policies/procedures/compliance)

Pharmacy Manager/Supervisor (hospital)

• Personnel/scheduling

• Staffing

Staff and Clinical Pharmacists (hospital)

Provide daily distributive and clinical services