SPHU 3010 Midterm 1
SPHU 3010 Midterm 1 SPHU 3010
Popular in Foundations of Health Care Systems
Popular in Public Health
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This 28 page Study Guide was uploaded by Cara Macdonald on Sunday September 18, 2016. The Study Guide belongs to SPHU 3010 at Tulane University taught by Arthur Mora in Fall 2016. Since its upload, it has received 22 views. For similar materials see Foundations of Health Care Systems in Public Health at Tulane University.
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Date Created: 09/18/16
This test will cover the following chapters in the textbook: The History of the U.S. Healthcare System Chapter 3 Organization of Care Chapter 9 The Health Workforce Chapter 10 Healthcare Financing Chapter 11 Healthcare Financing Chapter 11 “Health Care is Different” Fuchs, V. (2012) Health care is different – that’s why expenditures matt ournal of the American Medical Association. As well as the lectures delivered in the first 3 weeks of class. This guide is a combination of these two sources. Examples are highlighted in red Content ● PreIndustrial Era Healthcare ● Contributing Factors to Hospital Growth ● Effects of Urbanization on Health ● Rise of Insurance ○ KerrMills ○ Medicare Parts A, B, C&D ○ Medicaid ○ CHIP ○ Groups left out of insurance policies ● Republican/Democratic Stances ○ Opposition to Medicaid expansion ● Obama and The Affordable Care Act ● Prevention Services: primary, secondary and tertiary ● Types of Outpatient Care ● Types of Inpatient Care ● Emergency Care Triage System ● Public Health Organizations ● Types of Hospitals ● Changes in the Health Workforce ○ Expanding professions ● Primary Care Professionals ○ “Gatekeeper” function ● Critical Issues in the Health Workforce ● Insurance Terminology: ○ Beneficiary, Premium, Deductible, Copayment, Coinsurance, OutofPocket Maximum ● Types of Insurance & Plans Offered ○ Managed Care Organizations (MCO), Individual Private Health Insurance, Preferred Provider Organization (PPO) ○ Health Maintenance Organizations, High Deductible Health Plans, ● CostShifting ● Methods of Provider Payment ○ FFS, PPS, Capitation Week 1/Chapter 3: The History of the U.S Healthcare System ● Preindustrial era: ○ Practitioners visit houses ■ Quacks, faith healers, homeopaths, snakeoilers, midwives, salesmen ● Snake oil, cocaine drops, etc brought by traveling salesmen ● Charged generally low fees which were paid o ut of pocket ■ Wordofmouth and selfprescriptions ■ There was no science yet in medicine to prove other treatments ● Barbers and surgeons frequently shaved and bled with the same razors ■ Miasma theory of disease: ● If there was an odor, it meant disease was spreading a. Was coincidentally true ■ Dependant on oneself and family for survival ■ Lack of knowledge ■ No infrastructure for healthcare, most systems were managed on a local level ● What structure we did have wasn’t real healthcare ● No real hospitals had almshouses, homes for the poor, asylums a. All these places ended up being shelters→ institutionalized and removed people from society instead of treating and returning them b. For those unlucky enough to fall sick without family to take care of them c. Conditions were crowded, unsanitary, unethical and inhumane d. Services were only provided to the poor/disabled e. Had terrible reputations ecause of these reasons ○ Postindustrial Era ■ What changes occured to get us where we are today? ● Science of medicine confirmed what the MDs knew a. Homeopathic, faith and snakeoil healers fell behind without science to back up their treatments b. Confidence i n the medical system increased, knew no limits yet ■ Federal government funneled billions of $$ into academic medical research c. Supreme Court upholds and confirms medical authority in physicians graduating from reputable medical college ■ Highest court qualifies a legitimate system ■ Medical colleges advocated for these physicians ■ Enrollment increased ■ Transition to an Urban Society ● Industrialization shifted the workplace from the home to somewhere other than the home a. Concentrated areas of population b. Apartment dwelling, often alone tenantdwelling ■ Individualized he population: lost family support ■ If you got sick, you had no one to care for you ■ Conditions were somewhat deplorable ■ BUT this fueled the opportunity for further legitimization in the field of healthcare ● Improvement in hospitals removed the stigma gainst them a. Advent of antiseptic surgery ■ Previously, 50/50 prospect of surviving a surgery ■ Antiseptics saw this risk drop exponentially b. Anesthesia ■ Prior to its advent, amputations occurred without anesthesia or painkillers ■ Further reduced the stigma against hospitals c. Hospitals began to keep ecords ● Kept track of effective treatments ■ Statistics proved if a treatment was effective or not ■ Saw improvement in the performance of the hospital ● Rise of Insurance ○ Cost of hospital treatmen increase