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Health care org/management, week 5 notes

by: Loretta Hellmann

Health care org/management, week 5 notes HCA 340 -002

Marketplace > Western Kentucky University > Nursing and Health Sciences > HCA 340 -002 > Health care org management week 5 notes
Loretta Hellmann
GPA 3.75

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week 5 notes
Steven W. Maddox
Class Notes
health, health care, wku
25 ?





Popular in Nursing and Health Sciences

This 14 page Class Notes was uploaded by Loretta Hellmann on Thursday February 25, 2016. The Class Notes belongs to HCA 340 -002 at Western Kentucky University taught by Steven W. Maddox in Spring 2016. Since its upload, it has received 33 views. For similar materials see HEALTH CARE ORG/MGT in Nursing and Health Sciences at Western Kentucky University.

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Date Created: 02/25/16
Week 5 Notes Tuesday, February 23, 2016 9:16 AM Chapter 5 Ambulatory Care (outpatient care) Tuesday's class Overview and trends  Ambulatory care: medical care not requiring overnight hospitalization  Continuing volume shift from hospitals began in 1980s  Advanced technology --> safety improvement  Payer incentives to decrease inpatient states  Consumer and physician preferences  1990s: increasing number of facilities owned and operated by hospitals, physicians, independent corporate chains  Cancer treatment, diagnostic imaging, renal dialysis, pain management, physical therapy, eye, plastic and other surgery, etc..  Physicians and hospitals compete for patient business, altering prior relationships Components of Ambulatory Care  Private Medical Office Practice- predominant mode of ambulatory care in the US  Other (non-physician) ambulatory care practitioners  Ambulatory care services of hospitals  Hospital emergency services  Free-standing (non-hospital based) facilities Private Medical Office Practice  Predominant mode: 1 billion+ visits per year  568 million visits to primary care physicians  257 million visits to medical specialists  193 million visits to surgical specialists Transition to Physician Group Practices  Mayo clinic group practice of salaried MDs in late 1800s, controversial  Until 1930's solo practice was predominant  1932 Committee of the Costs of Medical Care reported recommended group practice as economically efficient, promoted insurance as a means to improve access  A blue ribbon panel of public health professions, academicians and economists Reactions to Committee report on the Costs of Medical Care: 1930s-50s  AMA condemned recommendations for group practice and salaried physicians as "unethical"  GHI (general health insurance? ) establishment (1937) erupted legal battle, AMA expelled GHI- salaried physicians and "blacklisted" them with hospitals  DC Medical Society and AMA indicted and found guilty of conspiracy to monopolize medical practice  Next few decades spawned controversy about MD participation in group health plans- physicians were socially ostracized Continuing Opposition to Group Practices  Physicians sought membership in evolving group health plans as local medical societies attempted and failed at obstructing group practices  Group physicians were ostracized and denied hospital privileges  Opposition subsided by 1950s due to legal challenges and physician shortages Transition from solo to Group- Practice in 1960s  Social and lifestyle changes- movement for life balance  Medical specialization- medical knowledge  Medicare and insurance complexities- increase coverage above 65 years old  Office technology costs and overhead spawned economies of scale opportunities  Malpractice insurance costs  Provided a professional supportive environment Group Practice features  Single and multi-specialty groups  After hours and vacation coverage  Informal collegial consultation  Seeking advice  Informal system of peer review  Shared office overhead (personnel and technology) Physician Employment by Hospitals  Number of physicians employed by hospitals: 32% increase in 2000-2012 due to: 70% in 2009  Flat/decreasing reimbursement rates  Complex health insurance and technology requirements  High malpractice premiums  Desire for greater work-life balance  Hospital advantages of physicians employment  Gain market share for admissions  Guaranteed use of diagnostic testing, other outpatient services  Referral to high-revenue specialty services  Gain a position with physicians networks for health plan negotiations, care coordination, quality monitoring, costs containment Integrated Ambulatory Care Models : Integration and coordination of care (two models)  Patients-Centered Medical Homes (PCMH)  Accountable Care Organizations  Seek remedies of service fragmentation: piecework reimbursement, no reimbursement for care coordination efforts, ineffective/ absent links for patients among/between multiple service providers, service duplications, inadequate aggression