USHC Review
USHC Review
November 20/2015
Definition of Health
Definition of Health by World Health Organization:
Health is a state of complete physical, mental and social
well-being and not merely the absence of diseases or
infirmity.
Determinants of Health
1. Societal factors
2. Economic variables
3. Physical factors
4. Personal factors
5. Healthcare system
Physical factors
Personal factors
Dental
Cavity
Healthcare system
Presently, healthcare services impact on health is late in the events that lead to
disease and illness.
- Focusing on changing the Sick Role to Normal Role
Epidemic of Obesity
Medical
Terms to learn
Incidence and prevalence are used extensively by researchers,
healthcare administrators to demonstrate social and ecological
distribution of diseases, impairments and/or accidents.
Incidence= Number of new patients/cases/afflicted individuals divided by
number persons at risk for the specific disease/impairment
Terms to learn
Prevalence: The proportion of individuals with a specific disease/health
condition during a specific period of time, usually one-year.
Prevalence: Total number of individuals with the disease or health condition/ Total population
e.g. Prevalence of drug addition among young women (age16-25)
Total number of young women diagnosed with drug addiction divided by the
population of young women ages 16-25
Categories of Healthcare
Primary Healthcare: Focus and objectives are to eliminate or reduce factors that can
increase the likelihood of diseases/adverse health conditions/ compromised quality of life.
- Environmental Quality
- Public Sanitation
- Public Safety
- Vaccination and Immunization
- Engineering and technology
- Education
- Legal System
- Food Safety
- Drug Abuse Prevention
- Suicide Prevention
Categories of Healthcare
Secondary Healthcare: Focus and objectives to reduce the
burden of disease through early detection and/or early
intervention
- Screening for chronic diseases
- Annual check-up
- Eye exam (ocular pressure check)
- Fortification of food items
- Fluoridation of water supply
- Pre-natal care
- Annual/semi annual dental check up
Categories of Healthcare
Tertiary healthcare: Focus and objectives are to eliminate
or moderate the disability/disease/health problem
presented in advanced stages
- Diagnostic and treatment interventions
US Government
The principal governmental health authority
- US Department of Health and Human Services
Direct Delivery of Health Services
- VA Hospital System
- Department of Defense
- State Mental Health Facilities
- Public Health Clinics and Hospitals
- Public Health Services
US Government
Indirect Delivery of Health Services
A: Surveillance and Monitoring
Centers for Disease Control and Prevention
- Surveillance Epidemiology and End Result (SEER)
- Cancer Registries
- Infectious Disease Control and Surveillance
- Chronic Disease prevention
- Healthy People Initiatives 2020
- National Health and Nutrition Examination Survey
US Government
US Government
Indirect Delivery of Health Services
- Food and Environmental Safety, etc.
-
US Department of Agriculture
US Custom
Private Sector
Not-for-Profit
- Solo Practice (Almost an extinct species! )
- Group Practice
- Healthcare System
What are the differentiating characteristics between group practice and healthcare
system?
Group Practice
Providers join together to form their own company. Company then contracts with a management (financing
&administrating) entity to provide services management entity sells prepaid healthcare coverage packages to
beneficiaries or their employers.
Five elements of medical practice can be shared
- Space
- Supporting Staff
- Practice Income
- Practice Expenses
- Medical Work
Healthcare System: A business entity that assumes or shares both the financial risks (insurance) and the
delivery risk associated with providing comprehensive medical service to a voluntary enrolled population
within a particular geographic area, usually in return for a fixed pre-paid fee. Health System may contain one
or several group practices, salary based providers or may contract with independent providers.
Comprehensive medical services is defined healthcare spanning from primary care to tertiary, nursing homes
and end of life care (hospice)
Private Sector
For-Profit or Proprietary Sector
A: Direct Operation of Healthcare Services
e.g. Vanguard Healthcare Services, LLC
B: Indirect Operation of Healthcare Services
- Pharmaceutical Industry
- Medical Information Technology
- Commercial Health Insurance
- Genomic Industry
- Home Health Care
- Nursing Homes
- Biotechnology Industry
2.
A.
B.
Medicare
C.
D.
E.
