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Health Care Systems Final


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Forces affecting the development of hospitals
1. advances in medical science
2. proliferation of technology and specialization
3. development of pro. nursing
4. teaching and research required to train MDs
5. growth of health insurance
When and by whom was the science of nursing introduced?
-Florence Nightingale introduced it during the Crimean War in the 1850s
-moved into US during Civil War
Changes in medical education for physicians
-prior to 1910: essentially like becoming a barber;training school
-after 1910: hospitals as training grounds
Example of advancement in medical science
-introduction of anesthesia
Examples of proliferation of technology and specialization
-laboratories and x-rays in the late 1800s
Majority of hospitals in the U.S. today are:
-not-for-profit or government owned
THE entity that governs the institution of the hospital
-Board of Trustees
Who do Board of Trustees have authority over?
-only over the CEO and not over the health care providers
What is unique about the organization of a hospital's governing body?
-two governing bodies running in parallel with one another
What has had the biggest impact on the fact that hospital beds and occupancy have decreased over the years?
-Managed care: limiting time of hospital stay
What percent of the cost of a bed is incurred whether that bed is occupied or not?
a) Resident duty hours have been limited to ____ hours per week.

b) List other requirements.
a) 80 hours per week
-one day off out of 7
-call every 3rd night
-work day limited to 24/30hrs
-10 hours off in between
To whom do Resident Duty Hours numbers NOT pertain?
-medical students
Libby Zion Case
-NY Hospital
-dies in ER as asthmatic because residents forgot about her
-her father was a writer for NY Times
Cons of enstating Resident Duty Hours
- less continuity of care
- residents watching clock
- more frequent transfer of pts.
- all leads to more errors
Hill-Burton Act
-made funds available for institutions to expand and be built
-stimulated a tremendous amount of hospital construction growth especially in rural areas
The catch of the Hill-Burton act
-if you take the money offered by it, you are obligated as a hospital to take all patients regardless of their ability to pay
-Emergency Medical Treatment and Labor Act
-hospitals receiving federal funding must provide service to any individual who presents in an ER
-violaters subject to monetary penalties of up to $50,000 for each offense
Interpretive guidelines clarifying EMTLA law issued on May 13, 2004
-allows PAs to take ER call
-on call physician is ultimately responsible
-diagnosis related groups
-over 500 in place
-single, flat payment irregardless of amount of time you are there, amount of services you use, amount of costs you incur
Do DRGs expand or contract (are patients in our out of hospitals) the system?
-Contracts the system
-get em in and get em out with few tests because the hospital is paying for anything above set dollar amount
-an expense for hospital rather than revenue
DRG Creep
-code differently to maximize payments
-legal to a certain extent
-upcoding beyond what is reasonable is fraud
Medical specialties can be divided into 6 major functional groups:
1. subspecialties of internal medicine
2. broad group of medical specialties
4. surgery of all types
5. hospital based radiology, anesthesiology, pathology
6. psychiatry
Physicians trained in _____ are considered PCPs or generalists.
1. family meds/general practice
2. general internal medicine
3. general pediatrics
5 main areas in which Primary Care differes from Specialty
Primary Care is:
1. first-contact care; portal to health care system
2. PCPs serve as gatekeepers
3. longitudinal
4. focuses on the person as a whole versus a single disease or organ system
5. training - PCPs spend more time in ambulatory setting vs. in inpatient settings like specialists
____ % of the US workforce are employed in health care.
-11 million people
Over ____ (#) health care occupations and professions
1. Licensure
2. Certification
3. Registration
-most restrictive, state defines scope of practice along with educational and testing requirements
-state or voluntary professional organization attests to educational achievement and/or performance abilities for practice, not a legal right to practice
-generally the least restrictive, usually a voluntary listing
Approximately _____ (#) allopathic physicians in practice
Approximately _____ (#) osteopathic physicians in practice
Advanced Practice Nurses
-resistered nurse
-certificate, AAS, BSN, MSN
LPN (aka LVN)
-licensed practical nurses
-aka licensed vocational nurses
-certified nurse midwives
-certified registered nurse anesthetics
-certified nurse specialists
-certified nursing assistants
Allied Health Professionals
1. Physical Therapists
2. Occupational Therapists
3. Speech Therapists
4. Respiratory Therapists
5. Radiation Therapist
Key changes that have shifted the balance between inpatient and outpatient services
1. reimbursement
2. technological factors
3. utilization control factors
4. social factors
Various settings for outpatient services
-private practice
-free standing facilities
-mobile facilities for medical, diagnostic and screening services
-outpatient long term care services
-public health services
-community health centers and free clinics
-alternative med. clinics
Hospital-based outpatient services can be broadly classified into 5 main types:
1. clinical (for uninsured or those in research studies)
2. surgical (pt. discharged on day of surgery)
3. home health (postacute care and rehab)
4. women's health
5. traditional emergency care
Types of Freestanding Facilities
1. Walk-in clinics
2. Urgent care centers
2 types of Long-term care services
1. case management
2. adult day care
Primary care is distinguished from secondary and tertiary care according to:
-duration, frequency and level of intensity
Secondary Care
-usually short-term
-sporadic consultation from a specialist
-advanced intervention
Tertiary Care
-most complex level of care
-needed for uncommon conditions
-typically institution based
-highly specialized
-technology driven
-large teaching hospitals (university driven)