were no longer affordable ○ Black Tuesday stock market crash left hospitals empty ■ Had no cash coming in from lack of patients ○ Baylor University Hospital Insurance Plan: ■ $6/year guaranteed up to 21 days of hospitalization ■ $6/year gave peace of mind, was worth the small price for the high risk ○ Blue Cross/ Blue Shield bega guaranteeing their employees health insurance ○ WWII wage freeze exempts health insurance ○ Women were pulled into the workforce ■ Lack of employees to fulfill businessgovernment contracts ■ Factories took employees from other factories ● Government contracts became more expensive, lost money ● Implemented a wage freeze ■ Companies started offering health insurance to incentivize employees ● Institutionalized attainment of health care ● Elderly was major group left out of healthcare ○ Jobless, had no employee benefits ○ Many presidents have aimed for universal healthcare, but failed ○ Kennedy insisted on providing healthcare for the elderly ■ 1960 revived effort to enact hospital insurance for the aged ■ Congress responded by enacting errMills Program: ● Distributed federal funds to states willing to pay health care providers to care for the indigent aged a. Later expanded to cover indigent disabled ■ After his assassination, wave of emotion left people obligated and inspired to carry out the tenets of his campaign ○ LBJ: those who have plenty should give to those who have none ■ Abundance of wealth in our country had to be shared ■ Enactment of the US “great society” made an opportune time to renew effort to enact national health insurance ■ BUT conservatives and the American Medical Association (AMA) cited the nation’s oversupply of hospitals esired to return to a physiciancentered delivery system ■ Congress compromised between the two and expanded on KerrMills: ● President’s proposal for hospital insurance for the elderly became Medicare Part A ● Republican proposal for physician insurance for the aged became Medicare Part B ● The AMA’s effort to expand KerrMills became edicaid ● Medicaid: not a single national program, ollection of 50 stateadministered programs providing health insurance to lowincome residents ○ Each state’s eligibility rules, benefits and payment schedules for Medicaid are different ■ Richer states have more generous eligibility rules ○ The federal government contributes between 5078% of Medicaid costs ■ During late 1980s, Congress imposed rules to increase state coverage ● Number of children insured nearly doubled in the next 8 years ● Medicaid expansion was the federal government’s ain strategy to reduce the uninsured population ■ During early 1990s, President Clinton proposed to require that employers offer health insurance to their employees ● Proposal failed, bu tates were given more autonomy and flexibility in Medicaid requirements ■ 2 trends dominating Medicaid policy: ● Encouragement or requirement o f managed care delivery systems ● Growth in Medicaid enrollees ended, low decline began a. Probably due to federal welfare reform in 1986 ■ People receiving Aid to Families with Dependent Children (AFDC) stopped being automatically enrolled in Medicaid b. Welfare recipients now had to apply separately for Medicaid ■ Millions didn’t know they even qualified ■ To everse this decrease i n enrollees, state and federal officials undertook some changes ● Simplified eligibility process ● Simplified eligibility rules ● Expanded outreach and education a. By mid1998, enrollment began to increase gain ■ Unfortunately, growth in enrollment has lead igher costs or prescription drugs, services for the disabled, and longterm care ● Prompted c ostcontainment efforts i n every state a. Most popular option was effort to control rising cost of pharmaceuticals, through either everaged buying (purchasing pools) or imits on access (formularies) ■ Recently, the ACA expanded on Medicaid eligibility further, requiring states to expand coverage to a higher percentage of federal poverty level ● Medicare: provided health insurance to segments of the population not generally covered by the mainstream employersponsored health insurance system ○ Differs significantl rom Medicaid; edicare is: ■ A social insurance program provided benefits to the aged and disabled regardless of income ■ Administered by federal offic and the private insurers they hire ■ Funded primarily by the federal government plus beneficiary copayments and deductibles ■ Limited benefit package that excludes much preventive care, longterm care, and until 2006, prescription drugs outside the office ● Medicaid offers a much more generous array of benefits ○ Began in 2 separate parts: ■ Medicare part A: covers inpatient hospital care ● Financed primarily by a 2.9% payroll tax a. Revenue contributed originally exceeded program’s expenses, but surplus $$ were exploited for bills, etc. b. Eventually, provider reimbursement had to be cut ● All beneficiarie utomatically receive part A coverage ● As the program