HSML 6202 Bonar Final

medicare's history

-Medicare is also referred to as Title 18 of the Social Security Act, which was passed in 1935

- Thirty years later in 1965 Congress passed Title 18, or Medicare

- Medicare has been "added to" and "modified" since then but still maintains fundamentally the same focus.

What 3 groups of people are covered under Medicare?

- Persons 65 years or older

- Disabled individuals who are entitled to Social Security Benefits

- People who have End Stage Renal Disease (ESRD)

How much of a "big deal" is Medicare?

- In 1967, shortly after it was enacted, Medicare had 19.5 million beneficiaries

- By 2015 Medicare covered 55.3 million beneficiaries

- The number of Medicare beneficiaries has continued to grow because of the aging of the U.S. population

Who constitutes that 55.3 million beneficiaries?

- The largest majority of the 55.3 million are just people who are 65 years old, or older

- But about 16% are younger than 65 years of age, but are just disabled

Medicare Structure

- medicare is a federal program

- operates under Centers for Medicare and Medicaid Services (CMS)

- CMS is a branch of the Department of Health and Human Services (DHHS)

- In 1997 Congress passed the Balanced Budget Act (BBA) which established an independent federal agency, the Medicare Payment Advisory Commission (MedPAC) to advise Congress on issues affecting the Medicare Program

Parts of Medicare

Part A: Hospital Insurance

Part B: Supplementary Medical Insurance

Part C: Medicare

Advantage

Part D: Prescription Drug Coverage

Medicare Part A "Entitlement"

- Part A is the hospital insurance part of Medicare, and it is what we would call a "true entitlement program."

- People contribute to Medicare throughout their working lives through the special Medicare payroll tax.

- Therefore, once turn 65, they are "entitled" to Part A (hospital insurance) no matter what their income may be or the assets that they have.

Part A Financing

- The employer and the employee both share equally in financing the Hospital Insurance trust fund.

- All working individuals (even those who are self-insured) have to pay the mandatory Medicare taxes. Since 1994 all earnings have been subject to the Medicare tax.

- In order to quality for Part A benefits, a person or the person's spouse must have worked, earned a minimum specified amount, and paid Medicare taxes for at least 40 quarters (10 years) to earn at least 40 credits.

- People who have earned less than 40 credits can still get Part A but have to pay a monthly premium.

Medicare Part A Coverage

- Not quite as much as you may think. It covers all of your hospital bills... for a specified period of time...

- Part A covers a maximum of 90 days of inpatient hospital per benefit period. Yes, but what is a "benefit period."

- A "benefit period" is a "spell" beginning with hospitalization and ending when the beneficiary has not been an inpatient in a hospital or Skilled Nursing Facility for 60 consecutive days. Clear as mud, right?

- Once the original 90 days of inpatient hospital care are exhausted, a lifetime reserve of 60 additional hospital inpatient days remains.

- These rules apply to acute-care hospitals and inpatient rehabilitation facilities only, and the number of benefit periods is unlimited.

- Psychiatric care- Part A covers 90 days of care per spell of illness. Once that is exhausted beneficiaries are allowed a 60-day lifetime reserve. Lifetime use is limited to 190 days of treatment.

Part A Additional Benefits

- Part A pays for up to 100 days of care in a Medicare-certified Skilled Nursing Facility (SNF), after inpatient hospitalization for at least 3 consecutive days, not including the day of discharge. The admission to the SNF must occur within 30-days of the hospital discharge.

- Part A also pays for home health care obtained from a Medicare-certified home health agency when a person is homebound and requires intermittent or part-time skilled nursing or rehabilitation. Payment is made for 60-day episodes of care.

- For terminally ill patients, Medicare pays for care provided by a Medicare certified hospice.

- A deductible applies to each benefit period (except for home health and hospice).

- Copayments are based on the duration of services (except for home health).

Part B Financing

- Part B is the Supplementary Medical Insurance (SMI).

- It is a voluntary program financed partly by general revenue and partly by required premium contributions.

- Estimates are that the beneficiaries bear about 25% of the total cost of the premiums.

- Since 2007 the Part B premiums have been income-based, as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

- Beneficiaries whose incomes exceed a threshold amount pay a higher premium, called the "Income-Related Monthly Adjustment Amount" (IRMAA).

- In 2017 the income threshold that triggered IRMAA was $85,000 per year, or $170,000 per couple.

- The whole idea behind the IRMAA was to reduce tax-financed premium subsidies for higher-income individuals. So, if someone individually earned over $214,000 in 2017, they had to pay $428.60 monthly for Part B, but if they earned less than $85,000, they only paid $134.00.

When you become eligible at age 65 for Part A (Hospital Insurance), what do you do about Part B?

