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Health Delivery

Finale Exam

Factors contributing to healthcare spending increasesa.New diagnostic and treatment technology i. •Equipment, devices & pharmaceutical agents, requiring advanced personnel training & new personnel roles1. –Computed tomography scanning, Magnetic resonance imaging, PET scanning2. –Pacemakers, implantable cardio-converters3. –Drugs •Direct ma 4. Managed care: a. Why was it developed? •Government failures to control rising health care costsii. •Incentives to utilize services without regard to costs 1. –Fee for Service Modeliii. •Rising health insurance premiums & corporate backlash iv. Health care costs impacting global competi 8. Significance of Medicare Prescription Drug, Improvement and Modernization Act of 2003 (creation of Medicare Part D prescription coverage) a. –Cost estimates range $400-720 billion over 10 yearsb. –Projections for 2008-2016 now over $900 Bc. –Provisions prohibit Medicare from negotiating discounts with drug companies 15. Characteristics ofa. Home care i. Eligibility for Medicare Part A home care benefits:ii. Skilled nursing, physical, occupational, speech therapies; medical social servicesiii. Client confined to homeiv. Physician must order that home care services are requiredv. Agency meets al
Factors contributing to healthcare spending increasesb. Growth in older population i. •Since 1900, 65+ year olds tripled in numberii. •85+ year old projected at 8.9 M by 20301. –Major consumers of hospital inpatient care2. –Advanced age accompanied by chronic conditions requiring surgeries, drug therapiesiii. •Baby Boomers1. – 4. Managed care: b. What is supposed to be accomplished? i. –legally organized entity responsible for both providing & financing comprehensive services for a defined population for a pre-paid feeii. –links provision & payment for serviceiii. –premium charged & financial risk shared with providers and subscr 9. Coverage expansion components included in new health reform law a. •Individuals required to have coveragei. −Medicaid expanded up to 133% FPLii. −Premium assistance up to 400% FPLiii. −Tax penalty to be phased in starting in 2014iv. −New state-based health insurance exchanged to help individuals shop & compare 1. Characteristics ofa. Hospice i. A philosophy of care for terminally illii. Palliative care for physical & emotional symptomsiii. Cure is not the goaliv. Low-tech:1. pain control, quality of remaining lifev. Settings: home, dedicated hospice facilities, hospitals, SNFsvi.
Factors contributing to healthcare spending increasese. Labor intensity i. •People-centered services require high staff to consumer ratioii. •New technologies require new, technically trained personneliii. •Aging population contributes to home care, other personnel needsiv. •27% of all wage & salary jobs created by 2014 4. Managed care: Impacts? i. •Higher worker contribution results in dropped coverageii. •Employers use “benefit buy-downs,” reducing benefit scope, increasing co-pays, and/or deductibles1. –1% increase in premiums= 164,000 additional uninsured 10. Familiarize yourself with other key components of new health reform law (for example, what does it do to promote a prevention/wellness focus?) a. •Establish national coordinating council to develop national prevention strategyb. •Grants to support delivery of evidence-based prevention/wellness servicesc. •Cover only proven preventive servicesd. •Eliminate cost-sharing for preventive servic 1. Characteristics ofRespite care i. Temporary, surrogate care for a patient in primary caregiver’s absenceii. Originated in 1970s: 1. deinstitutionalization of developmentally disabled and mentally illiii. Short-term service provides relief to in-home caregivers iv. Purpose: fore
Factors contributing to healthcare spending increasesc. Medidcal specialization i. •65% of physicians are specialistsii. •Americans demand specialty care1. –Results in higher use of diagnostic testingiii. •Managed care relaxing hurdles to specialty care referrals 4. Managed care: d. Backlash? i. •Organized medicine, consumers protested restrictions on choice of providers, referrals, other practicesii. •Late 1990s: Presidential commission established to review patient protections1. –President imposed patient protections on companies provid 11. Difference between HMOs and traditional insurance a. HMOi. Prepaid plan for specific populationii. Incentives to keep people healthyiii. Set fee for a set # of peopleiv. Provided by an organizations that provides treatment and paymentv. Links payment and provider for defined populationb. Trad 16. Reasons for home health care reforms a. Federal investigations of rising costs & quality concerns prompted executive & Congressional actions:i. Operation Restore Trust (ORT) targeted fraudulent Medicare billing practices ii. BBA of 1997 stiffened requirements for Medicare certification