recovered its debt, a change in insurance politics sparked 3 different responses: a. Emphasized the n eed to undo some provider reimbursement cuts b. Argued against new spending measures on behalf of either provider or beneficiary c. Fiscal conservatives: proposed that ny surplus remain in the Trust Fund to be used in future years ● Congress chose to u ndo some cuts in provider reimbursement a. The cuts were widely considered too harsh, and Congress proposed 2 giveback initiatives to reimburse providers ■ Medicare part B: covers outpatient care ● Voluntary program for a monthly premium ● 95% of beneficiaries choose to enroll in part B ■ Medicare part C: Allows private health insurance companies to provide Medicare benefits (private prescription drug plans) for beneficiaries who wish to stay in feeforservice Medicare ■ Medicare part D: beneficiaries can receive outpatient drug coverage through a managed care plan, ssuming they decide against a private prescription plan ● Republicans m aintained that the plan would provide significant coverage to millions of seniors ● Democrats argued t hat the initiative gives too little to needy seniors and too much to health maintenance organizations, big businesses and pharmaceutical industry ● The remaining uninsured: ○ Millions were still uninsured mostly from families with members selfemployed or employed in small businesses ■ States with nionized industrial/manufacturing b ases were likely to have fewer uninsured ○ Dramatic ncrease in uninsured ccurred during mid 1990s an era of economic growth, low unemployment and small rises in health care costs ■ Accelerated in economic downturn of early 2000s ■ Best explained by th ecline in number of americans with employersponsored private health insurance due to: ● Increased share of insurance bill paid by employees ● Elimination of coverage for spouses and children ● Elimination of retiree health coverage ● Hiring of more parttime workers, avoiding need to offer health insurance ● Job growth in service and small business sectors (notoriously lowpaying jobs that don’t offer insurance) ■ Employersponsored health insurance mandate was reinvigorated but failed yet agai ● Faced vehement o pposition from business community ● Opponents argued that m andate would be too costly and would force employers to eliminate jobs ● After its collapse, policymakers focused o eforms in 3 structural areas a. Small business employers often couldn’t afford to provide health insurance to employees b. Employees of small businesses/people who are self employed e arn too little to purchase insurance c. People at high risk medically were often excluded completely from the individual insurance market ■ By late 1990s, focus on insurance reforms were shifted toward programs that expanded health insurance for children (a sympathetic group by bipartisan agreement) ● Congress enacted Children’s Health Insurance Program (CHIP) a. States can use CHIP funds to l iberalize Medicaid eligibility rules b. Simplifies Medicaid enrollment for both client and state ● Early enrollment numbers in CHIP were isappointing because: a. Eligible amilies didn’t know they were eligible b. Complicated application process c. Stigma associated with government insurance programs ● However, i mproved outreach lead to a rise in enrollment a. Democrats proposed significantly ncreased funding b. Congressional R epublicans opposed, arguing expansion would undermine the nation’s private insurance system c. Political battle continued until Preside bama’s inauguration ■ He almost immediately signed for the expansion, and CHIP enrollment continued to increase ■ Despite growing numbers of enrollees in Medicaid and CHIP, number of uninsured kept rising ● Bipartisan debate continued: emocrats for further expansions, republicans against ● Obama decided to p ush hard for comprehensive health reform legislation to: a. Reduce number of uninsured b. Pay for such coverage w ithout adding to the nation’s budget deficit c. Slow the rising cost of health care more generally d. Encourage more efficient and highervalue health care system ● Several obstacles s tood in his way: a. Interest groups (i.e. employers, insurers, hospitals, doctors) b. America’s political institutions/veto system made it almost impossible to enact ● Obama needed to develop a new strategy: a. Declared h ealth reform to be his top domestic priority b. Urged health reform’s e nactment during his first year c. Delegated task of developing reform pla o congressional leaders ○ Congress enacted the Patient Protection and Affordable Care Act of 2010 (ACA) ■ Mandates that nearl ll americans have some form of health insurance ■ Requires state Medicaid programs to provide coverage to all persons with incomes below 133% federal poverty level ■ States ncouraged to create “insurance exchange” system in which the uninsured and smallbusiness community could purchase ore affordable coverage ■ Requires that employers with more than 50 fulltime