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6% of GDP spend 1.5 as much as any other country and twice the OECD average
the US is very far of the line of best fit
this is due to higher prices and higher service provision
US Healthcare Service Prices
US Services are 60% higher than average of 12 OECD countries (Itally is second highest)
US has significantly higher prices for the same procedures (double for some of them)
US MRI Machine Statistics
greatest supply of MRI machines
highest utilization
highest scan and imaging fees
Procedures and Products US doesMore than other countries
2nd in MRI units and Exams
3rd in CT scanners and Exams
1st in tonsillectomy and knee replacements
3rd in coronary bypass
6th in caesarean sections
True or False: US has higher hospital admission rates and average lenght of stay (LOS)
False
Catagories the US doesless then other countries
26th in practicing physicians and hospital discharges
29th in doctor consultations
28th in hospital beds
29th in average length of stay in hospitals
most based on on per capita or per 1k popultaion
True or False:Prescription Utilization, Prices and spending are all highest in the US
true
next highest country on drug prices is 75 percent of US price(canada)
UK sits at half and New Zeland at 34%
US double the pharmaceutical spending per capita as the OECD average
US Quality Outcomes
US ranks 6th of 7 in terms of quality but is variable
cancer care in US i particulary high based on 5year survival rates but have high rates of chronic disease admissions
has average performance on effectiveness and patient centeredness
low performance on safety and coordination
primary care sector is not performing well
netherlands seems to be the best
OECD Life expectancy
US has below average Life expectancy (80.4 female and 75.3 male)
also has the lowest of major countries in increase in life expectancy since 1988
Bismarck Model
multi-payer; private providers (Germany)
decentralized national health program (sickness fund)
Uses insurance system funded by employer and -ees
health insurance has to cover everybody; multi-payer does not make a profit
physicians and hopsitals tend to be private; tight regulation gives government cost control power that single-payer provides
National Health Insurance Model
single payer; private providers
socialized insurance model (national health insurance)
uses private sector providers with negotiated reimbursement
payment comes from a single, government run insurance program that every citizen pays into
example is canada, taiwan and south korea
Beveridge Model
single payer; government providers (socialized med.)
health care provided and finacned by government thorugh tax payments
government employs most health care practitioners, owns most facilities and administers health care systems
british people never get a doctor bill
tend to have low costs per capita because government is sole payer and controls physicians price
example england, spain, and N. Zealand
Undeveloped Countries(out of pocket Model)
plan used by most nations because are too poor and disorganized to provide any government sponsered or private health care system
basic rule is rich get medical care and poor stay sick and die
some may barter goods for care
in developed countries this includes uncovered services and amenities
US.
All four basic models of Health Care
Bismark = employer insurance
Beveridge = VA
Nat Health insurance = Medicare
Out of pocket = 15% uninsured and electives
US Forces driving Health Care Spending
administrative overhead and complexity
lack of coordinated care
pract of defensive medicine (overtreatment)
use of technologically advanced equipment
health disparities
price increases
loose government regulation
Urgent Aims for Ambulatory CareImprovements
safe
effective
patient-centered
timely
efficient
equitable
2011 Patient Centered Medical Home Standards
enhance Access and continuity
identify and manage patient populations
plan and manage care
provide self-care and community support
track and coordinate care
measure and improve performance
Enhance Access and Continuity
Patient Centered Medical Home Standard
patients have access to culturally and linguistically appropriate routine/urgent care clinical advice during and after office hours
the practice provides electronic access
the focus is on team-based care with trained staff
Identify and Manage Patient Populations
Patient Centered Medical Home Standard
the practice collects demographic and clinical data for population management
the practice assesses and couments patient risk factors
the practice identifies patients for proactive and point of care reminders
Plan and Manage Care
patient centered medical home standard
identifies patients with specific conditions, including high risk or complex care needs
care management emphasizes assesing patient progress toward treatment goals and adressing patient barriers to treatment goals
reconciles patient medications at visits and post hospitalization – uses e-prescribing
Provide Self Care and Community Support
patient centered medical home standard
practice assesses patient/family self management abilities
practice works with patient family to develop a self-care plan and provide tools and resources
practice clinicians counsel patients on healthy behaviors and medications
Track and Coordinate Care
patient centered medical home standard
practice tracks, follows-up on and coordinates tests, referrals and care at other facilities
practice follows up with discharged patients
Measure and Improve Performance
patient centered medical home standard
practice uses performance and patient experience data to continuously improve
tracks utilization and measures such rates of hospitalizations and ER visits
identifies vulnerable patient populations
practice demonstrates improved performance
Core Function of Accountable Care Organization
facilitate provider partnerships with patients, families and communities
redesign primary care medicine and advance the medical home concept
integrate the health care system across the continuum of care
provide tools and resources to health care providers
population health management
Hospitals acount for how much of US health care expenses?
