Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
71 Cards in this Set
- Front
- Back
|
ACA |
Broadly expands coverage, controls health care costs, and improves health care delivery system Requires most US citizens and legal residents to have health insurance Creates state based American Health benefit exchanges that individuals can purchase coverage Cost sharing credits are available to individuals/ families w/ income btw 133-400% of the federal poverty level Separate exchanges thru which small businesses can purchase coverage Requires employers to pay penalties for employees who receive tax credits for health insurance thru an exchange Expand medicaid to 133% of federal poverty level to 133% of the federal poverty level |
|
|
Requirement to have coverage US citizens and legal residents HAVE to have qualifying health coverage Without coverage, you have to pay a tax penalty (the fee increases every year) Exemptions granted for financial hardship, religious objections, AI, without coverage for less than 3 months, undocumnented immigrants, incarcerated individuals, lowest cost plan option exceeds 8% of income |
Expansion of public programs: -Expand medicaid to all non-medicare eligible individuals under age 65 with incomes up to 133% FPL based on modified adjusted gross income All newly eligible adults will be guaranteed a benchmark benefit package that meets the essential health benefits available thru the exchanges (This decision is optional for states) |
|
|
CHIP: Require states to maintain current income eligibility levels for children in medicaid and CHIP until 2019 and extend funding for CHIP thru 2015 |
Federal premium or cost sharing subsidies are not used to purchase coverage for abortions if coverage extends beyond saving the life of the woman or cases of rape/ incest -Provide small employers with no more than 25 employees and average annual wages of less than 50,000 $ that purchase health insurance for employees a TAX CREDIT Create a temporary reinsurance program for employers providing health insurance coverage to retirees over age 55 who are not eligible for medicare |
|
|
Impose new annual fees on the pharmaceutical manufacturing sector & health insurance sector Impose a tax of 10% on the amount paid for indoor tanning services |
State based american health benefit exchanges and small business health options program exchanges Administered by gov't agency or non profit org through which individuals and small businesses with up to 100 employees can purchase qualified coverage Restrict access to coverage thru the exchanges to US citizens and legal immigrants who are not incarcerated Consumer operated and oriented plan (CO-OP) to foster the creation of non-profit, member run health insurance programs to offer qualified health plans Establishment of a process for reviewing increases in health plan premiums and require plans to justify increases Children covered until age 26 Prohibit prohibitions on pre-exisiting condition exclusions Permits states to create a basic health plan for uninsured individuals with incomes btw 133-200% FPL |
|
|
Allow providers organized as accountable care organizations that voluntarily meet quality thresholds to share in the cost savings they achieve for the medicare program |
To qualify as an ACO, orgs must agree to be accountable for the overall care of their medicare beneficiaries, have adequate participation of PCP, define processes to promote EB medicine, report on quality, costs, and coordinate care |
|
|
Grants for small employers that establish wellness programs Require chain restaurants and food sold from vending machines to disclose the nutritional content of each item |
Increase workforce supply and support training of health professionals thru scholarships and loans Provide state grants to providers in medically underserved areas Promote training of a diverse workforce and promote cultural competence training of HC professional Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, creating a career ladder to nursing Provide grants for up to 3 yrs to employ and provide training to FNPs who provide primary care in federally qualified health centers and nurse managed health clinics |
|
|
ACA impact on nursing profession |
Changes in federal loan programs allow more nursing students to go to school on a full time basis Nurse managed health clinics receive increased funding which increases access to primary care services for thousands of low income pt Nursing students receive higher loan amounts from the federal government 50 mil in funding for nurse managed health clinics Medicare payments for services provided by certified nurse midwives & same pay as MDs for medicare covered services Increased medicare payments for primary care services provided by nurse practiconsers, clinical nurse specialists, Removal of cap that limited spending on doctoral nursing programs to help build ranks go nursing professors Monetary funds to test the effectiveness of pilot clinical initiatives that rely on highly skilled nurses Some insurers are beginning to change policies and reimbursement for NPs now recognized as PCPs and reimbursed as such ACA ID'd and defined nurse managed clinics as critical safety net providers for millions of people (at forefront of providing care to vulnerable populations) Reauthorized new discretionary funding for nursing workforce development programs under Title VIII of public health service act (the primary source of federal funding for nurse education programs) |
|
|
Importance of advocacy for profession |