employees either provide coverage or pay a penalty to federal gov’t ■ Private insurance ompanies are required to comply w ith federal regulations liminating discriminatio against persons with preexisting conditions ○ 4 Key Characteristics of the Policy Process: ■ Each health program or problem domain typically has a relatively distinct policy subsystem: ● Consists of actors from public or private sectors who are routinely and “actively concerned” about a policy problem or issue ● Each policy subsystem tends to be distinctive ■ The fragmented nature of America’s governing institutions makes it difficult to translate majority preferences into major policy decisions in the health arena ■ Implementation is a critical par of the policy process, markedly affecting who gets what from federal health programs ■ Establishment of health programs r econfigures policy subsystems and broader political factors in ways affect program durability ● Medicaid is often seen a ighly vulnerable to program erosion but has actually thrived over the decades ○ Opposition to Medicaid expansion s till existed, especially in the Republican party ■ Reagan’s arrival in the White House unleashed an effort to revamp and retrench Medicaid ■ George H.W. Bush also set to pare the program ■ Representative Henry Waxman o f California fended off the retrenchment initiatives and laid the foundation for substantial Medicaid growth: ● Played a significant role in establishing Medicaid’s Disproportionate Share Hospital program: a. could direct money to hospitls that served uncommonly high numbers of the uninsured and Medicaid enrollees b. Secured the passage of legislation tha equired all states to cover children younger than 6 and pregnant women in poverty ■ Federal and state Medicaid spending grew substantially between 19811992 ○ Medicaid W aivers: ■ Congressional delegation of authority to the executive branch to permit states to deviate from the ordinary requirements of law. Medicaid waivers assume two basic guises: ● Demonstrations a. Gives the federal executive broad discretion to experiemnt with alternative state approaches to Medicaid ● Targeted initiatives focused on longterm care ■ Clinton administration provoked an outpour of Meidcaid waivers ● Among the factors leading federal and state Medicaid outlays to more than double during this period ■ Presidents employ waivers to overcome barriers to adaptation and innovation rooted in the bias of American governance ○ Supreme Court decision in 2012 made state participation in Medicaid expansion voluntary rather than required ■ Movement over time toward a more positive social construction of Medicaid enrollees ● Reducing its image as “welfare medicine” ● Emerging as a program for working people and as a safety net for middleclass individuals needing longterm care ■ As republicans took control of the House of Representatives, they have passed budget resolutions that would repeal the ACA and convert Medicaid to a capped block grant wi educed funding Week 1 Recap: Legitimacy of traditional medicine was gained through scientific discoveries about the foundations of disease. Advancement of technology→ hospital improvement ● “Traditional” Public Health: ○ Primarily through education, clinical intervention and community intervention ■ Community intervention example eat belt laws, fluoridated water, bicycal helmets, etc ■ Clinical intervention: vaccinations ○ Continuum of interventions and care: ■ Primary interventions: basic information not targeted at a specific group to present disease down the road ■ Secondary interventions: identify atrisk group, find ways to treat and find more effectively Ex. mammogram, blood pressure screening ■ Tertiary: already have disease, efforts to manage and treat it ■ Categorized by services provided, settings where they are provided ● Need to separate locations from settings; rehabilitation care can be provided in a variety of locations Week 2/ Chapters 9 and 10: ○ Types of Health Care Services: ■ Prevention: ● Factors including: ○ health policy, individual behavior, social/physical determinants, biology and genetics, and availability of services ● Emphasis on prevention because of its rominence in the Patient Protection and Affordable Care Act of 2010 as an essential component of health insurance benefits ● Important to take a holistic view of communitybased prevention incorporating: ○ Cultural changes ○ Social changes ○ Environmental changes ● Primary Prevention Services: f ocused on preventing or reducing probability of occurrence of a disease in the future ○ Public and private institutions provide services ○ often focused on education ○ Examples include immunizations, smoking cessation programs, and the promotion of handwashing ● Secondary Prevention Services: f ocused on early detection and treatment of a disease in order to cure or control ○ Goal is to minimize effects of disease on individual ○ Examples include routine examinations such as blood pressure