they acount for 1/3
centerpiece of health care delivery system
most complex health care entity
5,700 hospitals in the US
Flexner Report
filled out in 1910
recomended reducting number of medical schools from 150 to 31, change admission requirements to baccalaureate degree and incorporate scientific method as foundation
some were adopted by AMA
hospitals became teaching and research centers for medicine and center for tech innovations
Advent of Health Insurance
provided financial stability for hospitals
increased demand for health care
initially covered only inpatient care (financial incentive to admit patients resulted in unneccesary admis.)
increased the demand for hospital beds, hospital services and health care in US
Hill-Burton Act
1946
created federal funding to: build hospitals, expand and renovate, increase bed capacity and add emerging tech
resulted in increase in number of beds and addition of new technology
Diagnosis-Related Groups (DRG’s)
1983
instituted to control increases in medicare spending
reimbursement moves from historical fee-for-service to reimbursement independent of services provided or Lenght of stay
new hospital incentives: LOS, # of procedures, Efficiency, evaluation of Dx procedures for appropriateness
Results on hospital: inpatient acuity, unbundled pre-op and post op Services, utilization review, financial support for uncompensated hospital care
Horizontal Integration
affliations between hospitals
affiliation vs ownership
improve efficiency-combine services
secure better contracts-supples and equipment
avoid duplication of patient care services
frequently, a partnership btw a small community hospital and a tertiary care hospital
Vertical Integration
organization provides a continuum of care
examples of services in addition to acute care
hospitals less dependent on declining revenues from acute care
hospitals can provide MCO’s with a variety of services
integrated delivery systems emerged
Economic Recession
decline in revenues, charitable donations, value of financial reserves
as unemployment increased, hospitals say decline in elective procedures increase in patients covered by medicaid and uncompensated care
responded by cutting administrative expenses and reducing staff and services
Most Hospitals can be catagorized as:
community hospitals
teaching hospitals
government hospitals
specialty hospitals
correct answer is community hospital
A hospital is classified as critical access when:
it has less then 25 beds
Hospital Management
board of trustees/directors(ultimate authorities)
hospital administration(health-system adm)
medical staff(most physicians are not hospital employees)
alignment of medical staff with the health-system
Hospital Committees
medical staff committees: pharmacy and therapeutics comittee, credentialing committee, infection control committee, medical staff executive committee
hospital committees: patient safety committee, various quality committees, various operations committees
Hospital Accreditation
The Joint Commission: sets standards and accredits hospitals against those standards; accredits hospitals, behavioral health facilities, LTC facilities, office-based surgery org, home care organization, ect
based on voluntary compliance with standards
standards focused on clinical processes and outcomes of care
Medicaid Defined
nations publically financed health and long term care coverage for low income people
most beneficiaries lack access to private insurance
dominant source of LTC coverage
financed thru federal-state partnership
each state designs and operates own program thru broad federal guidelines
The State and Federal Medicaid Partnership
states must cover mandatory services specified in federal law in order to recieve federal matching funds
they are permited to cover many services that federal law designates as optional
Whos is covered by Medicaid
62 million Americans (1 in 5)
pregnant women (40% of births)
39 million children
some parents in both working and jobless low income families
low income elderly with many complex health care needs
non elderly adults w/0 dependent children are generally excluded
ACA will significantly expand coverage
Medicaids Role in US Health Care System
Fills large gaps in our health insurance system