For consumers to have access and the choice of high quality HCPs and to have highly skilled RN when and where we need one -- it is important for the nursing provisions within ACA to be funded at the levels identified To ensure this happens, nurses need to take a stronger advocacy role |
|
|
Campaign for action A nat'l intitiative to guide implementation of the recommendations in IOM future of nursing: leading change, advancing health Envisions a HC system where all Americans have access to high quality care, w/ nurses contributing to the full extent of their capabilities Provides a blueprint for transforming the profession to improve the quality of health care and the way it is delivered Report calls on nation's leaders and stakeholders to act on recommendations in these 4 key areas |
Increase the proportion of nurses wit baccalaureate degrees to 80% by 2020 ~this was 51% in 2013 Double the number of nurses with a doctorate by 2020 ~DNP enrollment in nursing doctorate programs was 18,352 in 2014 (benchmark is 20) Advance practice registered nurses should be able to practice to the full extent of their education & training (this is versus reduced practice) Expand opportunities for nurses to lead and disseminate collaborate improvement efforts ~ Number of required clinical courses/ activities at top nursing schools that include both RN students and other graduate health professions students Health care decision makers should ensure leadership positions are available to and filled by nurses ~only 5% of hospital boards with RN members Build infrastructure for collection and analysis of IP HC workforce data ~Number of recommended nursing workforce data items collected by the states |
|
|
ANA impact in policy |
ANA policy experts present issue briefs that explore some of most pressing and exciting policy areas for the profession ANA policy influences comments that are submitted to the federal gov't reflecting ANA's opinion on how proposed federal rules, regs, policies, or guidance affect nurses and patients |
|
|
ACA |
Does not guarantee coverage for all Ends ability of insurance companies to deny coverage to people w/ preexisting conditions, to drop once they acquire a costly illness, apply annual and lifetime caps on coverage To improve health of public and reduce $, system must be remade into one that focuses on health promo and wellness, disease prevention, chronic care management |
|
|
ACA provisions for nurses |
-Opportunities to test models of care that already hold promise for decreasing $ and improving HC: transitional care to nurse managed centers -Testing patient centered "medical" or health homes that coordinate all of the care for patients it serves (nurses and social workers are already care coordinating) -Community based health centers expanded in a real where there are health care provider shortages (expansion of national health service corps) to staff these centers with RNs, APRNs -Demand for NPs with emphasis on primary care, additional support for primary care workforce development (loans, scholarships, educational program development, expansion of existing programs) -Payment reforms thru bundled payments and care coordination (ACOs) Bundled payments provide financial incentives to providers and health systems to keep patients healthy rather than the fee for service basis -Independence at home models of care to keep OAs healthy and functioning in their own homes -Boost in investments for public health in prevention research, health screenings, health education campaigns - A center for innovation will support research that focuses on how to improve the safety and quality of care --> lets nurse leaders and researchers w/ opportunities to demo new methods for improving care in cost effective ways -Funding for nurse managed centers, improved payment for APNs including nurse midwives, and workforce development, including the nursing workforce Nurse-family partnership Nurses can and must ID opportunities to implement and improve the law and shape local responses to it |
|
|
Implementation of law is dependent upon the regulations developed by the Department of HHS and state responses including expansion of medicare |
States responsible for developing health insurance exchanges to provide options for coverage for those who are not covered by employers With increasing financial restraints, nurses must advocate to shape health care policy |
|
|
Policy |
The deliberate course of action chosen by and individual or group to dealt with a problem Public policies are choices made by public or government officials to death with public problems Public policies are authoritative decisions made in the legislative, executive, or judicial branches of government intended to influence the actions, behaviors, or decisions of others Federal policy- medicare modernization act and workplace safety regulations by OSHA States- requirements for licensure in health profession, criteria for eligibility for medicaid, mandate immunization requirements for public university students |
|
|
US has this type of economy |
capitalist economy where private markets are permitted to control the production and consumption of goods and (health services) |
|
|
Allocative policies |
Used to provide benefits to a distinct group of individuals or organizations at the expense of others, to achieve a public objective aka redistribution of wealth ex: Implementation of Medicare |
|
|
Regulatory policies |
Used to influence the actions, behavior, and decisions of individuals or groups to ensure that a public objective is met ex: HIPPA (regulates how individually identifiable health info is managed by users and other aspects of health records |
|
|
Forces that shape health policy |