screenings, pap smears, and routine colonoscopies ■ Early detection often increase the probability of a successful outcome ● Tertiary Prevention Services: argeted at individuals who already have symptoms of a disease in order to prevent damage, slow down progression, prevent complications and ultimatley restore good health ○ Includes services uch as providing diabetic patients with education and counseling on wound care ○ Also includes institutional practices such as infection control in a hospital facility to prevent illness caused in the process of providing health care ○ Acute care: defined as shortterm, intense medical care provid iagnosis and treatment of communicable or noncommunicable disease, illness or injury ■ Delivered i many settings primary physician, emergency care in the ambulance, other prehospitalization services ○ Outpatient care: any care provided th oesn’t require a hospital stay ■ Prehospital care: nything rovided prior to relocation to the hospital provided by local, communitybased providers ● Ambulance services ● Stabilizatio of injury ■ Primary care: routine treatmen f illness and disease ● Ex: at campus clinic; doctors may refer to other physicians for severe diseases ■ Urgent care: ppropriate for illness, injury or condition erious s enough for a reasonable person o seek care right away ut not so severe to require ED care ● Convenient, cover wide range of services; meant eter people from emergency department ○ Unfortunately, we are not all qualified to determine whether something calls for emergency services ■ Emergency care: p rovide mmediate care for sudden, serious injury ● Classified by ES riage level ○ Immediate: less than one minute 1.1% ○ Emergent: 114 minutes, 10.2% ○ Urgent: 1560 minutes 43.4% ○ Semiurgent: (61120 minutes) ○ Nonurgent: 1 21 min24 hours 45.3% ● Unfortunately, since th D cannot turn people away for lack of insurance, it is frequently utilized for nonurgent care by individuals who are uninsured or underinsured ● Speciality care: focus on particular body system or specific disease or condition ● Chronic care: continual care and monitoring of conditions that can be controlled but not cured ○ Includes both physical and behavioral conditions, i.e. diabetes or depression ○ As the life expectancy of the population has increased, so has the need for chronic care ○ Chronic conditions can exacerbate or cause acute episodes of illness ■ Types of Inpatient Care: ● Tertiary care involve ospitalization for specialty car that requires highly specialized equipment and expertise and involves more complex therapeutic interventions ○ If a community hospital doesn’t have the necessary specialization or equipment, yo ay be referred to tertiary care ○ Ex: Oschner, Tulane ● Quaternary Care: very complex, specialized an ften experimental care for the most unusual cases ○ May involve: experimental procedures or medications or very uncommon surgeries or procedures ○ Not offered at every hospital; more likely to be found at academic hospitals ○ Ex: advanced trauma and organ transplantation ● Rehabilitation: imed at estoring a patient to original state of health ○ Includes physical therapy, occupational therapy, speech and language pathology and psychiatric rehabilitation ■ Longterm care: range of services and support mostly nonmedical for people who have lost independence because of a medical condition (any setting) ● May be provided in an individual’s home or in a community setting or institution ● Aging population & increase in longevity creates challenge of how to care for elderly population (Important Modern Issue hw question) ● Provides ssistance with activities of daily liv (bathing, dressing, eating, medicating) ○ Endoflife Care: care provided inal hours or days f an individual’s life and includes physical, mental and emotional support (any setting) ● Much m ore holistic than the rest of medicine ■ Includes alliative car ensuring comfort, maintaining disease), treatment of discomfort, symptoms and stress of serious illness ○ Extremely underutilize in the US ○ Usually brought in during t ast few days of life ■ Hospice care is end of life care provided when an individual is expected to live 6 mont (any setting) ■ Example: stroke ● Time is of the essence; certain amount of time increases chances and efficiency of recovery ● Chronic conditions managed by primary care physician or specialist ○ Call 911 ○ Taken to a hospital to receive care ○ Treated inside the hospital ○ Admitted to the hospital for 34 days ■ Could be ICU much smaller ratio of nurses to patients ● Specialists evaluate necessary posthospital care ○ LTACs: Longterm acute care hospitals ensure patients do not develop infection in the hospital while they are comatose, etc. ■ Provide basic services to make sure patient stays healthy while on a ventilator, etc. ■ Example: hip replacement ● Chronic pain overseen by a physical surgeon ● Hip replacement therapy is a routine procedure ● Subacute care: xtensive