healthcare systems final 2
Terms
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- IOM Definition of Health Care Quality
- The degree to which health care services to individuals and populations increase the likelihood of desired health and are consistent with current professional knowledge
- characteristics of quality healthcare
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Safe
Effective
Patient-centered
Timely
Efficient
Equitable - error
- the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
- Adverse event
- injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a “preventable adverse eventâ€
- rank of death due to medical errors
- 4th leading cause, under cancer, heart disease,
- most common cause
- drug iatrogenesis
- what is the % of adverse events with prolonged hospitalizations
- 3.7
- VA study
- 22.7% of deaths found to be possibly preventable by optimal care
- problems with VA study?
- majority male, smaller, sicker population sample
- most common number reported regarding preventable deaths
- 98k
- what is effective healthcare
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Providing services based upon scientific knowledge to all who could benefit and not providing services to those not likely to benefit (avoiding underuse and overuse)
Requires evidence-based practice - pt centered healthcare
- care that is respectful and responsive to individual patient preferences, needs and ensuring that patient values guide all clinical decisions
- what is IOM recommendation for timely healthcare?
- access 24hours/7days a week
- equitable healthcare
- Providing care that does not vary in in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status
- individual level of equitable care
- Individual level:care based upon need not individual characteristics
- how many American's are without health insurance
- 44 million, 47.5% of working-class uninsured
- Avedis Donabedian dimensions of quality
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1. structure
-bed size, board cert, # of procedures
2. Process
- # of mammorgrams, pap smears, VBAC's
3. outcome
-mortality rates and pt satisfction scores - tools to improve quality
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Disease Management
Evidence-based Medicine
Practice Guidelines
Clinical Pathways
Report Cards
TQM/CQI - quality equation
- pt satisfction + outcomes = cost
- what is managed care
- Organized effort by health insurance plans and providers to use financial incentives and organizational arrangements to alter provider and patient behavior so that health care services are delivered in a more efficient and lower cost manner
- extent of managed care
- An estimated 85% of Americans received health care through some type of managed care by the year 2000
- history of mangaed care
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1929 – Elk City, OK, rural farmers cooperative
1934 – Ross and Loos developed prepaid health care for water company employees of Los Angeles
1937 – Group Health Association (Washington, DC)
1942 – Kaiser Permanente (Vancouver, WA; Walnut Creek, CA)
1945 – Kaiser Permanente opened enrollment to the public
1947 – Group Health Cooperative of Puget Sound – first group practice cooperative with citizen oversight
1954 – San Joaquin County Foundation (Stockton, CA): prototype independent provider association (IPA) - Managed Care Principles
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Physicians accept financial risk, this represents a radical departure from fee-for-service
Prospective Payment vs. Retrospective Payment
Providers manage health care for an enrolled population not just individual patients
Preventing injury and disease is financially beneficial,though limited by short periods of enrollment - Capitation
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Specified amount paid periodically to a health provider for a group of specified health services regardless of quantity rendered
Amounts are determined by assessing a payment “per covered life†or per member
Shift of financial risk from insurer to provider
- - Withholds/bonuses
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Costs of referrals and ancillary services
Quality of care/pt. satisfaction - Controlling Risk Under Capitation
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Carve-outs
Type of service (preventive care)
Diagnosis (AIDS)
Referral specialty (Ophthalmology - Keys to Success Under Managed Care
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Keep patients out of the hospital
Keep patients out of the emergency room
Keep patients away from specialists - Types of Managed Care Organizations
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Staff model HMOs (Group Health of Puget Sound)
HMO employs the physicians and PAs
Group model HMOs (Kaiser Permanente)
The HMO contracts with a multi-specialty physician group practice to provide all physician and PA services to the HMO’s members - HMOs
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Network Model HMOs (Health Insurance Plan of Greater New York)
The HMO contracts with more than one group practice to provide physician services to the HMO’s members
Independent Practice Association (IPA)
Independent physicians join to form a group which contracts with HMOs. Most common model - what models are more likely to use PAs?
