Term
| Most common cause of hospitalization in childhood? |
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Definition
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Term
| General organization task facing all health care systems? |
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Definition
| One of "assuring that the right patient receives the right service at the right time and in the right place"...(and by the right caregiver) |
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Term
| Primary v. Secondary v. Tertiary care? |
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Definition
| Primary = preventative measures and common health problems (sore throats, diabetes, arthritis, depression, HTN). Secondary = more specialized expertise (acute renal failure). Tertiary care (rare and complex disorders) |
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Term
| 2 contrasting approaches can be used to organize a health care system around primary/secondary/tertiary levels of care? |
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Definition
| 1) The Dawson model of regionalized health care (e.g. British) 2) Free-flowing Model (e.g. USA) |
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Term
| Dawson Model - general overview? |
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Definition
| Different types of personnel and facilities are assigned to primary, secondary, and tertiary tiers, and flow of patients occurs in an orderly, regulated fashion. |
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Term
| Alternative Model - general overview? |
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Definition
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Term
| British System - Primary Tier? |
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Definition
| General Practitioners (GPs, like PCPs), are 2/3 of docs. Practice in small-to-medium sized groups |
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Term
| British System - Secondary Tier? |
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Definition
| Less docs, each covers more area, mostly in hospital clinics. Consultants from GPs who specialize in internal med, pediatrics, neuro, psychiatry, OBGYN, Gen Surg |
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Term
| British System - Tertiary Tier? |
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Definition
| Fewest docs, each covers a crapload of area in few tertiary care centers - cardiac surgeons, immunologists, etc. |
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Term
| British System - Patient flow? |
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Definition
| All pts are first seen by GP (except emergencies), who steer patients towards more specialized levels of care through referrals (can't refer themselves) |
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Term
| British system - multidisciplinary approach? |
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Definition
| GPs work with nurses and other HCPs, teams have a defined population, universal health care coverage, immunization tracking system |
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Term
| US Free-flowing Model - Referrals? |
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Definition
| Insured patients can take their symptoms directly to the specialist of their choice without the referral of the PCP - this happens a lot |
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Term
| US Free-flowing Model - PCPs? |
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Definition
| Have a broadened role - "GPs" do ambulatory care, but also provide substantial amounts of inpatient care. Only 1/3 of the docs in US. Other tier docs, NPs, and PAs fill this gap. |
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Term
| US Free-flowing Model - Hospitals? |
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Definition
| Compete with each other and provide a wide range of secondary and tertiary services in the middle |
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Term
| Criticism of US Free-flowing model (dispersed system)? |
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Definition
| Lack of organization and team approach, too top-heavy on secondary-tertiary care...all contributes to high cost of health care, and quality of care suffers. Also, too much tertiary training gives those HCPs an unrepresentative view of the health care needs of the community. |
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Term
| Defense of US free-flowing model (dispersed system)? |
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Definition
| Diverse care options promote flexibility/convenience, emphasis on specialization and high tech shit - patients like that |
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Term
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Definition
| Most health care resources are allocated to secondary/tertiary care, but most people have health care needs at the primary care level. |
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Term
| 4 key tasks of primary care? |
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Definition
| 1) First contact care 2) Longitudinality (sustaining a lasting patient-caregiver relationship) 3) Comprehensiveness (manage a wide range of health care needs, diff from specificity of specialty care) 4) Coordination (referral, follow up) |
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Term
| Core elements of good primary care advanced what "triple aims" of health care improvement? |
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Definition
| Better patient experience, better patient outcomes, and lower costs |
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Term
| Pros to primary care approach? |
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Definition
| Better perceived access to care, better health outcomes, more preventative measures, adherence to treatment, satisfaction with care, just overall better stuff |
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Term
| Describe the context around playing "gatekeeper" |
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Definition
| Pejorative connotations with managed care, when PCPs are provided incentives to "shut the gate" in order to limit specialist referrals and diagnostic services |
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Term
| Explanation of the new patient-centered "medical home?" |
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Definition
| 4 cornerstones: Primary care (And all those good qualities it should have), patient-centered care (e.g. same day scheduling option), new-model practice (e.g. reengineer workflows/tasks), and payment reform (blend fee-for-service with partial capitation/quality incentives) |
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Term
| Example of medical home - patient centered care. |
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Definition
| Same day scheduling options to see patients quicker, team-care models that reengineer workflows/tasks |
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Term
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Definition
| Several measures to strengthen, including 1) Increases in MCARE fees for primary care and 2) Support of patient-centered medical home reforms |
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Term
| What forces drive the organization of US health care? (3) |
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Definition
| Biomedical model, financial incentives, professionalism |
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Term
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Definition
