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Health care Coordination exam 1
Terms in this set (68)
Does the US have universal access to health insurance for its citizens?
long term care
What are the subsystems of US health care delivery?
Managed Care organizations
seeks to achieve efficiency by integrating basic functions of healthcare delivery. Employs mechanisms to control utilization and costs of services, determines the price for services and what providers get paid, dominant system of U.S. healthcare delivery today, HMOs and PPOs are examples
pay providers through capitation arrangement or discounted fee arrangement
What are the basic function that work all together for delivery of healthcare in a Managed Care System?
Active-duty military personnel - U.S. Army, Navy, Air Force and Coast Guard - healthcare given free of charge
TriCare - family of active military, retired career military
Veterans Administration (VA) - retired veterans who have previously served in the military
For the subsystem of military who is covered?
People with health need but inadequate resources (migrants/immigrants, poor/homeless)
Bureau of Primary Health Care (BPHC)- community health centers
Medicaid- low income
Children's Health Insurance Program (CHIP)- children of families with modest income
What are considered special/vulnerable populations?
Integrated Delivery Systems (IDS)
networks of healthcare providers and facilities that provide coordinated continuum of services to a defined population. These are strategic partnerships of hospitals and physicians and insurers that deliver a
range of services and are willing to be held fiscally and clinically accountable for the
clinical outcomes and the health status of the population served (makes it different than MCO's). Accountable Care Organizations (ACOs) - new model of this
1) emphasis on primary care
2) coordination of all care
3) accountability for health outcomes
What are the goals of integrated care?
Long Term Care
Healthcare provided to patients with chronic health issues and disabilities that prevent them from doing regular daily tasks
Delivery - in patient homes, assisted living facilities, nursing homes
Payment - not covered by Medicare, Medicaid may cover for indigent people, places burden on many patients because most don't buy this type of insurance
• Mission - to improve and protect community health
• Origin- An Act for the Relief of Sick and Disabled Seamen passed by the 5th Congress of the U.S. - origin of the Public Health Service
Public Health System
- identify and solve community health problems
- informing, educating and empowering people about health problems
- developing policies to support community health efforts
- providing people with access to healthcare
- assuring a competent healthcare workforce
- performing research to look for solutions to health issues
- Primary goal is to expand coverage and increase access to care
- Another key goal is to require private insurance to cover preventive services without
cost to patients
• The country's political climate
• The country's level of economic development
• Technological progress
• Social and cultural values
• Physical environment
• Population characteristics - demographics
A Country's Healthcare System is Influenced By?
gross domestic product (GDP)- total government expenditure
To compare the U.S. healthcare system with other countries we look at?
OECD countries (Organization for Economic Co-operation and Development)
countries that are like our own so we can compare to them
No Central Governing Agency; Little Integration or Coordination
Technology Driven and Focuses on Acute Care
Outcomes Poor or Average
Delivery of Healthcare Under Imperfect Conditions
Government Plays a Subsidiary Role to the Private Sector
Fusion of Market Justice and Social Justice
Multiple Players Balance of Power
Quest for Integration and Accountability
Access to Healthcare Services Selectively Based on Insurance Coverage
Legal Risks Influence Practice Behaviors
What are the Characteristics of the U.S. Healthcare System
Our health care system is made up of
-private financing (through employers) and public financing (government)
- large private infrastructure - hospitals, physicians are private businesses
- government control of Medicaid/Medicare reimbursement and minimal standards of
quality for healthcare
What do we mean when we say that the US healthcare system has No Central Governing Agency; Little Integration or Coordination?
- less costly
- less complex
- manage their expenditures through global budget and can control utilization of services
Most developed countries have centrally controlled universal health care systems. Why is this better?
- the U.S. has shrinking resources
- most advanced technology is sometimes not always the best care
- hospital competition
- legal risks - providers afraid not to offer the newest
The U. S. is a source of latest research and most up to date equipment. Growth in science and technology creates a demand for the newest services and technology. Why is this an issue?
the U.S. spends more than any other developed country on medical care
Why is high cost a characteristic of the U.S healthcare system?
- many Americans don't have access or have limited access to basic care
- restricted to those who have health insurance through employers or those covered under government program (Medicaid, Medicare, ACA) or those who can use private
Why is unequal access a characteristic of the US healthcare system ?
- experts believe that inadequacy of service and disparity in access to basic and routine primary care services cause U.S. poor outcomes
Why is Outcomes Poor or Average a characteristic of the US healthcare system?