Factors contributing to healthcare spending increasesd. Uninsured, underinsured i. •47 million, 16% of Americansii. •Almost 75% of uninsured in households with at least one full-time workeriii. •No insurance results in: 1. –late care2. –medical complications3. –emergency care4. –avoidable hospitalizationsiv. •Costs pass 4. Managed care: e. Types of cost control measures used? i. •Encourage cost-conscious, effective, efficient careii. •Capitation: 1. –per-member-per-month fee, paid in advance whether or not services deliverediii. •Withholds: 1. –retains percentage of customary fee, refunded if MDs meet targets for effic 12. Long-term care: a. Definition: •From birth to death, health care needs vary in intensity and durationb. Informali. institutionally based or operatedc. Formal i. family/friends; often a combinationd. Need for servicesi. •Lifespan increasing: 1. –more chroni 17. Significance of the Family Medical Leave Act a. Family Medical Leave Act (1993) i. important first stepii. 12 months unpaid leave isn’t feasible for manyiii. Doesn’t cover workers in small businesses
Factors contributing to healthcare spending increasesf. Rimbursement system incentives i. •Traditional payment for piece-work (per exam or procedure) drove high utilizationii. •Managed care, prospective payment dulled incentivesiii. •System still largely physician and hospital driven with continuing incentives for over-use 1. Favors p 5. Purpose of DRGs a. •(1983): Shifted Medicare from retrospective to prospective reimbursementi. –Pre-set hospital case reimbursement based on diagnosis using the International Classification of Disease (ICD) codes 1. •Rewarded efficient care, financially penalized ine 13. Long-term care abuses & reforms in the 1970s a. –Untrained, inadequate staffb. –Hazardous, unsanitary conditionsc. –Over & under-medicationd. –Overuse of restraintse. –Substandard physical caref. –Human dignity compromisedg. –Lack of activities for patientsh. –Discrimination against mi 18. Significance of World War I to mental health awareness “shell shock” a. National Mental Health Act of 1946:i. Created National Institute of Mental Healthb. Public funding for mental health training, research and servicec. Dept. of Veterans’ Affairs established psychiatric hospitals and clinics
2. Major components of healthcare spending (“where the dollar went”) a. •Hospital Care: 30%, $ 611.6 billionb. •Physicians: 21%, $ 421.2 billionc. •Prescription drugs: 10%, $ 200.7 billiond. •Administration: 7%, $ 143.0 billione. •Nursing Homes: 6%, $ 121.9 billion 6. Significance of Balanced Budget Act of 1997 to healthcare a. •Significant decrease in Medicare spending growth through 2002i. –$ 68 B in savingsb. •Private insurers’ entry through Medicare Part C & subsequent withdrawalsc. •Successful SCHIP implementationd. •Fraud & abuse financial recoveries 14. Differences between a. Skilled nursing facilities i. •Institution-based, “hands-on” nursing1. –Most common form of long-term carea. •1.5 million Americans reside in 16,100 SNFs2. –Federal certification required for Medicare, Medicaid reimbursement3. –State licensing of facilities, administrators 19. Evolution of mental health care in U.S. (pre-1960s vs. post-1960s)a. Pre-1960s i. 1930s: First effective biological treatments: insulin coma, drug-induced convulsions, electroconvulsive therapyii. By 1950, mental health care was still primarily delivered in inpatient settingiii. Over a half million patients were hospitalized in
3. History/characteristics of health insurance? a. •19th century: direct payments to employees for lost wages due to illness, injury b. •1930s: group hospital pre-payment plans i. –(Baylor) made direct payments to hospitals (Precursor to Blue Cross/Blue Shield plans)c. •1940s-1970s: Growth of Blu 7. Characteristics of the uninsured & impacts of being uninsured i. •47 million, 16% of Americansii. •Almost 75% of uninsured in households with at least one full-time workeriii. •No insurance results in: 1. –late care2. –medical complications3. –emergency care4. –avoidable hospitalizationsiv. •Costs pass Differences betweena. Assisted living facilities i. •Single homes to multi-unit apartments1. –supportive assistance instead of “hands-on” nursingii. •20,000 facilities house 1 million+1. –Capacity expected to double by 2025iii. •Primarily personal payment1. –average monthly cost = $2,3502. – 1. Evolution of mental health care in U.S. (pre-1960s vs. post-1960s)a. Pre-1960sb. Post-1960s i. Mental health care reforms such as shift from inpatient to outpatient care were supported by President Kennedyii. Additional pharmaceutical treatments developediii. Federal Mental Retardation Facilities & Community Mental Health Centers Constructio
Created by: rodrigocarbajal