Values - a policy reflects which value(s) is given priority in a specific decision Politics- the process of influencing the allocation of scarce resources, the efforts and strategies used to shape a policy choice True political skill is critical in HC leadership, advocating for others, and shaping policy |
|
|
Policy analysis and policy analysts |
Uses different methods to assess a problem and determine alternative ways to resolve it Encourages deliberate critical thinking about the cases of problems, IDs the various ways a government or other group could act, evaluates the alternatives, determines the policy choice that is most desirable Policy analysts have professional training and experience to analyze problems and weigh potential solutions |
|
|
Interest groups advocate for policies that are advantageous to their membership Lobbyist is someone that a group hires to advocate on their behalf |
Media is an influence on HP Scientific finding and research can be impactful in the first step of the policy process, defining the size and scope of the problem. obtaining support for a particular policy option and in lobbying for support of it Presidential power to draft legislation and provide guidance |
|
|
Framework for Action "spheres of influence" (4) |
used to conceptualize the places where nurses use politics to shape policy and to work for change in the HC system The workplace / workforce The government Organizations / associations & interest groups The community Addresses the policy work that is done in a variety of places to influence the size, educational prep, and competence of the nursing workforce |
|
|
Actions in the spheres of influence can shape policy that can then influence the health system and social determinants of health The spheres of influence are not discrete silos each is part of a broader, more complex system and they influence each other There are extensive opportunities for nurses to influence health and social policy in communities Nurse can be influential in communities by identifying problems, strategizing with others, mobilizing support, and advocating for change Workforce and workplace: Nurses work in a variety of settings, in all of these settings resources are finite and the nurse must work in each to influence the allocation of organizational resources -Policies guide activities in the health care workplaces where nurses are employed, internal organizational policies (staffing, clinical procedures, patient care guidelines) -external policies are operative in HC workplace such as state was regulating nursing licensure and immunization requirements of clinical practitioners, federal laws such as OSHA regs THE GOVERNMENT: -Government action and policy affects lives from birth until death. Most US HC is private sector, but much is paid for and regulated by the government --> how the gov't crafts HP is important Government influences nursing and nursing practice, states determine scope of practice, federal and state governments determine who is eligible for care under specific programs and who can be reimbursed for providing care |
|
|
ways nurses can influence policymaking in the governmental sphere |
Obtaining appointments or assignment to influential government positions Serving in federal, state, and local agencies Serving as elected officials working as paid lobbyists Communicating to policymakers their support or opposition to a policy Providing testimony @ gov't hearings or open meetings Participating in grassroots efforts, such as rallies to draw attention to problems |
|
|
Associations and interest groups |
Professional nursing organizations have played a significant role in influencing the practice of nursing Have legislative or policy committees that advocate for policies that support their members' practice Provide training and workshops for nurses interested in learning the ropes of political involement as well as online resources to assist members Working w/ group increases the chances for advocacy to be effective, provides an environment where resources can be shared, and enhances networking and learning serve on association policy or legislative work groups, providing testimony, and preparing position statements |
|
|
Health in framework for action |
Optimal health is viewed as the goal of nursing's policy effort It is the central focus of political and policy activity Ultimate goal for advancing nursing's interests must be to promote the public's health |
|
|
Creating policy |
First step is to get the problem on the agenda of those who have the power to implement a solution (ID problem is first) Public awareness and concern are often necessary for political action to get the policy process moving Moving from interest in a policy solution to action can be stimulated by interest groups where people can collectively share their concerns and work together to find solutions |
|
|
health policy within 3 domains |
Professional (need for standards and guidelines for practice) Organizational (consistent with needs of purchasers, payers, and health systems and providers) Community stakeholder and public sources |
|
|
Explore all potential options for the policy A policy intervention that will solve the problem is dependent on a thorough understanding of the problem itself as well as a viable policy options and an examination of the underlying evidence that the option will work in an effective and efficient manner |
Equity and fairness are important aspects of policy development Political viability is essential for a policy solution to a societal problem (policy that is considered desirable to politicians and stakeholders will have the best chance of passage by a policymaking body) So will a policy that furthers the interests of multiple constituents |