- As it turns out, almost everyone eligible for Hospital Insurance also chooses to enroll in Part B because they can't get similar coverage at the same price from private insurers.

- Effective January 5, 2011, the Affordable Care Act (ACA) also covered an annual physical wellness exam for anyone enrolled in Part B with no cost sharing.

What else does Part B cover?

- Physician services

- Emergency department services

- Outpatient surgery

- Diagnostic tests and laboratory services

- Ambulance

- Renal dialysis

- Blood transfusions and blood components

- Organ transplants

- Medical equipment and supplies

- Preventive services

Medicare Advantage (Part C) - What is it?

- Part C allows beneficiaries to enroll in private insurance plans that have won bids from the Federal government to provide "Managed Care-Like" services to those 65 or older.

- Part C does not add specifically defined new services, per se.

- But it does provide some additional choices of health plans with the goal of channeling more people into managed care plans.

Hows does Part C Work?

- Medicare beneficiaries have the option to remain in the traditional Medicare fee-for-service program,

but...

If CMA has contracted with a managed care organization that serves a beneficiary's geographic area, the beneficiary has the option to join the Medicare Advantage Plan

- If they join the plan, the beneficiaries receive both Part A and Part B services through the managed care organization.

- Further, prescription drugs covered under Part D are also included if they are offered by the managed care organization that the beneficiaries signed up for.

- Premiums for Medicare Advantage are in addition to those paid to Medicare for Part B coverage... so why would anybody in their right mind want to choose this option?

- The reason is because the beneficiary gets additional benefits that are not available in the original Medicare plan, there is no need to buy Medigap coverage, and Part C enrollees have lower out-of-pocket costs.

- Data suggests that Medicare Advantage Plans offer care of equal or higher quality for less cost than traditional Medicare, so they may be offering better value than traditional Medicare as well.

What is Medicare Part D?

- Medicare Part D was added to the existing Medicare program and was fully implemented in 2006.

- Medicare Part D is available for anyone who has coverage under Parts A and B.

- Low-income beneficiaries are automatically enrolled without having to pay a premium.

- But in 2011 the ACA imposed an IRMAA so that people in higher income categories have to pay higher premiums.

How does Part D work?

- Part D coverage is offered through two types of private plans approved by Medicare. Those are:

- Stand alone prescription drug plans that offer only drug coverage, and are used by people who want to stay in the traditional Medicare fee-for-service program.

- Medicare Advantage Prescription Drug Plans offered to those who are enrolled in Medicare Part C, if the managed care organization provides prescription drug coverage... and most of them do.

Medicare Out-Of-Pocket Costs

- One of things that many people really don't fully understand is that Medicare carries relatively high out-of-pocket costs. Too many people think, "Well, I paid in all my life, so when I retire, I'm fully covered." Well... no, not quite...

- Eyeglasses, dental care, and many long-term care services are not covered, and there is no limit on out-of-pocket costs (except that all Medicare Advantage Plans have cost sharing limits).

- Sources of help for these out-of-pocket costs can be Medicaid, employer retirement benefits, and Medigap.

What is Medigap?

- Medigap is a commercial health insurance policy purchased by individuals covered by Medicare to insure for the expenses not covered by Medicare.

- Sources of Medigap policies include numerous commercial insurance companies, AARP, etc.

Medicare Financing and Spending for Services

- Medicare expenditures are funded by general taxes and the Medicare payroll taxes.

- The largest bulk of Medicare benefits payments go to hospitals, and the private Medicare Advantage plans are the second largest funding recipients.

The Medicare Trust Funds

Medicare has two main trust funds:

1) The Hospital Insurance trust fund provides the money pool for Part A services.

2) The Supplementary Medical Insurance trust fund provides the money pool for Parts B and D.

Concerns About the Medicare Funds

- By about 2028, the Hospital Insurance funds are anticipated to cover only 87% of program costs, compared to almost 99% of program costs in 2015.

- The Supplementary Medical Insurance trust fund is adequately financed through about 2026.

Three Main Concerns About the Future Solvency of Medicare

1 ) The cost of delivering healthcare continues to grow at a rate faster than the rate of inflation in the general economy.

2) An aging population will continue to consume a greater quantity of healthcare services.

3) The workforce has been shrinking and wage increases to support payroll tax revenues have been smaller than the rise in medical inflation.

What is a means-tested program?

- This means that the person's eligibility is dependent upon their financial resources.

- Each state administers their own Medicaid program under Federal guidelines

- Medicaid is JOINTLY financed by both state and Federal governments

- The Federal government provides matching funds to each state, based upon that states per capita income

3 Categories of those who are automatically eligible for Medicaid

- Families with children receiving support under the Temporary Assistance for Needy Families (TANF) program.