U.S. healthcare is only partially governed by free market forces; it is a "quasi-market or
an "imperfect market"
Why is Delivery of Healthcare Under Imperfect Conditions a characteristic of the US healthcare system?
- physicians, insurance companies, government, large employers, administrators of health
- different economic interests are in conflict
- fragmented self-interests of varying players create counteracting forces
Why is Multiple Players Balance of Power a characteristic of the US healthcare system?
- Currently there is a push to use primary care as the focus for continuous and coordinated health services
- Emphasized the importance of the patient-provider relationship
- Provider Accountability - providing quality healthcare efficiently
- Patient Accountability - taking responsibility for one's own health and using resources wisely
Why is Quest for Integration and Accountability a characteristic of the US healthcare system?
1) pay physicians out of pocket at rates typically higher than those paid by insurance plans
2) seek care from safety net providers
3) obtain treatment for acute illnesses at a hospital emergency dept
What are the limited options for the uninsured?
Healthcare providers are engaging in ____ to protect against malpractice litigation
Most of western Europe has what kind of access?
• National health insurance
• National health system
• Socialized health insurance system
What are the Models for national health systems?
Canada's Healthcare System
• uses "national health insurance"
• Government finances health care through taxes
• Healthcare is delivered by private providers
• Tighter consolidation of financing and payment - coordinated by the government
Germany's Healthcare System
• uses a "socialized health system" which is financed by mandated employer and employee contributions
• Healthcare is delivered by private providers
• Sickness Funds pay for physicians, hospitals and all providers
• Insurance and payment are closely regulated
• Government exercises overall control
United Kingdom's Healthcare System
uses a tax-supported "national health insurance program"
Government manages the infrastructure for delivery of healthcare
Most providers are government employees or are tightly organized in a publicly managed infrastructure
- Quad Function Model - this countries government exercises tighter consolidation over all 4 functions
T or F
No country in the world has a perfect healthcare system
• Cultural Beliefs and Values
• Social changes
• Technological advances
• Economic constraints
• Political opportunism
• Ecological forces
What are some Forces of Change in Delivery of Healthcare?
• Strong spirit of self-reliance
• Distrust of strong federal government
What is the Traditional American Cultural beliefs and values?
- Creation of Medicare and Medicaid public programs
- The Affordable Care Act in 2010
- Prescription drug benefit to Medicare in 2003
Political maneuvering produced?
Look at p.53 Exhibit 03.02: Health Care Delivery in Preindustrial America
• medical training was largely received through individual apprenticeship rather than through university training
• Only a small number of medical schools existed
• To train a larger number of students American physicians began opening medical schools
• Medical education still lacked in science - 2 year M.D. degree required attending courses for 3-4 months during the 1st year and then repeating the same courses the 2nd year
• Low standards - admitted students without high school diploma
What was medical training like in preindustrial US?
• Was regarded as a trade and not a profession
• No requirement of rigorous course of study, clinical practice or exams
• Medical procedures were primitive - medical science was in its infancy
• The widespread use of bleeding, use of emetics, purging with enemas and other home remedies were used to "combat" illness
• Surgery was limited - anesthesia not developed yet
• Antiseptic techniques, stethoscope, x-rays, thermometer not discovered
• Since physicians mainly relied on their 5 senses and experience to treat and diagnose illness.....their technical expertise did not surpass family members or experienced neighbors
What was medical practice like in preindustrial US?
Who were primarily natural medical practitioners in preindustrial US?
Deplorable sanitation conditions, unhygienic practices, poor ventilation. Some were an infirmary, mental asylum, homeless shelter, orphanage and an old-age facility all in one. Much more dangerous to receive care in a hospital than at home - "houses of death". People went there not by choice - only under dire circumstances
The forerunner of inpatient psychiatric facilities. Usually built by state governments to provide care to mental patients with untreatable, chronic mental illness. Attendants used physical and psychological techniques to return patients to some level of "rational thinking". "Treatment" was often cruel by present day standards
Run by local governments to isolate people who had contracted a contagious disease (cholera, smallpox, typhoid). Main function was to contain the spread of communicable disease and protect the inhabitants
• outpatient clinics providing free care to those who could not afford to pay for care
• Forerunner of today's free and charitable clinics
1) Americans realized that medicine was a science and recognized that physicians were the most scientific practitioners who could give the highest quality of care
2) Dramatic growth in both the size and status of the U.S. hospital market
What 2 important changes fundamentally changed the U.S. healthcare system forever?