|
|
Incrementalism |
Policy makers face a complex, theoretical, resource intensive decision, lack the time, or understanding to analyze all various policy options, they may limit themselves to a set of strategies rather than tackling whole problem Incremental approach is restricted to a familiar policy options related to status quo, and the analysis may focus more on the problems than the solutions Process is associated with a process that is neither proactive, goal oriented, nor ambitious and tends to be conservative, with limited usefulness |
|
|
Policy streams model |
model reflects the issue of policy looking for a problem The problem stream, the policy stream, the political stream Problem stream (complexities in getting policymakers to focus on one problem out of many facing constituents) Until prob is defined, an appropriate policy solution cannot be effective Policy stream: describes policy goals and ideas of those in policy subsystems (researchers, agency officials, interest groups). ideas in the policy stream float around policy circles in search of problems The political stream: describes factors in the political environment that influence the policy agenda (economic recession, special interest media, or pivotal political power shifts) Streams are moving constantly and waiting for a window of opportunity to open through couplings for any of two streams creating new opportunities for policy change window is time limited |
|
|
The stage sequential model p. 52 |
Dynamic process that includes four stages: agenda setting policy formulation program implementation policy evaluation Each stage contains a set of actions and activities that produce outcomes or products that influence the next stage |
|
|
Rational decision making |
An approach to public policymaking that features a series of actions that are highly dependent on relationships among individuals, organizations, and policymakers Assumes that policymaking is a rational decision making process that combines influence from interest groups, data, political negotiations, ideology The model is circular rather than linear |
|
|
The advocacy coalition framework |
Role of advocate is to empower others to make informed decisions Authors define policy advocacy as the knowledge based action that is intended to improve health thru the influence of system level decisions The advocacy coalition framework is concerned about how interest rogues are organized within policy domains Tool used to develop an understanding of the various policy disputes among stakeholders Public opinion matters and the use of public opinion through the mobilization of coalitions to support or change legislation or regulations or to shift resources in favor of different programs is the strategy of the advocacy coalition framework |
|
|
STEPS IN THE POLICY PROCESS |
Define the problem and get it on the agenda -Requires getting the attention of policymakers and getting them to understand what the concerns of the interest groups are, why it requires a policy solution, what trends are supporting the growth and criticality of the problem -research the problem Learning as much about the problem to understand it and formulate possible, using any means necessary even translational research. Make the case that the problem is significant from an EBP perspective and political/ public perspective Develop public policy option -Step relies on evidence and opinion. Requires considerable analysis of the various options Involve interest groups and stakeholders -Policy development that is dominated by public interest generally follows a course of action that is based on data, information, and community values and addresses a solution to an actual or potential problem. Tends to be practical decision making. Policy generated by self interest often follows a course of action with a predominantly special interest forums connected to the concerns of individual preferences or group interests over public interest. Both important in generating dialogue and debate during policy process o all sides considered -Implement the selected policy differs at federal legislation (series of steps occur including development of regs) or organizational policy (affected parties need to be informed and educated about the decision and issues around implementation) Evaluate the impact of the policy -Determine if the policy worked and resolved the problem it was designed to address, determine if unintended consequences occurred Can modify, repeal, or leave the policy alone Communicate policy options -Thru a policy issue or decision brief or issue analysis paper |
|
|
Issue analysis Policy brief: summary of issue, background info, analysis of alternatives, your recommendation fora action, contact info |
Identify the problem alternatives for resolution and consequences of each Specific criteria for evaluating alternatives recommend the optimal solution *help to clarify arguments in support of a cause, to recognize the arguments of the opposition, and to develop strategies to advance the issue through the policy cycle -Policy brief is an easy doc for the policymaker to read quickly and get grasp of the issue or it can be helpful to policy analysts to provide more depth understanding of an issue |
|
|