- People receiving Supplemental Security Income (SSI) which includes the elderly, blind, and disabled with low incomes.

- Children and pregnant women whose family income is at or below 133% of the Federal Poverty Level

Federal Poverty Level (what determines it and what is is)

-The poverty level for a family of 4 in 2020 was an annual income of $26,200.

- To get at the poverty level for each family, add $4,480 for each additional person in the household.

- It is a measure of income used by the U.S. government to determine who is eligible for various subsidies, programs and benefits.

What is a dual-eligible beneficiary?

It simply means that a person is eligible for BOTH Medicare and Medicaid

- Low-income elderly

- Disabled young adults who are entitled to Medicare but also become eligible for some level of assistance under Medicaid.

- This population in general tends to have extensive health care needs because of chronic conditions and/or disabilities or a need for long-term care.

What happens when a state expands medicaid?

A combination of:

- The shortage of primary care physicians

- Low Medicaid participation rates by physicians

-An increase in use of the Emergency Department when Medicaid expands

Leads to:

- Staffing shortages in your Emergency Departments...

What are a couple of chronic problems with Medicaid?

1) Comparatively poor reimbursement for providers

2) Churning- the constant exit and re-entry of beneficiaries in the Medicaid system because their eligibility tends to change a lot based upon their wildly fluctuating income from month to month (data suggests that up to 30% of Medicaid beneficiaries will lose their eligibility within 6 months, and almost half lose it within 12 months... this disrupts access and continuity of care

What is CHIP and what does it do?

The Children's Health Insurance Program

- Initiated in 1997

- Part of the Social Security Act

- Intended to help families whose family income exceeded the Medicaid threshold levels, thus making them ineligible for Medicaid, but for various reasons, did not have access to an employee sponsored plan

- The Feds provide funds in the form of "block grants" to stares to cover those kids and teenagers up to age 19

- Federal law requires that ineligibility for Medicaid be established before a family is approved for CHIP, but financing is shared between the Feds and the states

- Each state is allowed to establish its own eligibility criteria for CHIP, but they have to comply with Federal guidelines

Has CHIP been effective? If not, why, and if so, in what way(s)?

- Short answer is "yes."

- Data indicate that CHIP has had a profound impact on reducing the number of uninsured children

- It has also improved access, increasing continuity of care, quality of care for kids in all racial and ethnic groups

- Has reduced racial and ethnic disparities in access, unmet need and continuity of care

What is the Veterans Health Administration (VHA or just VA) and whom does it serve?

- Also called the VHA or simply, the VA, it is the health services branch of the U.S. Department of Veterans Affairs

- It operates the largest integrated health services system in the entire U.S.

- It includes hospitals, outpatient clinics, nursing homes and other facilities.

- Serves about 8.7 million veterans

-Its Office of Research and Development focuses on health issues that impact veterans.

- Originally developed to take care of war related injuries, but that mission was expanded so today non-service related conditions account for most of the care provided.

What are third-party payers?

- It simply refers to insurance companies, Managed Care Organizations (MCOs), Blue Cross/Blue Shield, and the government payers (Medicare and Medicaid)

Remember: the other two parties in the triangle are the patient and the provider

- The Third Party Payer has two major functions:

1)Determine the methods and amounts of reimbursement

2)The actual payment of the bill after services have been provided

What is TRICARE and who does it sereve?

- Tricare used to be known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

- It is a health care program of the U.S. Department of Defense Military Health System

- Provides civilian health benefits for U.S. Armed Forces personnel and their dependents

- Tricare is the insurance arm of the Military Health System

- Beneficiaries are able and allowed to obtain health care either through the Department of Defense medical facilities or through services purchased from civilian providers

What is the difference between a "charge," a "rate," a "fee schedule," and a "claim?"

①Charge is a fee set by the provider

②Rate is a price set by any third party payer

③Fee Schedule is an index for charges listing individual fees for each type of service thus it is referred to as a fee schedule

Fee for Service

- Fee-for-service is the oldest method of reimbursement and is still in existence, but its use has been greatly reduced

- It assumes that health care is provided in a set of identifiable and individually distinct units of services, for example, an x-ray, a urinalysis, and a tetanus shot

- Initially providers established their own fee-for-service charges and insurers passively paid the claims but later, insurance started to limit reimbursement to what was called "usual, customary, and reasonable" (UCR) amounts

- Each third party payer determined on their own what the UCR should be

- Providers would then "balance bill" the patient

What do you see as a big problem with this system?

Bundled Payments

- Bundled payments are sometimes also referred to as "package pricing"

- It refers to a number of related services in one price

- Your textbook example was for optometrists packaging prices so that the eye exam, eyeglass frames, and the corrective lenses are all included into one price

- Bundled payments reduce the incentive to provide nonessential services

What does RBRVS do?