care, special care, intensive rehabilitation ● Emergency services NOT necessary ● Receive secondary care, tertiary care or quaternary care but should not require subacute care unless something goes wrong ○ Probably won’t take a severely ill patient in for an elective procedure ● Start physical therapy that night, stay 3 days in hospital to continue ○ Protects from blood clots, increases mobility/stability in hip, etc. ■ Example: ruptured ACL ● Evaluation and diagnosis of problem but no doctor oversight ● Can be done in a hospital or not ○ Subacute Inpatient care: l evel of inpatient care needed by a patient immediately after or instead of hospitalization for an acute illness, injury or exacerbation of a disease process ■ Centers on providing one or more active medical conditions or administering one or more technically complex treatments ■ Requires more intensive skilled nursing care ■ Applied to a broad range of medical and rehab services and settings providing care after acute episodes ■ For patients who need 10100 days of treatment ■ ● Public Health Organizations: ○ State health departments ○ Local health departments ○ Community health centers: for the uninsured ● Nongovernmental organizations (NGOs): ● Physician Organizations: ○ Solo practic physicians t ork independently ● Group practices: ost physicians in a practice together in more complex, multispeciality clinics ■ Singlespecialty ■ Multispecialty ○ Corporate Practices ○ Urgent Care Centers ○ Ambulatory Surgery Centers ■ Focus on providing sameday surgery care (*growing industry*) ● Telemedicine: remotely, see physician on a screen ○ Popular in suburbs ● Retail clinics x. Walmart clinics have no wait, administer shots and first aid ● Freestanding ED: doesn’t even have to be near a hospital ● Pharmacies: a ble to give shots/vaccinations ● Federally qualified health car regardless of ability to pay, they provide services ● Types of hospitals: ■ Federal hospitals ■ Nonfederal psychiatric hospitals ■ Specialty hospitals ■ Community Hospitals: n onfederal, shortterm general, and other special hospitals that are accessible to the public ● Either voluntary/nonprofit, investorowned (for profit) or public (state or government owned) ● Average length of stay (ALOS): l ess than 25 days ● Services provided on both npatient and outpatien asis ○ Over the past decades, more services have moved toward outpatient (ambulatory) basis to contain costs ● Grouped by ownership into 3 categories: ○ Voluntary, notforprofit ■ Teaching hospitals usually fall into this category ○ Investorowned (for profit, proprietary) ○ Public (state or local government owned and managed) ● Some are freestanding hile others are part ealth system: ○ Defined as a multihospital or diversified single hospital system ■ Cardiac ■ Orthopedic ■ Surgical ■ Others including: veterans administration, department of defense ■ Rehabilitation Facilities: ● Inpatient ● Outpatient ○ PostAcute Care: ● Home Health Agencies ● Hospice ○ Longterm care: organizations o pectrum ■ Independent living facilities→ assisted living facilities→ nursing facilities Lecture 4: The Health Workforce 9/8/16 ● It’s GIANT; may be largest workfor in nation ○ Almost ⅓ of professional degrees are in health care ○ Includes technicians and secretaries, not just obvious things like pharmacists and physicians ■ Includes those wit little education ranging to those with lots of education ○ Offers job security: ■ In 2008’s recession, healthcare jobs increased by 10.75% while all other industries sunk ■ Health care is NECESSARY ● Baby boomers were (are) all reaching retirement age at this time, requiring more care ● Our population is still agi which means jobs will continue to increase ■ Insurance coverage means you don’t have to pay much out of pocket ■ Doesn’t follow typical supply/demand ● Team settings are growing; physicians a no longer independent ○ Even nonclinical people may be part of this team ● Largest healthcare occupation sectors: those who actually touch people ○ RNs, nursing assistants, personal care aides, home health aides, etc. ○ Also have lots of people behind the scenes ■ Due to increasing technology ● Primary care professionals: first point of contact for your needs ○ Can be MDs (medical doctors) o Os (specialize in internal medicine, family practice, or pediatrics) ■ Foundation of Os around holistic medicine however their practices have become very similar to those of MDs ■ Both are required to go through medical training, residency and certifications ■ DOs typically focus more on primary care ○ Pediatricians and B/GYNs can also be PCPs ■ Specializing either in children or women’s health ○ These practitioners can be gatekeepers” for referrals to specialists ■ Primarily protect and monitor the basic health needs of their patients through: ● Performing hysicals ● Administering accines trep tests, blood tests, etc. ● Patient counseling ■ PCPs receive patients irect them to a specific doctor ● Rather than going