People that have private or public insurance who have access of HC service, primary and preventative care w/ appropriate specialty tx can produce the best medical care in the world US HC system as a paradox of excess and depression Some peeps recieve too little care because they are uninsured, inadequately insured, or have medicare coverage that many MDs will not accept Some cannot access the care they need, others receive too much care that is costly and potentially harmful |
Ecomonic changes of a service economy with lower paying jobs that are often part time and have poor or no benefits 3/4 of uninsured adults are employed, this is seen in the middle class of families of people who are self employed or work for small businesses Many people with health insurance have inadequate coverage where they can't get the care they need because they cannot afford to pay the bills |
|
|
Overuse of care pt receive care that is not appropriate. elderly patients in some areas receive 60% more services than patients in other areas this money is wasted |
The US has the least universal, most costly, health care system in the industrialized world High costs of care and lack of universal access can be viewed as indicators of serious failings in the HCS |
|
|
Access to HC is the ability to obtain health services when needed 2 components: Ability to pay and availability of HC personnel and facilities that are close to where people live, accessible by transportation, culturally acceptable, capable of providing culturally acceptable care (language) |
Financial barriers to HC: -Health insurance coverage (private or public) is key factor in making care accessible -Pattern of uninusrance is r/t the employment based nature of HC financing -People obtain health insurance when employers offer group coverage or help pay, if people's employers do not provide HCI, person is left to fend for themselves and a often are uninsured -Unemployed person is unable to have HCI as well -people without employment based insurance are not eligible for public programs such as M&M and are unable to purchase private coverage because cannot afford premiums -Since 1976, the # of uninsured persons has been growing (trend of decreasing private insurance coverage in US) -Increased number of peeps enrolled in Medicaid -A dwindling proportion of children and working age adults are covered by private insurance, exposing the limitations of the employment linked system of private insurance in US |
|
|
Why private health insurance coverage has decreased over past decades, creating uninsurance crisis |
- Skyrocketing cost of health insurance as made coverage unaffordable for many businesses and individuals (increased employer sponsored health insurance premiums) -Some employers responded to costs by dropping insurance policies for their workers or shifting cost of services to employees which have to drop health coverage because of unaffordablility -Shift ine economy from full time workers with employer sponsored health insurance (declined) to more low wage, increasingly part time, non unionized service and clerical workers whose employers are less likely to provide insurance (a lot of part time workers without health benefits) 2 factors- increasing health care costs and a changing labor force, eroded private insurance coverage * Major expansion of public insurance coverage through the medicaid and SCHIP programs -Link of private insurance w/ employment produces interruptions in coverage because of unstable nature of employment (laid off, death, divorce of spouse, or loose job = loss of insurance) -Small increases in family income can mean that families no longer qualify for medicaid / transient nature of employment linked insurance |
|
|
Uninsured are divided into the employed uninsured and the employed uninsured employed uninsured - low paying, small firms, that may be part time |
People lacking health insurance receive less care and have worse health outcomes no usual source of care, postpone seeking care due to costs, or went without needed care due to costs , more avoidable hospitalizations, tend to be dg at later stages of life threatening illnesses and are more seriously ill when hospitalized higher rates of cancer w/ lower survival rates, uncontrolled DM, HTN, CHO, higher overall mortality rate |
|
|
Medicaid overage does not guarantee access to care medicaid pays MDs a lot less than medicare or private insurance so many MDs do not accept these patients uninsured --> medicaid----> PRIVATE |
Underinsurance -Health insurance does not guarantee financial access to care -Health insurance coverage has limitations that restrict access to needed services -Have private insurance, but have low incomes or substantial medical expenditures -Low to moderate incomes, insurance deductable and co-payments may represent a substantial financial problem -Many elderly families spend life savings on long term care, qualifying for medicaid only after becoming impoverished -Cost Sharing plans (pay out of pocket for some things) reduces rat of se |
|
|
Non financial barriers to health care |
Inability to access care when needed Language Literacy cultural difference btw pt and HCP Factors of gender and race Growing shortage of PCPs, increased demand for primary care after health insurance expansion Fever PCPs are accepting medicaid pt and inappropriate ED visits growing due to inability to access timely primary care Cuturela differences may exist in pt beliefs about the value of medical care and attitudes toward seeking tx for symptoms ineffective communication btw patients and caregivers of differing races, cultures, and languages |
|
|
Health of individual or pop is influenced less by medical care than by broad socioE factors such as income or education |
X |
|
|
Primary care |
