- Before Medicare and Medicaid, drs often discounted fees for elderly or poor patients, and even afterward many physicians have continued to assist uninsured people in this way
---Under this method drs would get paid based on usual, customary, and reasonable (UCR) system
-Cost containment changed this and now Medicare moved to a fee schedule determined by a resource-based relative-value scale (RBRVS)
---- With this system, fees (which vary by geographic area) are set for each service by estimating the time, mental effort and judgment, technical skill, physical effort, and stress typically related to that service
----RBRVS tried to take away the bias of physician payment that paid for surgical and other procedures at a far higher rate than primary care and cognitive services.
- PPO pay contracted drs on a discounted fee-for-service basis and require prior authorization for expensive procedures.
*With fee-for-service payments, drs have an
economic incentive to perform more services because
more services bring in more payments and this has
contributed to the rapid rise in health care costs*
-Surgeons usually receive a single payment for several
services (the surgery itself and postoperative care) that
have been grouped together, and obstetricians are paid
in a similar manner for a delivery plus pre- and postnatal care
- With payment by episode, surgeons have an economic
incentive to limit the number of postoperative
visits because they do not receive extra payment for
extra visits, but have the incentive to perform more surgeries just like fee for service
- Under this system, one fee would be paid for one episode of illness, no matter how many times the patient visited the physician
- Concept of RISK comes into play and refers to the potential to lose money,earn less money, or spend more time without additional payment on a reimbursement transaction.
- Fee for service, the party paying the bill absorbs all the risk, but with this bundling of service, a portion of the risk from the payer to the physician
----The more services bundled into one payment,the larger the share of financial risk that is shifted from payer to provider
------PAYER: refers to whomever pays the bill
- Capitation payments (per capita payments, or payments "by the head") are monthly payments made to a physician for each patient signed up to receive care from that physician—generally a primary care physician
- There is a shift of financial risk from insurers to providers
- Under fee-for-service, pts who require expensive services cost their health plan more than they pay in
premiums and the insurer is at risk and loses money while drs and hospitals that provide the care earn more
-Capitation is a 180 degree turn and frees insurers of risk by transferring risk to providers
----An HMO that pays drs via capitation has pays a fixed sum, no matter how many services are provided and the providers earn no additional money, yet spend a great deal of time and incur large office and hospital costs (In the long term, HMOs do want to limit services in order to reduce provider pressure for higher capitation payments.)
METHODS TO MITIGATE FINANCIAL RISK
- Offer fee for service for certain services and called "carve outs" as their reimbursement is carved out ans paid separately (i.e.Pap smears, immunizations, office ECGs, and minor surgical procedures)
- Risk-adjusted capitation will provide higher monthly payments for elderly patients and for those with chronic illnesses
-Capitation has potential merits as a way to control
costs by providing an alternative to the inflationary
tendencies of fee-for-service payment.
- Have Beneficial influence on organization of care.
- Capitation payments require patients to register with a physician or group of physicians
- The clear list of the population of patients in a primary care practice offers advantages for monitoring appropriate use of service and planning for these patients' needs.
- It explicitly defines, in advance, the amount of money
available to care for an enrolled population of patients,
providing better allocation of resources and innovation in developing better modes of delivering services.
- For a large group of PCPs size of the capitation payments provides influence and flexibility over how to best arrange ancillary and specialty services
- Looking for less costly ways to produce the same or better health outcomes
----i.e. ARNP, PA instead of Dr for appropriate procedures, generic instead of brand name meds, chemo outpt instead of inpt,
- New technologies are introduced in hopes that they will prove to be less costly, but new technologies often fail to live up to cost-saving expectations
----i.e. lap chole made the procedure more affordable by making recovery time less, incision smaller, intraop time less, etc, but after the release of the lap chole surgery, there was a rise in the number of people having the procedure done compared to before when surgery was more extensive and expensive---so is it really an "efficient substitution"
------In one HMO, the cholecystectomy rate increased by 59% between 1988 and 1992
------Even though the average cost per cholecystectomy declined by 25%, the total cost for all cholecystectomies in the HMO rose by 11% because of the increased number of procedures done
-1st Medical School in the United States was University of Pennsylvania in 1765
----Curriculum emphasized the therapeutic powers of
blood letting and intestinal purging
----During this era other medical sects existed i.e. botanicas, "natural bonesetters," midwives, and homeopaths
----All groups were equal in dominance
-EARLY Medical Training
--Could be achieved through an informal apprenticeship or going to a medical school
-- Most medical schools operated as small, proprietary establishments profiting their physician owner rather than as university-centered academic institutions
-MODERN Era (1890-1910): Medical Training
--In 1893, John Hopkins University's School of Medicine started a new era of medical education
---Implemented many features that are still a standard in medical education:
----- 4-year course of study at the graduate
-----Competitive selection of students
-----Emphasis on the scientific paradigms of clinical and laboratory science, close linkage between a medical school and a medical center hospital, and cultivation of academically renowned faculty
--Flexner Report 1910 major event in modern reform
----The Carnegie Foundation for the Advancement in Teaching commissioned Abraham Flexner to perform an evaluation of medical education in the US
----(MORE INFO IN THE NEXT TWO SECTIONS)
--Homeopathic practitioners not considered "physicians"
--Osteopathy originated as a medical practice developed by a Missouri physician, Andrew Still, in the 1890s, emphasizing mechanical manipulation of the body as a therapeutic maneuver (and is still around today)
--Psychosocial support to patient and families
--Assist patients with navigation of healthcare system
- Tasks may include assessing person, their family, and home, access to medical equipment, placement for for hosp inpt for pts unable to go home, etc.