Primary Care
-focus often on type or level of services:
-prevention, diagnostic/therapeutic services, health ed. and counseling, minor surgery
WHO definition of Primary Care
-essential health care that is based on practical, scientifically sound and socially acceptable methods and technology
Domains of Primary Care
-point of entry
-coordination of care
-essential care
-integrated care
Coordination of an individual's total health care needs is meant to ensure:
-continuity and comprehensiveness
-Institute of Medicine
-the premier health policy body in the U.S.
-part of the national academy of sciences
Is the IOM a government agency?
-not technically a government agency but receive most of their funding from federal government and federal contract
4 Key Attributes of Primary Care
1. First Contact Care
2. Coordination of Care
3. Comprehensive
4. Longitudinality
Primary Care Providers include:
-family practitioners
-general internists
-OB/GYN (sometimes)
NPs and PAs: both professions begin in the early 1960s in response to:
-a national shortage of PCPs
There are _____ NPs and _____ PAs currently practicing in primary care.
____ % of primary care office-based physicians employ either an NP or a PA or both
Most data shows that only about 1/2 of trained NPs are currently practicing as NPs. Why?
1. ease of becoming an NP
2. salary difference between an NP and a staff/specialty nurse does not differ much
How many PAs?
-about 90% of trained PAs practice as PAs
NPs define their practice as _____ while PAs define their practice as _____.
-independent and collaborative
-dependent and interdependent
In Primary Care Medicine:
NPs tend to have a greater emphasis on ____ while PAs have a greater emphasis on ____
-counseling and education
-technical procedures
Cost-Effectiveness Comparison
(MGMA Compensation/Production ratio)
-Family physician
-medical group management association
compensation/production ratio
-amount of money you get paid compared to the amount of revenue you generate
-lower number is better
What group has the lowest compensation/production ratio and what does this mean?
-PAs generate more money
What is the one and only profession that has a lower compensation/production ratio that PAs?
What changes the compensation/production ratio numbers between NPs and PAs?
-procedures and volume
-PAs focus more on technical procedures and see more patients in a day
By 1993, ____% of US physicians were specialist. Why?
-income and prestige
Today, ____% of US physicians are specialists.
Specialization vs. Primary Care
1. specialty care more dz focused
2. specialists are experts while PCP must be able to tolerate ambiguity
3. specialists better at managing complex problems
4. PCPs see pts. at earlier stages of dz
5. studies show that specialists tend to overestimate the likelihood of serious disease
In 1980, only ____% of hospital revenue came from outpatient services while today over ____% is generated by outpatients.
Why the increase in outpatient care?
-managed care
Practice arrangement
-the organized structure where PAs are employed
-the percentage of primary care medical responsibilities that can be safely handled by a PA under optimal conditions.
-the PA's decision to request a physician's assistance in a specific medical office visit
States typically place certain stipulations on PA prescribing activity:
1.physician co-signature
2.limitations on drugs that may be used
3.excluding selected drugs
4.use of drug tx protocols
5.limiting quantities of certain drugs
The most frequently PA-prescribed classes of drugs:
-non-narcotic agalgesics
-cough and cold preparations
Internal medicine
-focuses on adult medicine
-care for patients for life
(from teen years to old age)
-training focuses on adult dz and prevention
-3-7 years or more of traning
Who is often seen as a threat by physicians?
-PAs are more readily accepted
Who tends to spend more time with patients, NPs or PAs?
-PAs are more productive
NPs and PAs: the masters degree
-now all NP programs offer masters degrees however nearly half do not have one
-by 2008 nearly all PA programs will offer masters degree but approximately 70% of PAs do not have one
Professional practice issues
-scope of practice
-prescriptive authority
-third party reimbursement
Delegation: physicians in ____ practices tend to delegate at higher levels than those in ____ practices.
Delegation: the level ranges from ___ to ___%
-an economic term defined as time devoted to overseeing a PAs performance
According to a limited number of performance studies, supervision averages _____%
-less than 10% per day
Are PAs required to be paid overtime?
-exempt from overtime provisions
-classified as "learned professional"
Considerations of employment costs of PAs include
-salary and benefits
-malpractice insurance
-office space
-support staff
The average primary care PA salary nationally
-$72,000 (2003)
-approximately 50% of an adult PCP's salary
Annual revenue generated by a PA (estimated)
-$324,000 gross charges
PA malpractice insurance is approximately ____% of the malpractice insurance rate for physicians in the same setting.
3 major cornerstones of health care delivery
1. cost
2. access
3. quality
Cost has 3 different meanings
1. for consumers: price of health care
2. for nation: how much nation spends on health care
3. for providers: cost of producing health care services
Anti-kickback act
-you can’t accept payment in exchange for referring Medicaid patients to specific hospitals
Stark Law
prohibits healthcare providers from referring patients to places for lab work/ect where the provider or their immediate family has a financial interest in that lab
All-payer system
centralized controls allow cost-containment efforts to sweep through the entire health care delivery system
“Top-down” approach
they establish budgets for entire sectors of the health care delivery system. In essence, total spending remains within pre-established limits
"bottom-up" approach
-each provider and MCO established its own fees or premiums
-competition created by both employers shopping for the best premium rates, and by MCOs contracting with providers help to determine what the total expenditures will be
Does US use "top-down" or "bottom-up" approach?
-bottom up

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