Involves common health problems (sore throats, DM, arthritis, HTN, depression) and preventative measures (vaccinations, mammograms) that account of 80-90% of visits to a physician or other caregiver |
|
|
Secondary care |
problems that require more specialized clinical expertise such as hospital care for a patient with ARF |
|
|
Tertiary care |
Involves the management of rare and complex disorders such as pituitary tumors and congenital malformations |
|
|
Dawson model Brits NHS |
Scaffold for a highly structured system Based on concept of regionalization : the organization and coordination of all health resources and services w/n a defined area Different types od personnel and facilities are assigned to distance tiers in primary, secondary, territory levels, and flow of pt across levels occurs in ordered regulated fashion |
|
|
Alternative model allows for more fluid roles of caregivers, and more free flowing mvmc of pt across all levels of care US HCS |
Places a higher value on services at the tertiary care apex than at the primary care base Insured pt in US have been able to refer themselves and enter the system directly at any level Pt are accustomed to taking their problems directly to the specialist of their choice Genrealists in US are not limited to the outpatient sector PCPs in Us have assumed a number of secondary care functions by providing a substantial amount of inpatient care -Organizational disarray |
|
|
British NHS has regimented primary-secondary-tertiary care structure |
1) Primary care level is exclusive domain of GPs who practice in small to medium groups and main responsibility is ambulatory care 2) Secondary tier of care is occupied by physicians in specialties (IM, meds, near) these MDs are located at hospital based clinics and serve as consultants for outpatient referral from GPs -also provide care to hospitalized pt -route pt back to GPs for ongoing care needs 3) tertiary care sub specialists (cardiac surgeons, immunologists, pediatric hematologists) are located at a few territory care medical centers -except in emergency situations, all pt are seen first by the GP who will steer pt toward a more specialized level of care there referral, pt may not directly refer themselves to a specialist |
|
|
Most people have health care needs at the primary care level But secondary and tertiary level of care is more expensive |
Key tasks of primary care 1) first contact care 2) longitudinality (long time relationship) 3) comprehensiveness (wide range services) 4) coordination "primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with pt, and practicing in the context of family and community" Core elements of good primary care advance the triple aims of health system improvement Having a regular source of care = better control and less reliance on EF services, proper indications, more satisfaction with care |
|
|
Within the United States, states with more PCPs per capita have lower total mortality rates, lower heart disease and cancer mortality rates, and higher life expectancy at birth compared with states having fewer PCPs, adjusting for other factors such as age and per capita income. In contrast, increases in specialist supply are associated with greater costs but not improved quality (Starfield et al, 2005). In an analysis of quality and cost of care across states for Medicare beneficiaries, Baicker and Chandra (2004) found that states with more PCPs per capita had lower per capita Medicare costs and higher quality. States with more specialists per capita had lower quality and higher per capita Medicare expenditures. |
Primary care provider as gatekeeper helping pt navigate the complexities of the health care system is that of coordinator of care Advocate, work in partnership to integrate array of services, avoid duplication of services, enhance pt safety, and care for whole person |
|
|
Patient centered medical home |
consist of primary care, patient centered care, new model practice, and payment reform goal of delivering accessible, comprehensive, longitudinal, and coordinated care |
|
|
Forces driving the organization of HC in the US |
The biomedical model Financial incentives for MD specialization and hospital expansion Professionalism (gov't provides financing for HC but without any real administrative control) Professional sovereignty of MDs emerged as the preeminent authority in HC |
|
|
Multi specialty group practice |
Ex: mayo clinic Clinics are owned and administered by MDs and featured physicians working in various specialties -Brought a large number of physicians together under one roof to deliver care -specialty oriented group practice model attempted to use the structure of the practice organization itself as a means for creating an environment for coordinated care among specialist physicians This type did not become the dominant organizational structure because of resistance by professional societies and hospitals assuming central role in medical are |
|
|
Community health centers |
Alternatives for fee for service medical practice -emphasis on primary and preventative care and striving to take responsibility for the health status of the community served by the health center Ex: Frontier Nursing Service desinged service to meet needs of poor rural area in Kentucky that lacked basic medical and obstetric care and suffered from high rates of maternal and infant mortality Both urban and rural models of community health centers waned during the middle years of this century -decline in public health nursing as prestige of hospitals became the center of activity for nursing education and practice -in 1980s many community health centers were in practice that melded clinical services with public health activities in programs of community oriented primary care -improved care of low income ambulatory pt, reduced ED/hospitalizations, some success in improving community health status In past decade, federal gov't invested in new pd of expansion of community health centers and centers are viewed as critical access point for the reforms enacted in ACA Community health centers serve uninsured or those covered by medicaid |