VA, DoD
Out of Pocket
B.
C.
4. Investment
5. Government Public Health Activities
A. Disease Surveillance
B. Inoculation & Immunization Programs
C. Public Health Laboratories
D. Disease prevention programs and initiatives
Fragmented services
2.
Duplication of services
3.
Medical Errors
4.
5.
Ineffective care
6.
7.
8.
Poor compliance
9.
Improving Quality of Care for : one of the major objectives of US Healthcare System for the 21 st
Century
1. Americans have shorter life expectancy than their counterparts in other developed countries.
- Disparity in life expectancy among various racial/ethnic groups in the US
2. Americans spend the most on healthcare and drugs than their counterparts in other
developed countries.
- Most of the healthcare budget is spent the last year of life
3. American are still dying from treatable disease.
- Disparity by socioeconomic status
- Disparity across the racial/ethnic groups
4. US life expectancy varies by skin color and gender and socioeconomic status
Improving Quality of Care : One of the major objectives of US Healthcare System for
the 21st Century
American Hospital
William Penn, a business man, established the first
American Hospital Poor House in 1731
Program stopped providing funds to hospitals in 1994; about 200 hospitals remain obligated to offer
free and/or below federal government poverty guidelines
Classification of Hospitals
I.
Health Condition
-
II.
III. Number of Beds: Per the American Hospital Association regulations, a minimum of
beds are required to meet the standards for a hospital
In patient Services
II.
Change of clothing
No Personal belonging
Rooms not personal
3. Control of resources
Further accentuation of dependency
4.
Control of mobility
Patients Responses
1. Withdrawal
2. Aggression
3. Integration
4. Acquiescence
Wall Street Journal: How House Calls Can Cut Medical Costs
For infirm older patients, Medicare finds that personal visits can keep people out of the hospital
2. Economic benefits
- Cost saving measures
- Prevention of unnecessary and costly intervention
1. Financial Reports
- Cost per Case (patient)
- Margin of Operation: How much $ left in my balance sheet after delivery of services
2. Clinical Quality
- Re-admission rate
- Infection rate (nosocomial infection)
- Length of Stay
- Other complications
3. Patient Satisfaction
-
other
healthcare
Consumers [private employers purchasers of health services, public sector purchasers of health services
(Medicare and Medicaid), and individuals] are demanding quality of care which incorporates, price, efficiency of
delivery of care, effectiveness of care provided and align these requirements with incentives.
Providers are rewarded by:
1. Improved reputation
2. Enhanced payment through differential reimbursement
3. Increased market share
2. The trade agreement of 1910 gave AMA the exclusive right and the sole
power to regulate medical profession
Decline of Power
Several Factors impacted this decline:
1.
American Association of Medical Colleges and individual schools began to take more
decisive and independent decisions about their curriculum
2.
3.
4.
Womens movement
5.
Nursing Profession
American Nursing Association was founded in 1896 as the Nurses Associated Alumnae; in
1911 it was renamed to American Nursing Association
Five foci of nursing profession
1. Assessment
2. Diagnosis
3. Planning
4. Intervention
5. Evaluation
Traditionally patient not the disease in the emphasis of the nursing profession
in contrast to medical profession
Practicing Medicine in US
Governmental Agencies
- State and local Health Departments
-
Prison System
Department of Defense
VA Health System
Private Agencies
-
Group Practice
Solo Practice
Pharmaceutical Industry
Pattern of Practice
1. Privilege for ambulatory basis care and in-patient hospital patients
2. Hospitalists
3. No hospital privilege
- Native Americans
- Military veterans
Financing of Operations
- Cover the cost of operating its own programs, VA hospitals, municipal clinics and
hospitals, state mental hospitals, state public health agencies.
II.
Terms to remember
Third-Party: Any one, other than patient for the patients family, responsible for payment of
a healthcare cost to the provider
Out-of-Pocket Expenditure: Costs that are not covered by your health insurance
- Co-pay
- Direct payment to providers for non-insured services
- Deductibles
- Co-insurance
Point-of-Service: Receiving health services from a provider of the choice within a
plan/managed care
Terms to remember
Four parts to Medicare
1. Part A/Hospital insurance: Hospital insurance and skilled nursing facility care,
hospice and home health care
Terms to remember
Hospitals with the most financial resources to offer charity care are not in
geographic areas where people most need it. In high-income areas,
hospitals are better funded and more able to provide charity care. But for
hospitals in low income areas, i.e. inner city, the demand is the highest.