Under the Omnibus Budget Reconciliation Axt (OBA) of 1989, Medicare developed a reimbursement mechanism to pay physicians according to a "relative value" assigned to each physician service.

- The "resource-based relative value scale" was implemented in 1992

- Since then third-party payers adopted the RBRVS system.

- The RBRVS incorporates RVUs based on the time, skill, and intensity it takes to provide a given service

- RBRVS is a form or variation of fee-for-service, so it has not definitively addressed the issue of "volume-driven" payment.

What is value-based reimbursement?

- It is a reimbursement method that gives more emphasis to improved quality and reduced cost

- The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) implemented a quality payment program so that providers get paid based on performance as measured through certain quality measures and resource costs

OR

- For providers who participate in an Accountable Care Organization (ACO) based upon measures developed through the ACO

What are the key elements of managed care, and what are the key differences between HMOs, PPO, and Point of Service Plans?

- Any managed care plan functions somewhat like an insurance company.

- Most MCOs simply arrange the delivery of medical services through contracts with physicians, clinics, and hospitals operating independently.

- MCOs use three (3) main types of payment arrangements with providers

a. capitation

b. discounted fees

c. salaries

What is Capitation?

refers to the payment of a fixed monthly fee per member to a health care provider, and since all services are included in one set fee, the risk shifts from the MCO to the provider

What are the major HEDIS domains?

- Effectiveness of Care.

- Access/Availability of Care.

- Experience of Care.

- Utilization and Risk-Adjusted Utilization.

- Health Plan Descriptive Information.

- Measures Collected Using Electronic Clinical Data Systems.

Discounted Fee Arrangements

is just a modified form of fee-for-service where after the services are provided, the providers bill the MCO for each service separately but are paid according to a pre-negotiated schedule called a fee schedule

Salaries

this just means exactly what it says... the providers are paid salaries, often coupled with bonuses or withholdings, and in this case the provider is actually an employee of the MCO. So the physicians get paid a fixed salary, and at the end of the year, a pool of money is distributed among the physicians in the form of bonuses based on various performance measures

What is the NCQA

is a private non-profit that began accrediting MCOs in 1991 in an effort to provide standardized, objective information about the quality of MCOs

and from NCQA we developed HEDIS

What does good Utilization Require?

- (1.) An expert evaluation of which services are medically necessary in a given case and steps to ensure that unnecessary services are minimized.

- (2.) A determination of how the medically necessary services can be provided most inexpensively while maintaining acceptable quality standards.

- (3.) A review of the process of care and changes in the patient's condition to revise the course of medical treatment if necessary.

HMOs have employed tighter utilization controls than other managed care plans. What are the key utilization controls of an HMO plan?

(1) Choice restrictions on where and from whom the patient can obtain medical care. While the insured still has a choice of physicians, the choice is restricted to those who are either employed by or contracted to the HMO

(2) Case management that relies on a client-centered approach for evaluating and coordinating care, especially for patients who have complex, potential costly problems. Case management is typicially highly individualized for high-risk patients.

(3) Disease management, which is a population oriented strategy for people with chronic conditions like diabetes, asthma, depression and coronary artery disease. After sub-groups are identified of patients with these conditions, disease management focuses on patient education, training in self-management, ongoing monitoring, and follow-up to ensure that people are complying with their medical regimens. It is really "self care with professional support."

(4) Pharmaceutical Management such as use of formularies (a list

6 Distinguishing Traits of an HMO

(1) While traditional indemnity insurance paid only when a person was ill, HMOs not only provide care during illness, but also cover a variety of services to help people maintain their health

(2) The enrollee is usually required to pick a primary care provider from a "panel" of physicians

(3) The providers receive a capitated fee regardless of whether the enrollee uses health care services or the quantity of services used

(4) All health care must be obtained from in network hospitals, physicians, and other providers

(5) Specialty services like mental health and substance abuse are frequently "carved out" with a special contract outside regular capitation that the HMO funds separately

(6) The HMO is responsible for ensuring that services comply with certain established standards of quality.

What are the major physician "employment" models in HMO plans?

(1) Staff model: where the HMO employs its own salaried physicians

(2) Group model: where the HMO contracts with a single multispecialty group practice and contracts separately with one or more hospitals to provide comprehensive services to its members

(3) Network model: the HMO contracts with more than one medical group practice. This model is especially adaptable to large metropolitan areas and widespread geographic regions where group practices are located

(4) Independent Practice Association Model (IPA): the IPA is a legal entity separate from the HMO, and it contracts with both independent solo practitioners and group practices. The HMO then contracts with the IPA instead of contracting with the individual physicians or group practice

4 Distinguishing Characteristics of a PPO

(1) The PPO establishes contracts with a select group of physicians and hospitals. These providers on the PPO's panel are referred to as "preferred providers."