|
|
Prepaid group practice and health maintenance organizations |
Ex: Kaiser health plan Surgeon Sidney Garfield began providing prepaid medical services for industrialist henry Kaiser's employees working at a dam Garfield was paid a fixed sum per employee Company sponsored medical care in a remote area gave birth to today's largest alternative to fee for service practice |
|
|
Contemporary systems that grew out of Kaiser and consumer cooperative models share these features: Renamed HMO |
-Rather than preserving a seperation between insurance plans and the providers of care, these models attempt to meld the financing and delivery of care into a single organizational structure -The premium serves to directly purchase, in advance health services from a particular system of care. This is the "prepaid" notion of care The second component is care delivered by a large group of practitioners working under a common administrative structure "group practice" |
|
|
First generation HMOs and vertical integration: The kaiser permanente medical care program |
Consists of 3 interlocking admin units: 1) Kaiser foundation health plan (the health insurers) 2) Kaiser foundation hospitals corporation (owns and administers kaiser hospitals) 3) Permanente medical groups (MD organizations that administer the group practices and provide medical services to kaiser plan members under a capitated contract w/ the kaiser plan |
|
|
Kaiser Permanete HNO is VERTICAL INTEGRATION |
Consolidating under one organizational room and common ownership of all levels of care, from primary to tertiary care, and the facilities and staff necessary to provide this full spectrum of care ~ Most K-P regional units own their hospitals and clinics, hire the RNs and other personnel staffing these facilities, and contract with a single large group practice (permanent) to exclusively serve pt covered by the kaiser health plan -regionalized tertiary care services to a select number of specialized centers |
|
|
Second generation HMO and "Virtual integration" |
San Joaquin Foundation for Medical Care was set up as a network of physicians in independent private practice to contract as a group with employers for a monthly payment per enrollee Foundation would then pay the MDs on a discounted fee for service basis and conduct utilization review to discourage over treatment -Hope was that the plan would reduce the costs to employers, who would choose the foundation rather thank kaiser -In network models physicians can establish contractual relationships with numerous HMOs and IPAs |
|
|
Integrated medical group |
Tighter organizational structure than IPAs, consisting of groups in which physicians no longer own their practices and office assets, but become employees of an organization that owns and manages their practice |
|
|
Physician hospital organization (PHO) |
Physicians partnered with a hospital to jointly contract with health plans for both physicians and hospital payment rates FTC deemed that some PHO arrangements constituted collusion in price setting between physicians and hospitals to an extent that voluted anti trust laws |
|
|
Network model HMO |
represents an alternative to the vertically integrated HMO managed care relationships involving IPAs and medical groups consist of a network of contractual links between HMOs and autonomous physician groups, hospitals, and other provider units, rather than an everything under one roof model of vertical integration integration of services based on contractual relationships rather than unitary ownership In virtually integrated systems, HMOs do not directly provide health services through their own hospitals and physician organizations |
|
|
enrollement in virtually integrated systems is greater than that of traditional HMOs |
Preferred provider organization (PPO) Allow pt to see physicians not in the insurer's physician network, with stipulation that patients pay a higher share of the cost of out go poled when they use non-network physicians and hospitals MD joining the PPO network agree to accept discounted fees from the health plan with the hope that being listed as a "preferred" provider will attract more pt to their practice |
|
|
Vertically integrated HMOs of the traditional prepaid group practice model tend to rank higher than network model HMOs on across measures of care (EB care of chronic illnesses) Pt are more satisfied with integrated HMOs such as kaiser ahead of network model HMOs Larger medical groups more likely to have systems in place for care coordination, enhanced patient access, and related processes |
More organized model (even if only of a virtual network variety) can improve the delivery of care and coordination of care The dispersed model does appear to have one important strength from the patient perspective, which is the satisfaction that comes from receiving care from a small practice where patients have a sense that clinicians and staff know them personally and the patient–clinician relationship is less encumbered by organizational bureaucracy. Studies of patient preferences have found that satisfaction is highest whe |
|
|
Accountable care organizations |
