Finale Exam
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| 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 |
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| 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. |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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