(2) Generally the PPO allows an open panel option in which the enrollee can use out-of-network providers, but incurs a higher cost sharing. These additional out-of-pocket costs act as a deterrent to going outside the panel. If a PPO does not provide an out-of-network option, it is referred to as an Exclusive Provider Plan

(3) Instead of using capitation as a method of payment, PPOs make discounted fee arrangements with providers. The discounts can range between 25% and 35% of the providers' established charges. Negotiated payment arrangements with hospitals can be based on DRGs

(4) PPOs apply fewer restrictions to the care-seeking behavior of enrollees. In most instances, primary care gate keeping is not employed. Prior authorization (prospective UR) is used only for hospitalization and high-cost outpatient pro

What is a Point of Service Plan?

combine features of classic HMOs with some of the characteristics found in the PPO. They are thus a "hybrid" plan. They borrow features from the HMO like capitation or other risk-sharing payment arrangements and the gatekeeping method of UR, but they allow the patient to choose between an in-network or out-of-network provider at the point (time) of receiving services... hence, the name "point of service

Integration Strategies

(1) Outright ownership such as through merger or acquisition

(2) Joining hands with another organization in the common ownership of an entity such as a joint-venture

(3) Having a stake in an organization without owning it

What is integration?

various strategies that health care organizations employ to achieve economies of operation, diversify existing operations by offering new products or services, or gain market share. Some strategies include

3 Major Forms of Integration

(1.) Management Services Organizations (MSOs): supply management expertise, administrative tools, and information technology to physician group practices; today this is used mostly by smaller group practices because they find it uneconomical to employ full-time managers

(2) Physician Hospital Organizations (PHOs): these are legal entities that form an alliance between a hospital and local physicians which contract with MCOs, and if a PHO is large enough, it can contract its services directly to employers, while engaging a third-party administrator to process claims. Today, hospitals and health systems seem to be in the drivers seat as physicians increasingly turn to hospitals and health systems for financial support

(3) Provider-sponsored Organizations: these are risk-bearing entities that incorporate the insurance function into integrated clinical delivery... referred to as a provider-sponsored organization (PSO). PSOs emerged in the 1990s and are sponsored by physicians, by hos

What are Integrated Delivery Systems and Accountable Care Organizations?

1) IDS: An IDS is 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 services. In 2015 more than 54% of all U.S. health care providers were affiliated with IDSs

2) ACOs: An Accountable Care Organization is an integrated group of providers who are willing and able to take responsibility for improving overall health status, are efficiency, and satisfaction with care for a defined population. ACOs are motivated to eliminate unnecessary care because their contract payments from insurers cover the entire continuum of care. In a attempt to achieve the Triple Aim of lower cost, higher quality (patient experience), and improvement in population health (better population health outcomes), ACOs use mechanisms already prevalent in managed care and IDS including disease management, care coordination, sharing

Development vs Intellectual Disability

Developmental Disability: describes the general physical incapacity that a patient may face, either at a very early age, or into adulthood

Intellectual Disability: refers to below-average intellectual capacity, which can be caused by disorders such as Down's Syndrome

What should long term care focus on?

(1) Holistic care focusing on every aspect of what makes a person whole and complete, including medical care delivery and all aspects of daily living

(2) Quality of life as a sense of satisfaction, fulfillment, and self-worth are critical

(3) Lifestyle factors and personal enrichment making one's life meaningful through activities they formerly enjoyed

(4) Clinical palliation should be available for relief from unpleasant symptoms

(5) Use of current technology such as personal emergency response systems (PERS)

(6) Use of evidence-based practices to assure effectiveness through clinical research.

"High Level" or Major Types of LTC

(1) Informal and formal care

(2) Respite care for the family of caregivers

(3) Community-based and institutional services

What are the major types of care that are provided under the imprimatur of "long-term care services?"

(1) Medical care, nursing and rehabilitation

(2) Mental health services and dementia care

(3) Social support

(4) Preventive and therapeutic long-term care... in this context this means preventing or delaying institutionalization through various types of community-based LTC services performing the preventive function by providing good nutrition and access to services like vaccines and routine care

Type(s) of high-level "housing" for LTC services?

(1) Private housing such as upscale retirement centers where residents can expect to pay a fairly substantial entrance fee plus a monthly rental of maintenance fee

(2) Public housing is more modest and includes complexes providing government-assisted, subsidized housing for low-income people.

Clients generally fit into a continuum of clinical categories, that range from basic personal care to sub acute care and specialized services. What are those components of the continuum of care?