ACA concept of ACOs emerged as a centerpiece of delivery system reform "provider led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population" Shared savings program --> Medicare would still pay MD by fee for service and hospitals by DRGs, and pt would be allowed free choice of physician and hospital Medicare compare costs and quality for medicare patients cared for by this virtual network and, medicare would share portion of savings to MDs and hospitals in ACO network if they met goals and kept costs low ACO concept aims to focus more on proactive care for individual patients and on holding providers accountable for the quality and costs of care delivered |
|
|
Medical neighborhood term used to describe the services, providers, and organizations in a health system that contributes to the care of a population of patients |
Organizations that are structurally integrated have an advantage in being able to provide care that is functionally integrated -have assets such as mutlispecailty groups, EMR, interD health teams, QI infrastructure to promote care coordination and the free flow of info among among all providers involved in pt care |
|
|
GERMANY |
Health insurance thru a sickness fund that insures employees Required by law to join the sickness fund selected by employer Employer contibutes % and another part is w/h from employee's paycheck and sent to the fund sickness funds are organized by geographuc area, Contributions to funds are collected by a gov't run health fund, which then distributes the money to health funds based on risk adjusted amount per insured person Funds are not allowed to excluded on basis of age, or medical condition Wages supporting HC financing are declining relative to health care costs, employers are proposing that their contribution be capped so that further increases are borne by employees Sickness funds are maintained even when person retires or is disabled and unable to work German health insurance will cover its members whether or not they change jobs or stop working for any reason If you are wealthy, you can opt out of a sickness fund and purchase private health insurance (this private pays MDs more so the policyholder can receive preferential tx) Merged social insurance and public assistance structure so that no distinctions are made btw employed and unemployed (gov't contributes) Strict separation of ambulatory care physicians and hospital based physicians Allowed to have own PCP and able to make appt to see a specialist without referral from the PCP Sickness funds pay a global sum each year to the physicians association (regional), which pays MDs on the basis of a detailed fee schedule Concerted Action (german cost containment) meets 2x/yr and makes up guideliens for fees, rates, prices of meds Physician fees are controled and physicians have been capped |
|
|
CANADA |
Universal medical insurance passed by the Canadian federal government Taxed financed, public, single payer health care system Single payer is the provincial government Funding is generated from taxes Everyone receives the same health insurance, financed the same way (regardless of wealth or status) No preferential t because private health insurance is banned by the gov't Canadians have free choice of physician, need a referral from family physician to see a specialist Can see pt w/o referral, but will revive a lesser fee (so most don't do this) Canadian family MDs are allowed to care for their pt in hospitals Longer wait for elective operations Canada regulates pharmaceutical prices and provincial plans maintain formularies of drugs approved for coverage |
|
|
The UK |
National Health Service (NHS) Funding comes from taxes 0 No distinction exists between social insurance and public assistance funding 0DUK allows private insurance companies to sell health insurance for services also covered by NHS (allows for preferential tx) If you have private insurance, you still pay taxes to support NHS -GP as the gatekeeper, if you want to use the NHS you have to have a GP -The choice of GP is free to choose -GPs do not provide care in hospitals -Payment for GPs is capitation -GPs eligible for pay for performance -NHS has relatively low GDP for HC |
|
|
JAPAN |
An employment linked social insurance program that is mandatory Universal Coverage -Has different categories of health plans with even more numerous individual plans and less flexibility in choice of plan Employee--> society managed insurance plan (each co operates its own health plan) Employee and employer contribute a premium to fund the society Employees in co w/ < 700 employees are compulsorily enrolled in --government managed insurance plan Self employed or retired --> community based health insurance "citizens insurance" from each municipal gov;t in japan If you are unemployed, remain enrolled in health plan w/ payroll tax waived Uses additional general tax subsidies to create a universal insurance program health plans place no restrictions on choice of hospital and physiican and do not require preauthorization before using medical services Most clinics and small hospitals are family owned businesses founded an operated by independent physicians Governemtn owns and operates larger medical centers Clinics permitted to operate inpatient beds and become classified as hospitals when they have > 20 beds Physicians paid fee for service GOv't regulates physician fees, hosptial payments and med rices Fee schedules, things are cheap, MD make up for low fees w/ high volume such as seeing 60 pt/day MD can disperse meds HCS relies heavily on payroll taxes and requires a large employed population (BUT has a large aging population) |