- Group and staff-model HMOs are more likely to use PAs and NPs to deliver part of primary care to their members than IPAs or PPOs. (86% of HMOs employ PAs or NPs)
- Types of Managed Care Orgs
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Point-of-Service Plans
Preferred Provider Organizations (PPOs) - Providers’ Views of Managed Care
- Perceived loss of autonomy is an emotionally-charged issue.
- what is the size and scope of cost of healthcare in America
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1.6 Trillion dollars
$4,100 per capita
Currently 14% of GNP up from 6.3% in 1965 - International Comparisons
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Germany - 10.7%
Switzerland - 10%
France - 9.6%
Canada - 9.2%
Japan 7.2%
UK – 6.8% - History of Health Insurance
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Originated in Europe early 1800’s.
Primary function was to protect against loss of income.
In 1911 policies began to be issued to cover health care costs.
1929 first hospital policies involving school teachers and Baylor University Hospital in Dallas. This was the beginning of Blue Cross. - Moral Hazard
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Health insurance is highly discretionary
Individuals who purchase health insurance are more likely to use health services than if they were uninsured
Requires the use of disincentives to control utilization i.e. copayments and deductibles - Distribution of Health Care Costs
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In any given year
20% incur no health care costs at all
70% of pop. incurs 10% of total costs
1% of the pop. incurs 30% of total costs - Cost-Sharing
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Deductible: payment before insurance benefits kick-in
Co-payment: out-of-pocket expense each time health services are received
Stop-loss: maximum out-of-pocket liability
Premium: employee pays a portion of the health insurance premium - Managing Risk
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Community rating: premium based upon utilization in a defined geographic area. Healthy people subsidize the costs for the unhealthy, leads to adverse selection.
Experience rating: premium based upon demographic characteristics and/or actual group experience. - The Blues
- Blue Shield- Started in 1939 by California physician group to pay for physician services
- Size and Scope of healthcare workforce
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11 million people, 10% 0f the U.S. work force are employed in health care
Over 200 health care occupations and professions
Bureau of Labor Statistics estimates that half of the 10 fastest growing occupations will be in health care - Allied Health Professionals
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Physical Therapist
Occupational Therapist
Speech Therapist
Respiratory Therapist
Radiation Therapist - HISTORY of HOSPITALS
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Initially built as isolation houses and quarantine stations
Served a social welfare function housing the mentally ill, homeless, infected patients and petty criminals - Evolution of the American Hospital
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1736- Poor House of New York became Bellevue Hospital
1752- Pennsylvania Hospital became the first voluntary hospital designated to care for the sick
1789- the Public Hospital of Baltimore for the poor, sick and suffering of Maryland was founded, in 1889 became JHH
1809- St. Vincent de Paul Sisters of Charity began to establish hospitals around the country - Forces Affecting the Development of Hospitals
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Advances in medical science
Proliferation of technology and specialization
Development of professional nursing
Teaching and research required to train MDs
Growth of health insurance - Forces Affecting the Development of Hospitals 2
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Introduction of anesthesia
Laboratories and x-rays late 1800s
Florence Nightingale introduced the science of nursing during the Crimean War 1850s which moved into US during the Civil War
Flexner Report 1910 - organization of hospital tier
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board of trustees
president/ceo
senior vp,
controller,vp nursing,professional, support
-bzi off, er, hosp units, or, radiology, lab, pharm, amb, cardio, neuro,
admin - VP nursing includes
- ER, hosp units, OR
- senior VP operations tiers
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vp nursing
vp professional servs
VP support servs - VP professional services tier
- radiology, labs, pharm, ambulatory,cardio,neuro
- VP support services tier
- dietary,houskeeping,security
- Senior VP finance tier
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controller
biz office
admin - Hospital Beds and Occupancy
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1975 =
Beds 1,465,828
Occupancy 76.7%
1998 =
1,012,582
65.4% - Resident Duty Hours-ACGME
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Maximum of 80 hours per week
One day off out of seven
Call every third night
Work day limited to 24/30 hours
10 hours off between shifts