to physician after physician before finding the root of a problem ○ Nurse practitioners NPs) are nurses with graduate training ■ Nurses that have gone back to school for an additional degree ave a little more autonomy ■ Can serve as a primary care provider, pediatrics, adult care or geriatrics ■ May work in women's health ■ Can prescribe medicine ■ Services may include: patient history, physical exam, order lab tests, writing prescriptions/referrals, providing handouts on disease prevention and healthy lifestyles, certain procedures such as bone marrow biopsy and lumbar puncture ■ Some NPs work in clinics ithout doctor supervision others work together with doctors as a joint healthcare team ● Their scope of practice and authority depends on state laws ○ In some places, they may be able to work completely alone whereas in others, they must have a doctor in the room ○ A physician assistant PA) can provide a wide range of services working alongside the physician ■ Prepared academically and clinically to provide health services under the direction and supervision of an MD or DO. PA unctions includ ● performing iagnostic, therapeutic, preventive and health maintenance services ■ Practice in a ariety of settin in nearly every medical and surgical industry ○ RNs have graduated from a nursing program, passed state board exam and are licensed by the state ○ Licensed practical nurses (LPNs) are statelicen caregivers who have been trained to care for the sick ○ Advanced practice nurses have education and experienc eyond the basic training and licensing required of all nclude NPs and the following: ■ Clinical nurse specialists (CNSs): training in fields such as cardiac, psychiatric or community health ■ Certified nurse midwives (CNMs) have training in women’s healthcare ■ Certified registered nurse anesthetists (CRNAs) have training in anesthesia ■ *Goal is to expand each of these professions to decrease the amount of trained professionals necessary to carry out an operation or procedure* ○ ALL of this clinical care is what people have in mind when they think “public health” ■ BUT it is so much more: there are people that ensure safe places to exercise, accessibility of healthy foods, etc. ○ Education requirements: ■ NO formal training: personal care aides, medical secretary ■ Postsecondary education: s urgical technicians, LPNs, EMTs ■ Associate degree: d ental hygienists, respiratory therapists, Lab technicians, RNs ■ Postgraduate: p hysicians, pharmacists, physical therapists, optometrists, physician assistants, nurse practitioners ■ The ability to work toward these highpaying jobs makes medicine an attractive workforce ● Critical issues: ○ Little national workforce planning: ■ The United States oes not ave a highly centralized health care workforce, and engages in limited national planning efforts ■ Traditional supplyanddemand approach t o workforce planning doesn’t really work here: ● Can rarely estimate changes in overall supply that might arise due to the development of new health care occupations ● Two fundamental shortcomings of workforce planning are that: ○ It is usually tied to current care delivery models ○ It treats each health professional independently ● Innovative teambased care delivery approaches, expanded roles for nonphysician health professionals, increased use of technology and integrated primary care delivery models coul ddress shortage of health professionals ● Healthcare system ontinues to absorb all these new workers ● Utilization increases limitlessl if we do not have a systematic way to plan for the workforce ○ Emergency rooms overused because we are acking the “gatekeeper” function ■ People come in for walkins, strep throat, acid reflux, etc. ○ Not an adequate workforce to meet the needs of the growing population ■ People who are uninsured already ave less access o healthcare providers ■ Extension of insurance may lead to a urge in demand or health care services ■ If shortages exist when demand is greater than supply, the economic response to a shortage is n increase in wages hich leads t reater supply (because compensation is more attractive) and lower demand (because cost becomes unaffordable) ○ Ongoing shortages ○ Health care financing ○ New technologies ○ Increasing importance of health ca abor unions n management partnerships ○ Need to revamp regulations to ncrease health professionals’ efficiency nd effectiveness ■ In 2012, about alf of NPs were practicing in primary care settings ■ Studies show that NPs can manage 8090% of care provided by PCPs ● Physicians with 8 years of training may argue that a nurse with 4 years cannot replace them UT ○ Evidence shows that primary care utcomes are comparable between patients served Ps and patients served b PCPs ■ Ex. Optometrists vs ophthalmologists in LA arguing about who is certified to perform Lasik surgery ● Who gets the larger scope of service? Why pursue more education if the opportunity for potential with more training goes