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Terms in this set (64)

The Chronic Care Model: Case management, access to information on both individual and populations, Patient's own self-management, Emphasize that patients who are informed about their conditions and who assume an active role in managing their care, More productive health care interactions and better outcomes. Patient-centered medical homes: A physician-directed medical practice with a team of providers in which each patient has an ongoing relationship with a personal physician,The personal physician coordinates the patient's acute care, preventive care, chronic care, and end-of-life care, across and within accessible health care providers in the patient's community. Accountable Care Organizations: a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients, A group of coordinated health care providers form an ACO, which then provides care to a group of patients, The ACO may use a range of different payment models (capitation, fee-for-service with asymmetric or symmetric shared savings, etc.), The ACO is accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the health care provided. Bundled payments that combine hospital and outpatient care for a specific episode of illness, Case rates, which would pay providers for an individual's episode of care instead of the individual treatments provided, Could span multiple providers and settings, Create incentives for practitioners and providers to communicate and coordinate their care plan
Insurance: If the patient is enrolled in a health maintenance organization (HMO), the physician may need to conceptualize the patient's needs in the context of a population of HMO members. If the patient has traditional fee-for-service insurance, the physician would be more likely to think of the patient's needs on an individual basis. If a patient has a federally supported insurance plan, such as Medicare or Medicaid, the physician would need to comply with federal rules and standards. If a patient has no insurance, the physician would need to decide whether he or she is willing to treat the uninsured patient and decide what fees to assess for services. Different insurance plans create different rules regarding preapproval for visits and procedures, the necessity of referral to specialists, and annual limits on services, such as physical therapy, and so forth. Physicians must work within these rules when treating patients. Meanwhile, patients must work within insurers' rules, such as which practitioners qualify as "preferred providers," which are in-network versus out-of-network, and how those designations influence out-of-pocket costs. Medical knowledge: Physicians' stores of medical knowledge influence how they evaluate and treat their patients. Physicians must retain a command of the medical knowledge in their disciplines, which becomes increasingly more difficult as medical knowledge expands. Patients gather medical knowledge from diverse sources including Web sites, self-help books, television commercials, newspapers, and information passed through their social networks. Unlike in the past, when patients relied almost solely on practitioners' expertise, some patients today might approach their physicians with specific medication requests, questions printed from a Web site, self-diagnoses from Web sites and books, and so forth. Physicians must contend with informed patients who might feel they know more about their specific health problems than their doctors do. Nevertheless, many patients have very low levels of health literacy and have difficulty coping with the complexity of their diseases and treatments that are made possible by today's advanced medical science. Technology: Both patients and physicians use information technology to access medical knowledge. Today's physicians are more likely, than in the past, to use advanced imaging technology, such as MRI and CT scans, and today's patients are more likely to have had one of these scans. The electronic medical record is another form of technology that influences the patient-physician relationship, depending on the type of program a physician uses. The most robust electronic medical record systems can prompt patients to schedule follow-up appointments, have laboratory tests, obtain vaccinations, and so on, without a physician's review of the record. Some physicians' offices have Web sites that allow patients to access laboratory results, schedule appointments, e-mail questions to their doctors, and so forth, without having to visit or call the office. Presumably, these efforts give physicians and their staff more time to focus on patient care.Both accreditation and regulation: create a context in which each patient-physician relationship takes place. Accreditors set standards for patient care that physicians must follow to gain accreditation. These standards shape how physicians diagnose and treat their patients. Regulation has a wide-ranging effect: from setting rules for physician licensure and certification, creating standards of physician practice, mandating minimal hospital stays for certain procedures (such as childbirth), defining qualifications for federal and state-subsidized health insurance, and so forth. Patients trust that physicians, who are accredited and licensed by the state, will provide competent and appropriate medical care.
Complexity in the U.S. medical care field stems from the specificity and depth of medical knowledge and science, the multiplicity of insurance plans and programs, and the extent to which Americans suffer from chronic conditions and use prescription drugs. Complexity complicates patient care. For some conditions, physicians must choose from various possible tests and treatments, which creates uncertainty. The variety of insurance plans creates complications for record keeping, billing, and physician referral. Practitioners must treat patients who take multiple prescription drugs and suffer from multiple chronic conditions, which can complicate an acute episode of illness. For example, treating a patient for bronchitis becomes more difficult if the patient is asthmatic. The field is diversified in that there are many different types of physician/practitioner specialties, provider organizations, and insurance plans. For patients, the diversity of provider organizations can mean that treatment for one condition takes place in multiple practice settings. In addition, to diagnose an illness, patients might need to see multiple providers, each with a specific specialty. Practitioners must navigate the diverse field as they make referrals, order procedures, and decide where to treat their patients. The specialization and "superspecialization" of physicians fragments the field, because physicians from different fields do not share common knowledge. Fragmentation also stems from underdeveloped health information technology, lack of care coordination and incentives to coordinate care, and the focus of the field on acute care. Fragmentation detracts from quality health care. Different physicians who see the same patient for the same condition may not communicate with each other. Patients in this situation can receive varying diagnoses and treatment plans, all for the same underlying condition. The consequences can be life threatening if different treatments (especially medications) conflict. The focus on acute care creates unmet needs for patients with chronic illnesses and downplays preventive care to the detriment of the patient and population health. The U.S. medical field is stratified in the sense that some Americans are "haves" and some are "have nots." Americans without health insurance are much more likely to be ill, have unmet medical needs, lack access to regular health care, and fail to obtain medical care because of out-of-pocket costs. Compared with insured Americans, poor and vulnerable Americans are more likely to seek routine care at emergency rooms, which overburdens emergency departments and diverts resources from true emergencies. Some provider organizations, such as public hospitals, provide more than their share of uncompensated care that puts them at risk for insolvency
It would appear to be in society's best interest to ensure adequate access to essential health care services. Adequate access enhances the productivity of the workforce and, in most instances, allow individuals to manage their health care more effectively throughout their lifetime. However, an executive of a hospital must reach a balance in providing free or under-reimbursed (where payments do not cover costs) care to ensure the financial sustainability of the hospital. If the hospital executive does not pursue this balance, the hospital will suffer a financial loss that may result in its closure, thus eliminating a larger share of the community's access to services. A hospital in a low-income area may therefore constrain its emergency room staffing and the size of the waiting and treatment areas. This would make it unattractive to those with less serious conditions, who may easily choose a different provider or wait until the next day to visit a clinic. More recently, some hospitals have collaborated with community physicians to establish physician offices with extended hours near their emergency rooms, in order to divert patients needing only basic care away from the emergency room. These physician offices generally operate at a much lower cost than an emergency room because of the limited services provided and far less regulation. Hospitals will often curtail free and under-reimbursed care by limiting programs and service locations. For example, in an area where there is a high concentration of low-income women of childbearing age, a hospital may intentionally limit the number of obstetrical beds, and in some cases, will completely eliminate its obstetrical program. This forces at least some of the women to seek prenatal care elsewhere