1) Personal Care- light assistance with basic activities of daily living (ADLs)

2) Custodial Care- nonmedical care provided to support and maintain the patient's condition, but requires no active medical or nursing treatments (e.g., personal care with basic ADLs, range-of-motion exercises, bowel and bladder training, and assisted walking). This is typically provided by paraprofessionals such as aides, rather than by licensed nurses

3) Restorative Care- rehabilitation that involves short-term therapy treatments like therapy for orthopedic surgery recovery, stroke, and prolonged illness. This is generally provided by trained personnel like physical therapists, occupational therapies, and speech-language pathologists. The care is often provided via home health agencies

4) Skilled Nursing Care- medically oriented provided mostly by licensed nurses under the direction of a physician in accordance with a plan of care. Typically includes things like wound care, tube care management, I

What are the major types of Home and Community-Based Care?

1) Home Health Care-involves a community or hospital-based home health agency that sends health are professionals and paraprofessionals to patients' homes to deliver services approved by a physician. Skilled nursing care is the service most often received by home health patients and Medicare is the single largest payer for home health services in the U.S., though Medicaid is not far behind

2) Adult Day Care- also called "adult day service," is a daytime group program designed to meet the needs of functionally and/or cognitively impaired adults and to provide partial respite to family caregivers so they can work during the day or pursue other responsibilities of life. Most ADC services are highly focused on prevention and health maintenance, with the objective of preventing or delaying institutionalization, but also incorporate nursing care

3) Adult Foster Care- is characterized by small, family run homes providing room, board, and varying levels of supervision, oversight, and

What about institutional Long Term Care Continuum Options?

1) Residential and Personal Care Facilities- also known as "domiciliary care facilities," "board-and-care homes" or "sheltered care facilities," typically provide physically supportive dwelling units, monitoring and assistance with medications, oversight, and personal or custodial care. But no nursing or medical services are provided. Services are provided by paraprofessionals and minimal staffing is provided 24-hours a day. Services typically include meals, housekeeping and laundry. Some of these are luxurious while others are less so

2) Assisted Living Facilities (ALF)- provide personal care, 24-hour supervision, social services, recreational activities, and some nursing and rehabilitation services. These facilities are good for people who cannot function independently but do not require skilled nursing care. ALFs operate primarily on a private pay basis. All states now require ALFs to be licensed, but regulations vary from state-to-state

3) Skilled Nursing Facili

Two Main Categories for Nursing Home Certification

- Those that admit Medicare patients, which are true "SNFs"

- Those that admit only Medicaid, and are called "nursing facilities or NFs."

- However, there are also "dual certified" facilities that can admit both... and most SNFs and NF are now essentially the same and an admit both Medicare and Medicaid patients

What are the primary sources of funding for all of these arrangements?

(1) Medicare under certain circumstances

(2) Medicaid under other circumstances

(3) LTC insurance if the client could have afforded same

(4) Private pay offered at the time the services are needed

6 Steps to Environmental Sustainability

1) make the commitment

2)create a structure for sor supporting environmental sustainability

3)support and finance environmental sustainability

4) set goals and measure, report, and evaluate change

5) celebrate and share successes

6) continue to assess and identify new opportunities

Environmental Sustainability Step 1

Make the Commitment-

Hospital and care system executives and trustees should consider the drivers behind their decision to pursue environmental sustainability. Reasons to pursue it might include:

- Saving money

- Demonstrating corporate social responsibility

- Making facility operations more efficient

- Increasing employee satisfaction, engagement and retention

- Fostering a positive public image

- Compliance or regulatory requirements

- Improving the patient experience

environmental sustainability Step 2

Create a structure for supporting environmental sustainability. Implementing real change requires participation from multiple leaders across multiple departments. Consider starting:

- Sustainability Leadership Council

- Sustainability Committee or Green Team

- Value Analysis Committee

- Departmental Sustainability Coordinators

environmental sustainability step 3

Support and Finance Environmental Sustainability

Leaders set the tone for sustainability in their hospital or care system. Sustainability often requires a cultural change supported by effective leadership, appropriate policies, adequate resources and a clearly communicated vision.

- Electrical Power purchasing agreements are an example.

environmental sustainability step 4

Set goals and measure, report and evaluate change. Hospitals and care systems can begin by measuring baseline levels of energy use, water consumption and the waste stream.

- Energy initiatives

- Water consumption

- Supply chain

- Waste management

- Commissioning and retro-commissioning

Leadership in Energy and Environmental Design (LEED) Rating System

- LEED Certification is used to evaluate the "greenness" of a project or building and achievement is recognized via LEED certification.

- Projects or building must comply with minimum program requirements, meet prerequisites, and earn a minimum number of points in credit categories to achieve LEED certification at one of four (4) levels.

What are the four (4) levels of LEED Certification?

