HTH 354 Final (Howley; JMU)

Outpatient

Refers to health care services that are NOT provided based on an overnight stay, in which room and board costs are incurred.

Reasons for growth in Outpatient care

-Reimbursement

-Technological factors

-Utilization Control Factors

-Physician Practice Factors

-Social Factors

Urgent care

Medically necessary treatment that is required for illnesses or injuries that are not life-threatening but need immediate treatment.

Limitations of urgent care

- Doctors may misdiagnose you

- One-and-done kind of care

- Does not look at the full medical history

- Less of an incentive to provide quality care

Strengths of urgent care

- Significantly cheaper than an ER visit (ER has facility fees)

- Accessible

Primary care

Health care at a basic rather than specialized level for people making an initial approach to a doctor or nurse for treatment.

Strengths of primary care

- Complete history of patients

- Preventive care (annual visits)

- More of an incentive to give quality care

Barriers to good primary care in the U.S.

- Always busy

- Short appointments (15min average)

- Potentially long wait

- Grossly underfunded

Healthcare systems that emphasize primary care have.....

- Better health levels

- Higher satisfaction

- Lower expenditures

The World Health Organization's view of primary care

- Point of entry

- Coordination of care

- Essential care

The Institute of Medicine's view of primary care

- Integrated (comprehensive, coordinated, and continuous)

- Accessible

- Accountable

Primary care and the ACA

- Increase Medicare and Medicaid payments to primary care providers

- Created new incentives such as funding scholarships and loan repayment for primary care providers working in underserved areas

- Expanded the health center program and bolstered the capacity of health centers

- Established additional training programs

Home Health Care

- Services typically include

- Nursing care (dressings, bathing, medications)

- Short-term rehabilitation therapy (PT & OT, speech)

- Other services include Homemaker

- Medicare/aid will cover some of these

- US Trends show an increase in demand for home health care

Hospice Services

- Life expectancy 6 months or less

- In 2011, 1.65 million patients received hospice services with average length of services at 69.1 days

- Special kind of care that includes:

- Meeting physical needs and emphasis on pain management and comfort (palliation)

- Family's emotional/spiritual needs

- Support for family members before and after death

- Focus on maintaining quality of life rather than prolonging

Public and Voluntary Clinics

- Community Health Centers (ex. Harrisonburg Community Health Center)

- Free Clinics (ex. Blue Ridge Free Clinic)

Complementary and Alternative Medicine (CAM)

- 38 % of adults use CAM (More common with women)

- $33.9 Billion

11.2% of total out-of-pocket expenses

1.5% of total health care expenditures

- Office of Alternative Medicine (1993) - National Center for Complementary and Alternative Medicine (1998)

Hospital Transformation in the U.S.

1. Primitive institutions of social welfare

2. Distinct institutions of care for the sick (The Pennsylvania Hospital, New York Hospital,

Massachusetts General Hospital)

3. Organized institutions of medical practice

4. Advanced institutions of medical training and

research

5. Consolidated systems of health services delivery

Classification of Hospitals

- Ownership (state, universities, private, federal gov) if it is owned by a non-profit that is a tax classification, there are no shareholders, can make money, but cannot own it

- Public access (just because it is publicly owned does not mean public access)

- Type of service (general service/short term, trauma center, preo/neo natel, rehabilitative or psychiatric hospital, long-term)

- Length of stay (less than 25 days, short-stay)

- Location (urban, suburban, rural, etc.)

- Size (less than 100 small, medium is 100-500 beds, and large is more than 500)

- Other (research hospital, teaching hospital, etc.)

Non-Profit Hospital Expectations

- Must provide some defined public good, such as service, education, or community welfare

- Does not distribute any profits to any individual

- Tax-exempt status (Provena vs. Department of Revenue)

Licensure, Certification & Accreditation

- Licensure

- Certification (Conditions of participation for Medicare & Medicaid)

- Accreditation

Joint Commission (JCAHO)

American Osteopathic Association

Deemed status

Legal Rights

Bill of Rights and Informed Consent

- Patients' Bill of Rights

- Informed consent

Advanced Directives

- Do-not-resuscitate order (DNR)

- Living will

- Durable power of attorney

What is managed care?

An organized approach to delivering a comprehensive array of health care services to a group of enrolled members through efficient management of services needed by the members and negotiation of prices or payment arrangements with providers.

HMO Act of 1973

authorized federal grants and loans to private organizations that wished to develop health maintenance organizations (HMOs), which are responsible for providing healthcare services to subscribers in a given geographic area for a fixed fee

Capitation

A SET payment a month to a provider for each patient that they have, regardless of how many times a month that patient does or does not come in to the office. Incentive becomes to see them less. Keep them healthy so they don't need to see them as much.