--Minimum bachelor's degree
--Most work positions require a master's degree in social work plus state licensure
-Licensed clinical social workers (LCSWs)
--Must have a minimum of a master's degree plus 2 years of academic and practical experience in the field, during which they serve as members of the care teams in hospital, primary care, and behavioral health settings
--They may be generalists or may be specialized in mgmt of geriatric, children, or persons w/ developmental disabilities, mental health, and substance abuse dx
-Statistics on Medical Malpractice Payouts & Lawsuits
-Medical Malpractice Payouts
--Dollars in payouts: $3.6 billion (3.4 percent less than in 2011)
--Total payouts for medical malpractice: 12,142 (one every 43 minutes)
--Payouts resulting from judgments: 5 percent
--Payouts resulting from settlements: 93 percent
-Top 5 States for Medical Malpractice Payouts
--New York - $763,088,250
--Pennsylvania - $316, 167,500
--California - $222,926,200
--New Jersey - $206,668,250
--Florida - $203,671,100
Chronic Disease Prevention seen in two distinct perspectives:
--Medical model seeks to identify high-risk individuals and offer them prevention through patient education
----Medical model may target interventions to wrong individuals
--Examples: Smoking cessation & low fat diets
--May lead to tunnel vision regarding cause and prevention of disease
----i.e. Cholesterol as an exmaple
------In Finland, CHD common, 20% of diet saturated fat, and 56% of men aged 40 to 59 years had cholesterol levels > 250 mg/dL. In Japan, CHD was rare, 3% of saturated fat, and only 7% of men aged 40 to 59 years had cholesterol levels > 250 mg/dL.
-------If we compared two individuals in east Finland who eat the same diet, one with a cholesterol level of 200 mg/dL and the other with a level of 300 mg/dL, we might conclude that the variation in cholesterol levels among individuals is caused by genetic or other factors, but not diet.
--This model believes the concept that in noninfectious chronic disease, individuals play a major role in causing their own illnesses by such behaviors as smoking, drinking alcohol, and eating high-fat foods.
--Public health model seeks to reduce disease in the whole population through mass education campaigns, campaigns to reduce drinking and driving, taxing tobacco products, labeling of food products
--Looking at the cholesterol example from above, If we look at entire populations, studying the average cholesterol level and the percentage of fat in the diet in east Finland and in Japan, we will conclude that high-fat diets correlate with high levels of cholesterol and with high rates of CHD (under this model, they strive to reduce population cholesterol levels rather than looking at individuals w/ high cholesterol as being high risk)
-----10% reduction in the serum cholesterol distribution of the entire population would do far more to reduce the incidence of heart disease than a 30% reduction in the cholesterol levels of those relatively few individuals with counts greater than 300 mg/dL
-- This model believes that modern industrial society,
rather than the individuals living in that society, creates
the conditions leading to heart disease, cancer, stroke, and other major chronic diseases of the developed world (i.e. marketing)
-To implement the 2nd epidemiologic revolution, the medical (individual) and public health (population) models must be joined
-Medical caregivers must try and help individual patients make lifestyle changes
-Society must look for ways to reduce consumption of alcohol, tobacco and high-fat foods
--One model that bridges the medical and public health approach is the community-oriented primary care model