- LEED Certified requires 40-49 points

- LEED Silver requires

50-59 points

- LEED Gold requires 60-79 points

- LEED Platinum requires 80+ points

Purpose of the LEED Certification Categories

- The purpose of the categories is to define green building standards and

performance. Each category contains possible credits of varying

points.

- The building and project owners determine which credits to pursue and

how to achieve them.

- Since 2000, LEED rating systems have been revised and expanded for

Various project or building types and now include...

Rating Systems Have Been Revised and Expanded to now Cover

- Core and shell development

- New construction and major renovations

- Homes

- Schools

- Commercial interiors

- Retail

- Neighborhood development

- Healthcare

- Existing Building - Operations and Maintenance

Tragedy of the Commons

- Each of the professions has its own practitioner group(s) and are represented by their own professional associations, each of which tends to work on representing the interests of that particular group.

- There is no particularly centralized unity to bring it all together.

Osteopathic vs Allopathic

Osteopathic: practiced by DOs, emphasize the musculoskeletal system of the body, such as correction of joints or tissues. DOs stress preventive medicine and consider how factors such as diet and environment might influence natural resistance to disease.

Allopathic: practiced by MDs, views medical treatment as an active intervention to counteract and neutralize the effects of disease. They may also use preventive medicine along with allopathic treatments. Around 9% of all active physicians are osteopaths, and the rest are allopathic physicians. Of those roughly 48% are in primary care.

1990 Hospitaliist

- Physicians who practice "hospital-based" medicine are called Hospitalists.

- Driven by the desire of hospitals and insurance providers to bring hospital care on board with tighter protocols and more efficiency.

- Also by a desire of primary care physicians to increase their productivity and not have to round in the hospital every day.

Main Source of Funds for Medical Education and How It Works

- Medicare pays hospitals for training physicians

(1) Direct Graduate Medical Education (DGME) sometimes just shortened to DME.

(2) Indirect Medical Education (IME).

Maldistribution of Physicians

- Specialty physicians tend to practice around larger cities to improve compensation and avoid a certain degree of professional isolation.

- Specialists almost have to be located where there is clinical throughput sufficient to generate income equal to their overhead and compensation needs.

What has higher compensation of specialists led to?

An oversupply of specialists in some areas and locations...

IMGs

International Medical Graduates and Foreign Medical Graduates (and they mean essentially the same thing) play a very important role in the U.S. Healthcare System.

FMGs

About 25% of all residency positions are FMGs and they account for 51% of physicians in primary care with an increasing number going into family practice.

Other type of Doctoral Level Health Professionals

(1) optometrists

(2) psychologists

(3) podiatrists

(4) chiropractors

(5) doctoral nursing degreed personnel

Advanced Practice Nurses

- a general classification of nurses who have education and clinical experience beyond that required of an RN. APNs include four areas of specialization

- Clinical nurse specialists (CNS)

- Certified registered nurse anesthetists (CRNA)

- Nurse practitioners (NP)

- Certified Nurse Midwives (CNM)

Mid Level Providers

- Mid-Level Providers (MLPs)- clinical professionals who practice in many areas similar to those in which physicians practice, but who do not have an MD or a DO degree.

- MLPs-receive less advanced training than physicians but more training than RNs. MLPs in may instances can substitute for physicians. MLPs include physician assistants (PAs) and NPs.

- PAs are licensed to perform medical procedures under the supervision of a physician who may be on site or off site.

- In most states PAs have the authority to prescribe medications.

- PA programs award bachelor's degrees, certificates, associate degrees, master's degrees, or doctoral degrees... the mean length of training is 26 months

Impact of Consolidation

Experience has shown that when physician practices and hospitals consolidate the resulting market power leads to higher commercial prices, at the same time Medicare has held the line on such increases more lately.

Impact of Vertical Integration of Physicians and Hospitals

- When hospitals and physician practices vertically integrate, history reflects that Medicare has traditionally paid more for services when provided by on-campus hospital-owned physician practices than for services provided by independent physicians due to facility fees.

- Therefore, Medicare policy has recommended the implementation of "site-neutral" fees so that integration that results in efficiencies would still occur, but consolidation that results in increased costs by capturing new facility fees would NOT be passed along to Medicare.

Solutions for getting more people in PC

(1) Increased use of Advanced Practice Nurses and Physician Assistants

(2) Distribution of more FMGs who tend to enter primary care fields

Urban vs Rural Primary Care

Ease of access to a physician is greater in urban areas. The patient-to- primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas.

CEO Authority Over Hospital Credentialed Medical Staff

If a private practice physician practices at a hospital... in other words, has what are called "privileges" and is "credentialed" at that hospital, can the chief executive officer fire or terminate the physician?

How Can we be sure that we spend too much?