Risk

MCOs use shared risk (or extracting discounts) to promote the delivery of health care that is economically prudent

Medical Loss Ratio (MLR)

- The percentage of premium revenue spent on medical expenses

- The remainder is used for administration, customer service, marketing and profits

- Affordable Care Act – Minimum MLR set at 85%

Flaws in the fee-for-service model

- Uncontrolled utilization

- Uncontrolled prices and payment

- Focus on illness rather than wellness

“An ounce of prevention is worth a pound of cure”

Cost control methods in managed care

- Choice restriction

- Gatekeeping

- Utilization review

- Case management (individual)

- Disease management (population-oriented strategy)

- Pharmaceutical Management

Types of managed care organizations

• Health Maintenance Organization (HMO)

• Point of Service (POS)

• Preferred Provider Organization (PPO)

Health Maintenance Organization (HMO)

- "Health Maintenance"

- Focus on PCP

- Capitated Fee

- In-network

- Standards of quality

Preferred Provider Organization (PPO)

• Discounted fee arrangements with providers (25-35%)

- Larger networks

• PCP not employed (in most cases)

• Prior authorization is generally employed only for hospitalization and large outpatient procedures

•Very common today – most popular MCO

Point of Service (POS)

- "Hybrid Plan"

- Cross between HMO and PPO

- HMO features are retained (utilization controls, capitation)

- PPO features (open plan option)

Trends in Managed Care Enrollments

- PPO plans are the most common MCO today

- High-deductible health plans (consumer-driven plans) are becoming more popular

- Medicaid Enrollment

- Medicare Enrollment

Managed care impact on Cost, Access, and Quality

• Cost Containment

- Earlier successes

- Full cost containment potential not realized

• Access

- Improved access to primary and preventative services

• Quality

- In some ways, it has been increased

Managed Care Backlash, Regulation and the Aftermath

Backlash:

Three main reasons:

- Employees faced barriers to free choice of providers

- Employees did not see lower out-of-pocket costs

- Physicians reacted negatively to utilization management and lower reimbursement

Regulation

- Federal: Newborns’ and Mothers’ Health Protection Act, 1996

- Numerous laws were passed across states

Aftermath:

- Better relations with providers

- Relaxed utilization controls

- Consumers will accept less choice at lower out-of-pocket costs

- Emergence of high-deductible health plans

Integration (of hospitals)

• Lots of ways to integrate

- Mergers and acquisitions, joint ventures, alliances, networks, & virtual organizations

• Negotiating POWER

• Future of integration?

Integrated Delivery System (IDS)

- 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 served.

- Kaiser Permanente

Independent hospitals

An example is Augusta Health, a standalone hospital that has not integrated with any other hospital, which allows insurance companies to push it around since this one hospital does not have a lot of power. Negotiations are not equal between insurance companies and the hospitals.

- This is why we are seeing less and less independent hospitals

What % of the individuals who need long-term care are under the age of 65?

37%

What % of older Americans will eventually need some type of long-term care?

70%

What is long-term care associated with?

Chronic conditions

What % of Americans over the age of 65 will have at least two chronic conditions?

77%

Long-term care and COVID-19

Residents and workers of long-term care facilities have made up many of the US COVID-19 deaths (especially in the beginning). Less than 1% of Americans live in long-term care facilities.

Long-term care facility residents and staff account for more than _______ COVID-19 Deaths, and at least ____________% of ALL COVID-19 deaths in the U.S.

201,000. ; 23%

Activities of Daily Living (ADLs)

- Bathe

- Dress

- Eat

Instrumental Activities of Daily Living (IADLs)

- Prepare meals

- Housework

- Manage medication

Long Term Care (LTC)

- Variety of services

- Individualized services

- Well-coordinated total care

- Maintenance of residual function

- Extended period of care

- Holistic care

- Quality of life

- Use of current technology

- Use of evidence-based practices

Quality of Life

- Lifestyle pursuits

- Living environment

- Clinical palliation

- Human factors

- Personal choices

Long-Term Care Services

- Medical care, nursing, and rehabilitation

- Mental health services and dementia care

- Social support

- Preventive and therapeutic long-term care

- Informal and formal care

- Respite care

- Community-based and institutional services

- Housing

- End-of-life care

Informal Care

- Most long-term care in the US is provided informally

- Family members play a big role

- Respite care (at-home provider)

Community-Based Services

- Deliver long-term care in the most economical and least restrictive setting

- Supplementing informal caregiving when more advanced skills are needed

- Provide temporary respite to informal caregivers

- Delay or prevent institutionalization

Financing of Community-Based Services

- Out-of-pocket

- Private and long-term care insurance

- Medicare (65+)

- Medicaid (Low-income)

- Other public sources (Older Americans Act of 1965)

Older Americans Act of 1965

Legislation that was enacted to address the lack of community social services for older adults. It established federal support for a wide range of programs, including nutritional assistance, in-home services, and elder abuse prevention, by providing grants to state and local agencies on aging and their service providers.