| 1) Insurance benefits cover hospital costs more than physician/outpatient visits 2) Higher cost procedures are under specialty care realm, high fees means higher specialty salaries...disparity between PCP/specialty incomes is continuing to grow 3) Federal health care involvement has led to expansion of hospital/specialty care instead of ambulatory services (MCARE & MCAID pay higher reimbursement for specialists) |
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Term
| Explain the "professionalism" force. |
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Definition
| Unlike other countries, the US govt provides much of the financing for health care but without much administrative control...docs emerged as the health care authority as a result. Professionalism is a social contract: in return for the privilege of autonomy, docs bear the responsibility for acting as the patient's agent, and the profession must regulate ITSELF to preserve the public trust...more than just a business. |
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Term
| Hospitals in the 1950s relationship with docs? |
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Definition
| Docs were usually most dominant power in the hospital cuz they would work for several hospitals and would admit the patients (hospitals without pts had no income, and there was always the implicit threat of taking patients to another hospital). |
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Term
| 3 medical care structures that blossomed in early evolution of modern medicine? |
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Definition
| Multispecialty group practices, community health centers, and prepaid group practices |
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Term
| Explain early multispeciality groups |
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Definition
| Clinics were owned and administered by docs and featured docs working in various specialties all working under 1 roof collaborating with each other. |
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Term
| Goals of developing community health center model? |
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Definition
| Combined comprehensive medical care and public health to improve the health status of low-income communities, built multidisciplinary teams, and headed by community members |
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Term
| The Kaiser-Permanente Medical Care Program was an example of what? |
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Definition
| First-generation HML and vertical integration |
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Term
| 3 interlocking administrative units of the Kaiser-Permanente Medical Care Program (KPMCP)? |
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Definition
| Kaiser Foundation Health Plan (Health insurance role), Kaiser Foundation Hospitals Corporation, and Permanente medical groups (administer group practices under capitated contract with Kaiser plan) |
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Term
| What's vertical integration? |
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Definition
| Consolidating under one organizational roof and common ownership all levels of care (from primary to tertiary), and the facilities and staff necessary to provide this full spectrum |
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Term
| How does the Kaiser form of HMO differ from traditional fee-for-service models? |
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Definition
| Pays physicians with salary and hospitals with global budget |
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Term
| Vertically integrated systems v. UK Health System? |
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Definition
| Both have an ability to coherently plan and regionalize services. BUT KP is not responsible for the entire population of a region, but rather for a population of plan enrollees. |
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Term
| How can physicians interact with network models (like HMOs)? |
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Definition
| Docs can establish contractual relationships with numerous HMOs and IPAs. A doc may participate in more than one IPA, and each IPA may in turn have contracts with many HMO and managed care plans. This open-ended network approach can be appealing, but can cause frustration cuz as a doc you gotta figure out all the rules of all the different HMOs. |
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Term
| What's an integrated medical group? |
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Definition
| Tighter organizational structure than IPAs, consist of groups in which docs no longer own shit, but become employees of an organization that owns and manages their practice. They contract with multiple managed care plans and typically care for patients in fee-for-service private insurance plans and MCARE. |
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Term
| Community Rating? Net Effect? |
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Definition
| SOCIAL INSURANCE scheme - EVERYBODY in a geographic area pays for the same HI premium. This covers the costs for ALL THE PEOPLE in that area. Net effect: Healthier people subsidize less healthy people. |
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Term
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Definition
| Isolates the costs of health are within a DEFINED GROUP (not necessarily geography). Everybody in that group pays the same premium, BUT limit the exposure to people in that group. This helps organized entities control costs by providing this insurance only to people who they want to subsidize (private insurance) |
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Term
| What would happen to patient/system costs if NPs were given more patients? |
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Definition
| For an individual, the individual costs MIGHT go down, but the total system cost would go up. Docs would keep seeing the same patients, NPs would increase their volume, total volume goes up, total cost to the system also goes up. If NP becomes a substitute/competitive, PCP might have to lower cost to compete. |
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Term
| Types of hospitals, in decreasing number? |
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Definition
| US Community Hospitals, Nonfederal Psychiatric Hospitals, Federal Govt Hospitals, and Nonfederal Long-Term Care Hospitals |
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Term
| What is a community hospital, and 3 types? |
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Definition
| Hospital that treats multiple conditions. Nongovernment Not-For-Profit, Investor-Owned (For Profit), and State/Local Govt |
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Term
| Explain non-government not-for-profit. What does not-for-profit mean? |
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Definition
| MGH, Quincy, Milton - Entity with its own governing board, self-perpetuating, surplus is retained to use for benefit of patients, rebuild/expand. Not-for-profit does NOT mean not-for-surplus...it means that the surplus stays there. |
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Term
| Explain invest-owned (for profit) |
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Definition
| If they get a surplus, a portion is returned to investors in form of a profit. Doesn't guarantee that they'll make money... if you lost money investors have to contribute money. - tend to not be teaching hospitals, higher insurance rates. The different departments don't look too different, though. |
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Term
| What kind of entities would own state/local govt hospitals? |
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Definition
| State universities with medical schools, community owned hospitals |
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Term