1) International comparisons, but be careful because other countries have the government deciding how much to spend on healthcare.

2) The rise in health insurance premiums in the private sector.

3) We can look at government spending on healthcare for beneficiaries who get health care through various public insurance programs.

Why do americans feel like their take-home pay isn't keeping up with the rise in healthcare costs?

- Because it isn't!

- Between 2006 and 2016 the following happened:

1) The cumulative growth in healthcare insurance was 58%

2) But cumulative inflation was only 19%

3) And, cumulative wage growth was only 33%

major reasons for the cost escalation in U.S. Healthcare

- Third party payment causes the consumer to be ignorant of what her/his care is actually costing.

- Remember the imperfect market? The U.S. healthcare system follows neither the highly-regulated single-payer system nor the truly free-market model, utilization remains largely unchecked and prices charged for healthcare services remain higher than the true ecomonic costs of production in the first place.

- Growth of technology... we follow the early start/fast growth pattern.

- Increase in the elderly population.

- Medical model of healthcare...our medical system tends to intervene AFTER a person has become ill.

- Mulit-payer system and Administrative Costs associated with the management of the financing, insurance, delivery, and payment functions.

- Defensive medicine due to fears of litigation.

- Fraud and abuse... a knowing disregard for the truth, especially in Medicare and Medicaid... one of the biggest is "upcoding."

- Practice variations where there are wide ranges of treatment patterns for very similar patients.

Key regulatory approaches to cost containment

- While single payer systems in other countries have established a top-down mechanism of total expenditures, in the U.S. it is a combination of government regulations and so-called "market-based" competition... this approach allows providers to shift costs from low payers to higher payers.

- Health planning where government takes steps to align and distribute health care resources so that the system will achieve the desired outcomes for all people. CON was one attempt to do so.

- Price controls such as the shift in hospital inpatient reimbursement from "cost-plus" to Prospective Payment Systems (PPS) based on Diagnosis-Related-Groups (DRGs), but this just changed it from "inpatient" generated payments to "outpatient" generated revenue... so "after all was said and done, there was a lot more said than done..."

- The "Resource-Based-Relative-Value-Scale" to determine physician payments seems to have worked, somewhat.

- Pay for performance has some unintended consequences, which has some drawbacks, but can work if monitored closely.

- Peer review... the process of medical review of utilization and quality when it is carried out directly by or under the supervision of physicians.

- Quality Improvement Organizations... private organizations made up of practicing physicians in each state who are paid by CMS under contract to review the care provided to Medicare beneficiaries.

Key competitive approaches to cost containment

- Demand-side incentives- this is really cost-sharing, and is based upon the idea that if consumers pay out of pocket a larger share of the cost of healthcare services they use, they will consume services more judiciously.

- Supply-side regulation- antitrust laws prohibit businesses from practices that stifle competition among providers. This helps prevent price fixing, price discrimination, exclusive contracting arrangements, and mergers that the DOJ considers anticompetitive

Payer-driven price competition which comes in two forms:

1) Employers shop for the best value in terms of the cost of premiums and the benefits package (this provides for competition among insurers).

2) MCOs shop for the best value from providers of health services (this provides for competition among providers).

What do we mean when we talk about access?

Availability - refers to the fit between service capacity and individuals' needs

Accessibility - refers to the fit between the locations of providers and patients

Affordability - refers to the individual's ability to pay

Accommodation - refers to the fit between how resources are organized to provide services and the individual's ability to use the arrangement

Acceptability - is based on the attitudes and compatibility of patients and providers

4 Key Types of Medical Errors

- Medication errors or adverse drug events (ADEs)

- Surgical errors

- Diagnostic inaccuracies

- System factors such as the organization of healthcare delivery and distribution of resources leading to preventable adverse events

Quality Assessment vs Quality Assurance

Quality assessment is the measurement of quality against an established standard. You define how quality is to be determined including identification of specific variables or indicators to be measured, collect the appropriate data, use statistical analysis, and interpret the results of the assessment.

Quality assurance is the same as quality improvement and includes the process of institutionalizing quality through ongoing assessment and using the results of assessment for continuous quality improvement (CQI). Quality assurance is based upon the principles of total quality management (TQM), which is also referred to as CQI.

What is the Donabedian model?

Very simply it is a model that proposes three domains within which health care quality can be examined:

Structure Process Outcome

Donabedian Model

Structure - refers to thinks like facilities, equipment, staffing levels, staff qualifications

Process - refers to things like technical aspects of care, diagnosis, treatment procedures, current prescriptions, accurate drug administration, waiting times, cost communication, dignity and respect, etc.

Outcomes refer to patient satisfaction, health status, recovery, improvement, nosocomial infections, rehospitalization, mortality, etc.