Look at Exhibit 03.03: Notable Developments During the Postindustrial Era (p.57)
Urbanization led to office-based practice instead of house calls
Medicine became driven by science and technology - outside the expertise of laypeople
Groundbreaking medical discoveries further legitimized doctors
Some unfavorable effects occurred with the "new" American preoccupation with science and technology:
- bias toward specialization in medical practice
- increased cost of medical care
What was the medical profession like in postindustrial US?
• Horace Wells: discovery of anesthesia (nitrous oxide "laughing gas"
• Ignaz Semmelweis: aseptic technique
• Louis Pasteur: germ theory of disease
• Joseph Lister: father of antiseptic surgery
• William Roentgen: discovery of x-rays
• Alexander Fleming: discovered the antibacterial properties of penicillin
What were some ground breaking medical discoveries in postindustrial US?
American Medical Association (how healthcare is delivered today)
• It helped galvanize the profession and protect the interest of physicians. The concerted activities of physicians through this is referred to as "organized medicine". Gained power by controlling medical education. Supported states in establishing medical licensing laws. Discouraged employment of physicians by hospitals and insurance companies thereby promoting complete independence
Medical schools began affiliating with universities.
Following the European model, Harvard revolutionized medical education
- academic year went from 4 to 9 months
- medical education went from 2 to 3 years
-labs and clinical courses included: chemistry, physiology, anatomy and pathology for the first
What was the education reform like in postindustrial US?
Came to symbolize the institutionalization of healthcare. Medical science advancements created the need to centralize expensive facilities and equipment in an institution
Became the center for the advanced technology used in medical diagnosis, treatment of patients and for the training of the various healthcare personnel.
"voluntary health insurance"
Private health insurance is also called?
the elderly and the poor
U.S. Congress created the publicly financed Medicare and Medicaid programs when rising healthcare costs made it difficult for who to get healthcare?
The first broad coverage health insurance in the U.S. Originally designed to make cash payments to workers for wages lost because of job related injuries and disease. Later became compensation for medical expenses and death benefits for survivors. Was a trial for the idea of "government - sponsored" health insurance
Private Health Insurance
began as a form of disability coverage that provided income during temporary disability due to bodily injury or illness. Americans purchased disability coverage with their own funds.
The dire economic conditions of the Great Depression caused sharply decreased hospital occupancy rates as patients could not pay for healthcare. Many hospitals went bankrupt. Individual patients faced loss of income from illness and burdensome debt from healthcare costs. Baylor University Hospital started the first hospital insurance plan and the American private insurance industry began! What was this plan called?
Birth of Blue Shield (first physician plan)
It was designed to pay physician fees. By endorsing hospital insurance and actively developing plans that covered their services, physicians protected their own financial interests
"government - run" national health insurance
The American Medical Association ensured that private insurance was preserved and remained opposed to?
Employer Based Health Insurance
Congress made _____ nontaxable. This was equivalent to getting extra money that was not taxed - provided an incentive to seek employment at companies that provided health insurance
• Unlike in Europe (labor unrest threatened political instability), national healthcare failed to get an early footing because of political stability in the U.S.
• American government was highly decentralized and had little control over social policy
• Anti-German feelings during WWI denounced German social insurance as a "Prussian menace"....the label of "socialized medicine"
• The AMA played a leading role in opposing national health care
• The AMA campaign directly linked national health insurance with communism and the public "bought into" the idea
• Middle class Americans have traditionally held beliefs that are consistent with capitalism, self-determination and distrust of big government
• Middle class Americans have been adverse to higher taxes to pay for the increased cost of a national healthcare program
Why did national health insurance fail in the US?
Medicare Parts A and B;
What is the 3 part program that was adopted to serve 2 distinct populations who could not receive health care?
Medicare Part A
was designed to use Social Security funds to finance hospital care
Medicare Part B
was designed to cover physicians' services through government-subsidized insurance (elderly would pay part of the premium)
was upheld by broad grassroots support and had no class distinction since it was
tied to Social Security
carried the stigma of "public welfare program"
benefits vary from state to state. Eligibility is confined to people below a certain pre-determined income level. Has uniform national standards for eligibility and benefits:
- it covers anyone over the age of 65
-was expanded to include the disabled on Social Security and those with End Stage Renal Disease
- Information revolution
What are the three main features of the Corporate Era?
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