| Nonfederal Long Term Care Hospitals? |
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Definition
| Average stay of >25 days. Aren't many of them. |
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Term
| How was the number/style of community hospitals changed since 1990? |
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Definition
| Not an enormous amount of change - but they mask dramatic hospital changes within the industry. Change from single free-standing institution to a mid-sized conglomeration of centers that are owned (ambulatory care clinic, acute care unit, etc), to a large hospital SYSTEM |
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Term
| Example of number/style of community hospitals changing since 1990? |
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Definition
| In Mass 29 acute care hospitals have closed completely, merged, or acquired |
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Term
| Variation in hospital beds across states in US? |
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Definition
| Lots of variation within states. More in east, fewer in west. This reflects historic trends and differences in clinical practices today. |
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Term
| Change in number of hospitals in health systems since 2000? |
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Definition
| Steady, steep curve toward consolidation, more hospital system formation |
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Term
| Change in inpatient admissions in community hospitals since 1990? What about a standardized population? |
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Definition
| Increase, then plateau in early 2000s. Due to recession? IF you standardize per 100 people, not much of a change at all. |
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Term
| Change in average length of stay in community hospitals since 1990? |
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Definition
| Average length of stay is going down. Either there's higher efficiency in care (also, technology can enable shorter stays) or difference in hospital payment (if per illness, giiiitttt out!), patients are under pressure (prefer to not stay as long, work?). Consequence? Create a whole bunch more hospital beds, new patients. |
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Term
| Change in growth rates of inpt admissions, ED visits, OP visits, and OP surgeries? |
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Definition
| All are experiencing positive growth rates that are declining in size. Exception is inpt admissions, around 2009 the rate starts to shrink (negative) |
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Term
| Reasons for the change in these growth rates? |
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Definition
| 18-64 year olds are going less, so the people driving force are MCARE (65+) and MCAID (kids) patients. |
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Term
| Since 1990s, changes in type of surgery? |
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Definition
| Less invasive surgeries are becoming predominant, and if they're less invasive AND smaller recovery times pts are more willing to get more procedures done. Also, improvements in the outcomes of regular surgeries cuz of improvements (e.g. knee replacement) boosts pt confidence, more of those surgeries. Preventive procedures are more likely since demand goes up (colonoscopy, endoscopy, etc). |
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Term
| What is the goal of hospital finance? |
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Definition
| MAXIMIZE REVENUE. Why? Make as much money as possible now because our cost base is hard to change, pts will keep coming in, and we live in an UNCERTAIN reimbursement environment. |
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Term
| Change in annual growth rate of median hospital revenue since 2000? |
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Definition
| Early 2000s - revenue growth rate was high, but expenses were lower. Since 2002, it's been going downhill, and sometimes expenses are even higher than revenue. It's still pretty bad, ACA is suppose to help with this. |
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Term
| How are hospitals paid? (5) |
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Definition
| Fee for service (MOST DOMINANT), fee for service with bonuses/penalties, cost-based reimbursement, capitation, and budget |
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Term
| Explain 4 types of fee for service. |
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Definition
| Charges by service, with or without discount...charges by day/intensity....price per admission (DRG)...and price per episode. |
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Term
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Definition
| Largely used by MCARE: Hospital has 500 "diagnosis" products, for which they establish a price for. |
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Term
| Explain price per episode. Potential benefits? |
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Definition
| Doesn't JUST include admission - also includes outpatient, different providers, etc for that WHOLE EPISODE). Forces efficient care, coordination among different providers, cuz the person giving you the money can force that to happen. |
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Term
| Cost-based reimbursement? |
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Definition
| Going out of style...payers would pay whatever it takes for the hospital to stay afloat. |
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Term
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Definition
| Institutions like public hospitals and veteran hospitals get paid by budgets. GLOBAL BUDGETING SCHEMES budget for care of population. |
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Term
| Biggest single payer for HOSPITAL care? |
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Definition
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Term
| How has MCARE rule changed since 10/1? |
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Definition
| Some reimbursement is based on meeting performance measured. To start off, MCARE will withhold 1% (this number will increase) and redistribute based on performance scores (process measures (percentage of patients getting some sort of treatment, for quality purposes) & pt satisfaction). If you do well you may get > 1%, if not you don't get shit back. There is also a penalty (now 1%) for exceeding target 30 day readmission rate for certain diagnoses. |
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Term
| Distribution of outpatient v. inpatient revenue since 1990? |
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Definition
| Big shift from inpatient to outpatient revenue. |
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Term
| Consequences of hospital consolidation? |
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Definition
| Costs tend to increase, hospitals that close are smaller, weaker, cheaper, non-teaching. There may be marginal improvement in quality. Access can go down when rural and inner city hospitals close. |
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Term
| Community v. Teaching hospitals? |
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Definition
| Teaching hospitals have more services than community hospitals. |
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Term
| General v. Specialty hospitals? |
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Definition
| General = lots of diagnoses, and specialties = just a few specialties (aka NEBH - orthopedics) |
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