down? ○ Public health agencies are NOT immune to economic downturns the way healthcare is; they are experiencing severe and increas orkforce shortages ■ Recent loss of 46,000 state and local positions due to budget cuts ■ Foreseen necessity of 200,000 new workers ○ Physician workforce diversity: the health workforce should accurately reflect the people it serves ■ We are more likely to listen to someone if they look like us ■ People of the same race are more likely to understan otential health problems and barriers to public health in a racial community ● Ex. Hispanic educator more likely to effectively teach in a hispanic community ○ As healthcare evolves into a hightech industry orkforce will require more technicians and employees who understand how this technology works ■ Healthcare is in the relative dark a compared to industries like banking ○ Seeing curriculum changes a nd examination changes n medical schools ■ Taking a more holistic view, incorporating interpersonal skills, wellness, nutrition ○ Health administration: medical and health service managers, etc. in management occupations ■ Need health leadership, not just management ● Seeing 17% growth ■ 34% of people with this training go to hospitals/health systems, others seek additional education ■ Roles of finance, physician relations, human resources, etc. ■ In the future, we look toward increased roles entailing: ● Retail medicine ● Medical home coordination ● Robotics ● Destination medicine ● Patient experience ● Population health ● Social media ● Longevity health Week 3/ Chapter 11: Health Care Financing ● 3 Dimensions ○ Insurance: how do we protect against risk? ■ Risk is defined as t robability of a substantial financial l from an event of which the probability of occurrence is relatively small ■ We have to determine our own risk in many situations: determine whether we want insurance (where is the money more valuable?) ■ Insurance: m echanism whose primary purpose is protection against risk ● Insurer is wh ssumes the risk ● Underwriting i s systematic technique for evaluating, selecting and classifying rating risks ○ Ex: patient history of heart disease is taken into account when insurer decides to provide a plan or not ● Fundamental Principles: ○ Risk is unpredictable for the insured individual ○ Risk an be predicted with a reasonable degree of accuracy f or a group or population ■ The l arger the population, the more accurate the prediction will be ■ Certain populations may be higher risk than others ● Ex. the elderly ○ Insurance rovides a mechanism for the transferring or shifting risk from the individual to the group through pooling of resources ■ First form of insurance was in the battle leagues ● Knew 4% of soldiers would die ● Individual soldier risk varied ● If each soldier gave a small amount of money to the total, they would all benefit from insurance ○ All members of the insured group hare actual losse on some equitable basis ● Basic terminology: ○ Beneficiary or insured: ny person eligible for service under a health plan contract ○ Premium: amount charged (usually monthly) by the insurer to insure against a specific set of losses. Also covers marketing, administration, claims processing, profit, etc. ■ You pay this even if you don’t exercise the benefits of insurance ○ Deductible: amount the insured must pay each year before receiving any benefits ○ Copayment: flat amount the insured must pay each tim e health services are received (eg $25 copay for physician visit) ○ Coinsurance: set proportion paid as beneficiary uses insurance ○ Outofpocket maximum: the maximum amount the insured must pay for care; once reached, the plan pays 100% of additional expenses ○ Financing: how do we pay for this coverage? ■ Most common way of getting insurance is through employers ● Companies offer to employees as f urther incentive other than higher wages ○ They usually ick 2 or 3 insurance plan to offer for employees to choose from. This ensures the employees won’t just pick the most expensive option out there, for which the employers would have to pay ○ Employers m ay place you on a group plan w ith other, similar individuals to create an insurance pool. This is called roup insurance: ■ Third party ■ Selfinsured ■ Ex. Tulane is selfinsured; sets aside own money, saves money from paying insurance provider ● Tulane assumes all the risk, saves money that would be spent insuring small risk ○ Individual Private Health Insurance: ■ Health insurance marketplace ■ Private market ○ Managed Care: ■ MCO (Managed care organization) is an entity that links the financing and delivery of health care services ■ Arrangements often include ome type of financial consequences for risky event ( i.e. high medical bills) ● Ex. offer $2500 for all healthcare, you decide how it is used. ● COMPLAINT: P hysicians used to decide how to use that money, but there was a lot of discomfort with the burden of health de
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