Floor-and-Trade System
To address this mismatch, the researchers propose a floor-andtrade system, where all hospitals are required to provide some charity
care to low-income patients. Currently, the average nonprofit hospital
devotes 2.3 percent of its operating expenses to charity care. In the
proposed system, hospitals would set a floor, or a minimum, for the
amount of charity care theyll provide each year.
To incentivize hospitals to provide charity care and rectify the current
geographical mismatch, hospitals would be able to purchase and
trade charity-care credits. Under this system, a hospital in a lowincome area can receive funding allocated for charity care from one in
a high-income area thats not providing as much charity care.
Mortality Rate
Morbidity Rate
Disease-Specific Death Rate
Life Expectancy
Time lost to Premature Death
Infant Mortality Rate (IMR)
Quality Adjusted Life Years
Healthy Life Expectancy
Years of Potential Life Lost
YOU NEED TO KNOW THE DEFINITION OF THESE TERMS. REFER TO YOUR
TEXT, GOOGLE SEARCH, LECTURE NOTES, 10/30/2015
Narrow Network
Narrow Network: A cost containment strategy. Insurance company offer
lower premiums by limiting the group of providers available to the plan
enrollees.
Four factors will be used to assess if a network providers is sufficient
1.
The ratio of people enrolled in a health plan to the number of physicians in each specialty
2.
3.
4.
The ability of health plans to meet the needs of low-income people and children and
adults with serious chronic or complex health conditions or physical or mental disabilities
Final Words
Curiosity, Imagination and Persistence
Fee-for-Service
Does not calculate additional time for inefficacies, waste and duplication
3.
Does not reward provider for better quality of care, improved efficiency
4.
Fixed Price
Productized: A service that can be marketed or sold as a
commodity.
Implication: A fixed price will buy a known quantity of
the service
The known quantity is referred to as Customer-Centric
Outcome
Fixed Price system of reimbursement was developed for
and adopted by federal government in 1983 to curb the
cost of Medicare
Fixed Price
Under the Fixed Price system, hospital is paid a pre-determined
rate for each Medicare enrollee, adjusting for medical condition.
Each patient is classified into Diagnosis-Related Group (DRG)
The $$ amount for each patient/case is determined by a formula based on a
fiscal construct that is called Diagnosis-Related Group (DRG)
Fixed Price
Excluding certain highly cost patients, hospitals receive a flat rate
for the DRG, regardless of the volume of actual services rendered
Advantage
System is rewarded for efficiency
System is rewarded for quality of care
Disadvantage
Providers can abuse the system by exaggerating the reported severity of the disease
(up coding) because classification of the disease determines reimbursement (DRG).
Providers can attract or seek healthier patients
Preventive medicine usually receive a low priority score
Capitation
A fixed prepayment per person to the provider for a pre-agreed
set of services.
Payment is fixed regardless of type of service or frequency of
utilization of services
Advantage
- Promote the least expensive service
- Promote preventive medicine
Disadvantage
- Focus on enrolling healthier patient
Capitation
Global Budgeting: One form of capitation, often used by
the federal government.
Covers the cost of healthcare services sectors with direct
delivery of health services.
US congress approves the operating budget for VA
system
State government approves budget for mental health
facilities, and local health departments
Value-based Compensation
This method of payment is gaining momentum in healthcare industry
The organization/institution is rewarded for the value of product that is
rendered.
- Value of service/product should be easily measured
- Value of service/product should be agreed by all parties
involved
Effective value-based compensation is an external motivator for providers to
provide effective and efficient, safe care, timely, patient-centered, and
equitable healthcare services
Value-based Compensation
A framework for value-based compensation
1. Standardized performance measurement
- Performance measurement should be conducted on multiple levels,
including health plans, hospitals, physician groups and individual
healthcare providers.
- Measurement should be able to answer question