expands to cover more people during economic downturns
main source of LTC coverage in US (31% of total medicaid expenditures are for nursing facility
supports safety net institutions that provide halth care to low income and uninsured people
Medicaid is largest Coverage for Certain Groups
mental health
HIV/AIDS
american children
LTC coverage
4.7% of medicaid expenditures is for RX
Medicaid Cost
about 414 billion in 2011
16% of total national spending (2.3 trillion)
aggregate costs high and adm costs low
acute care spending has been rising
beneficiaries are not proportional to spending (more schildren but account for less of spending)
5% of the medicaid patients account for 54% of the spend
Medicaid Federal Match Rate
normally it is 50% but may be higher in poorer states (highest is 73%)
overall the federal share of spending is 57%
Medicaid Access to Care Problems
low provider rates (31% of surveyed physicians wont accept new medicaid patients
administrative burden to providers
access to specialist and dental care is a major concern
providers often do not locate in low-income neighborhoods
Medicare Defined
the federal health insurance program for people 65 and older
also covers younger adults with permanent disabilities and medical conditions
it + medicaid is 960billion in health care expenditur
Medicare Advantage is:
part a
part b
part c
part d
it is part C
Medicare Part A eligibility requirement
age 66
US green card
Hx paying into medicare program
pay premium
the correct answer is Hx paying into the medicare program
Medicare Eligibility: Part A
work history ; 10 years
us citizen or perm resident ; 5 years
age 65
no montly premium
disability benefits ; 24 mo
have als and receive disability
ESRD
MEdicare Eligibility Part B
standard montly prem of 105/mo in 2013
hold harmless provision prohibits states from increasing premiums in amount ; SS cost of living adj
higher income beneficiaries pay higher premium (capped)
Medicare Part C and Part D
part C is medicare advantage option to participate in private health plans (HMOS and PPOs) about 26% of medicare beneficiaries participate
part D is prescription drug benefit (about 30million enrolled)
Not A medicare Funding Source:
state governments
payroll taxes
beneficiaries
general federal government funds
state governments do not fund
funding does come from payroll taxes, beneficiary cost sharing (25% of contributions) and general federal fund
Medicare Administration
HHS responsible for adm of medicare program through SS admin (eligibility and enrollment)
CMS develop operational policies, formulate conditions of participation, maintain review utilization, oversee general financing of the program, contract with claims and work with state gov agencies
Medicare Part A inpatient hospital care
60 consecutive days or 90 days per benefit period
60 lifetime reserve days
$1,156 deductible per benefit period
co-insurance 61-90 289 per day and 91-150 578 per day
Medicare Part A: Hospice Care
must have life expectancy ; 6 months
voluntarily waive right to traditional treatment
cost sharing involved
services covered are pain relief, physician services, nursing care, counseling
Medicare Part B does not cover
physician care
physician assistant care
hospice care
outpatient radiology
hospice care
Physician accepts medicare approved charge
balance billing
assignment
diagnostic related grouping
fee-for-service model
assignment
Coverage Gap in Medicare Prescription drug benefit
deductible
catastrophic threshold
donut hole
co-pay
donut hole coverage gap above $2970 to $4700 in out of pocket spending
Medicare Part D: Standard Benefit
pay first 325$ (deductible)
then pay 25% of cost from 325-2970
donut hole is 2970-6734 and you pay 47.5% on brand names and 79% on generic
pay 5% of catastrophic coverage
Mechanisms by Which IT Improves Safety
improving communication
making knowledge more readily accessible
prompting for key pieces of information
assisting with calculations
monitoring and checking in real time
providing decision support
patient access to health records
Potential Impact of EHR Adoption
net savings from increased savings and operational efficiencies (371 billion for hospitals and 142 billion for physician practices)