Home and Community-Based Services (HCBS)

- Home health care

- Adult day care

- Adult foster care

- Senior centers

- Home-delivered and congregate meals

- Homemaker services

- Continuing Care at Home

- Case management

Level of Care Continuum

Residential and Personal Care Facilities ->Assisted Living Facilities ->Skilled Nursing Facilities ->Subacute Care Facilities ->Specialized Care Facilities

Residential and Personal Care Facilities

Physically supportive dwelling units, monitoring, and or assistance with medications, oversight, and personal or custodial care.

Assisted Living Facilities

Provides personal care, 24-hour supervision, social services, recreational activities, and some nursing and rehab services.

Skilled Nursing Facilities

A typical nursing home is at the higher end of the institutional continuum.

Subacute Care Facilities

Subacute care is provided on an inpatient basis for those individuals needing services that are more intensive than those typically received in skilled nursing facilities but less intensive than acute care.

Specialized Care Facilities

Provide services for individuals with distinct medical needs (ventilator care, intensive rehab, closed head trauma care, Alzheimer's/dementia care)

Institutional Trends, Utilization, and Costs

- Emphasis on community-based care

- Elder Abuse

- Aging population

- Memory care units

What is the largest minority group in the US?

Latino Americans

HPSA stands for...

Health Professional Shortage Area

MUA stands for...

Medically Underserved Area

Intention was to recruit and retain physicians to provide needed services in areas with physician shortages...

National Health Service Corps

Low birth weight was highest amongst this population?

African Americans

What federally run program is designed to provide health services to American Indians and Alaska Natives?

Indian Health Service

Among women over the age of 40, what population was most likely to have mammograms?

White women

What is the leading cause of death for children and adolescents?

Unintentional injuries

What demographic (race and gender) is most negatively impacted by HIV/AIDS today?

African American men

What population has the highest percentage of uninsured?

Hispanics/Latinos

This legislation permitted NPs and PAs to be reimbursed by Medicare/Medicaid.

The Rural Health Clinics Act

Number one cause of death in the US?

Cardiovascular Disease (CVD)

The virus that causes AIDS (spelled out) is:

Human Immunodeficiency Virus

When did AIDS peak in the US?

Early to mid-1990s

EpiPen was hiked _______ times since _________. (**as of 2016)

15; 2009

On average in the U.S., how much are EpiPens sold for? (**as of 2016)

$609

CEO of Mylan

Heather Bresch; her father was a senator, and her mother was on the national school board

Significance of Heather Bresch's parents' occupations

Heather donated significant amounts of money to the school board(where her mother worked), which helped push lawmakers to want EpiPens in schools (father was in the senate).

Why do drugs cost so much?

- Third-party payment

- Imperfect market

- Growth of technology

- Increase in elderly population

- Medical model of health care delivery

- Multipayer system & administrative costs

- Defensive medicine

- Waste and abuse (fraud)

Cost Containment (2-types)

1. Regulation-Based Cost-Containment

2. Competition-Based Cost-Containment

Regulation-Based Cost-Containment

- Price controls

- Reimbursement Formulas

Competition-Based Cost-Containment

- Antitrust regulation

- Competition

Access to Drugs/Medicine Depends on...

- Availability

- Accessibility

- Accommodation

- Affordability

- Acceptability

Quality of Care

- Dimensions (Micro & Macro)

~ Micro = Individual

~ Macro = Population

- Quality Assurance (improvement)

- Quality Assessment

~ Donabedian Model

- Public Reporting on Quality

Donabedian Model: Structure

- Facilities (Licensing & accreditation)

- Equipment

- Staffing levels

- Staff qualifications

Donabedian Model: Process

- Actual delivery of care

- Technical aspects of care (diagnosis, treatment procedures, correct prescriptions, wait time)

- Interpersonal aspects of care (communication, dignity & respect, compassion, etc.)

Donabedian Model: Outcome (Final Results)

- Patient satisfaction

- Health status

- Rehospitalization

- Mortality

- Incidence and prevalence of disease

Which type of managed care uses a gatekeeper?

HMO

Medicare/Medicaid

What was Lyndon B. Johnson associated with

Karen Ignani

Who was the lobbyist for insurance companies

pharmaceutical companies

Who did Billy Towson represent

$1.8 million

what was the salary of MD Anderson's ceo

$77

how much did MD Anderson charge for a package of gauze bandages

$1.50

how much was one tablet of ibuprofen from MD Anderson

Older americans act of 1965 (LBJ)

which law provides funding for programs Meals on Wheels

democrats

who has been against malpractice reform

Rahm Emanuel

who was president Obama's chief of staff when ACA passed

hispanics

what is the fastest growing minority in the United States

Olmstead vs. LC

what court case started a movement of people with mental disabilities to community based care