management of chronic diseases
prevention opportunities
Computerized Provider Order Entry (CPOE)
eliminates illegible handwriting
reduces medical errors and adverse drug events through access to information
reduces medication errors through structured orders
improves patient care through standardization
allows remote access
simplifies billing process/justification
new types of errors
high cost
mixed reviews on effectiveness
Surescripts
company that provides connectivity between prescribers, insurance companies and pharmacies
Clinical Decision Support Systems (CDS)
provides clinicians, patients or individuals with knowledge and person specific or population information, intelligently filtered or presented at appropriate times to foster better health process, better individual patient care and better population health
makes it easy to do right thing and hard to do wrong
provides alerts, however important ones might be lost if there are too many in total (alert fatigue)
Population Aging Trends
in 2010 1:8 us citezens are over 65+
by 2030 1:4 us citezens over 65
4 million seniors over 85 in 2010 will go to 9 million by 2030
Ultimate Objectives of the Afordable Care Act(ACA)
morality
acountability
transperancy
Supreme Court Ruling onAffordable Care Act
individual mandate is constitutional (penalty vs tax)
expansion of medicaid is constitutional
expansion decision made by each state
rest of ACA is constitutional
Affordable Care ActCoordination of Care
ACO: groups of doctors, hospitals, and other health care providers to give coordinated high quality care to their medicare patients
Patient Centered Medical Homes (PCMH) is a transition away from a model of symptom and illness based episodic care to a system of comprehensive coordinated primary care
tiered networks/narrow networks: tiered assign physicians into tto or more seperate tiers and narrow is a small or select network of physicians within a larger physician network
Top Reasons for Calling theClinical Communications Centerz
urinary symptons
post op symptoms and questions
blood sugar
abdominal pain
trauma
Patient-Centered Medical Home
redesign of primary care: delivered in a team-base approach that care is highly coordinated
delivers high quality, cost efficient care with concurrent increases in patient and provider satisfaction
55% increase in patient satisfaction and 35% increase in provider satisfaction
Racial Disparity vs medical advances
1991 -2000: 176,633 lives were saved through medical advances
if we could have resolved racial disparities 886,202 deaths could have been avoided
could save more lives through resolving racial disparities but spends more money on medical advances
Why are transitions in longTerm care important?
$225 billion spent in 2012 on LTC services
will escalate with demographic changes
major impact on national and state budgets
major impact on individuals: -cause of catastrophic expenses and 20% elders average 25,000/yr out of pocket
Cost of poor Coordination of Care
acounts for 25-45 billion in wasteful spending
unnecessary hospital readmissions
inadequate management of care transitions
Discharge Function
activities of daily living (ADL)-dressing, bathing, toileting, transferring, eating and continence
instrumental activities of daily living (IADL) managing medications, housework, finances, shopping, telephone, transportation
cognitive abilities: dementia and inellectual disability
Assisted Living
less restrictive, less expensive, more home-like setting
wide variability but most offer meals, housekeeping, laundry, transportation, personal support
cost range from 2k-4k/month
may be paid for by medicaid waiver for dual eligible individuals, but mostly covered by private pay
Hospice Care
accepts death as the final stage of life
affirms life and neither hastens nor postpones death
offers a holistic team-based approach to patient adn family care
palliative rather than curative care
terminal illness with 6 months or less to live
quality of life
Errors Across Transitions
49% of adults experience a medical error after hospital discharge
19-23% suffer adverse consequences
most commonly a medicatin error
breakdown in communication btw hospital team and or patient and primary provider