of data of patient outcomes  Patient-Centered Medical Home  Team based model of care led by a personal physician provide continuous and coordinated care throughout a patient's lifetime including linkages with other professionals for preventative, acute and chronic illness and end-of-life assistance  Since 2006, Patient-Centered Primary Care Collaborative of 1,000 members organizations, e.g. primary care physicians, insurers, govt. agencies, academia and others  Affordable Care Act provisions supporting PCMH  Expanding Medicaid eligibility  Medicare and Medicaid payment increased for primary care and designated preventive services  Funding to place 15,000 primary care providers in shortage areas  Funding for health professional training and more primary care residence  Center for Medicare and Medicaid innovation  Transitions to PCMH  "wrenching culture and system changes"  Substantial payment reforms  Highly motivated physicians, redesign of staff roles and care processes, health information technology, and other support  National Committee for Quality Assurance NCQA: provided primary practices "recognitions" for adherence to standards, new 2013 credentialing certification for PCMH Content Expert  Accountable Care Organization (ACO)  Affordable Care Act adopted model: group of providers, suppliers of health care, health- related services, others involved in patient care to coordinate care for Medicare patients (PCMHs are ideal primary care component)  Goals: Timely, appropriate care; avoid duplications, medical emergencies and hospitalization  ACO definition- legally constituted entity within its state including providers, suppliers, Medicare beneficiaries on its governing board  Responsible for 5,000 Medicare beneficiaries for 3 years  Meet Medicare-established quality measures  Payments combine fee-for-service with shared savings, bonuses linked with quality standards applicable to all providers  ACO providers and suppliers  ACO physicians, hospitals in practice arrangements  Networks of individual practices of ACO professionals  Partnerships or joint venture between hospitals, ACO professionals, or hospitals employing ACO professionals  Other DHHS (department of health and human services)-approved providers, suppliers Other Ambulatory Care Practitioners  Licensed professional in independent practice: solo or group, single of multidisciplinary practices  Dentists, podiatrists, psychologists, optometrists, physical therapists, social workers, nutritionists Early Hospital Ambulatory Care  19th century: clinics poorly equipped and staffed, often remote "dispensaries"  Served community's poorest; charitable mission  Teaching sites for medical students  Staffed by low-ranking physicians, often to earn admitting privileges Tradition Teaching Hospital Clinics  Organized into specialty areas for teaching and research purposes; ""anatomic" orientation  Patients benefit from sophisticated care  Specialty orientation causes fragmentation, challenges in coordinating care across multiple clinics Hospital Clinical Evolution- 1980s  Primary care as "core" service with salaries physicians, not volunteer, physicians  Improved care coordination  Specialty (boutique) services to attract paying patients Hospital Ambulatory Care-Today  Continue "safety-net: functions  Teaching sites for primary and specialty care  Well-equipped and staffed  Profitable referral centers: acute care and ancillary services, 42% total hospital revenue  Continuing challenges for providers and patients in coordination care across multiple clinics will be aided by HER use Thursday Hospital Emergency Services  Staffed and quipped for life-threatening illness and injury, physician and nurse specialists  136 million annual visits- 259 a minute  Community "safety nets"- 2008-2009: 10% upsurge in usage, the highest increase on record  1990-2009: total number of urban EDs declined 27%, from 2446 to 1779 due to for profit ownership, market competition, low profit margins  Visit payments status: 19% uninsured; 39% privately insured  Inappropriate use of ER from patients: 8% or 10M are "non-urgent"  Patient self-determination of symptoms  Physician referrals (off-hours, office scheduling issues)  1/3 of visits: injuries, poisonings, adverse effect of prior treatment Freestanding Facilities  "Freestanding"- non-hospital based facilities: owned, operated by hospitals, physicians groups, for profit entities, corporate chains  Urgent care  Retail clinics  Ambulatory surgery centers  Federally qualified health centers  Public health ambulatory services  Not-for-profit agencies Urgent care Centers  First in 1970s  UCAOA (Urgent Care Assoc. of America): provide walk-in, extended hour access for acute illness and injure care that is either beyond the scope or availability of typical primary care practice or retail clinic  Operate under licensed physician auspices  8,700+, 150 million visits annually  Ownership: for profit, physician groups, managed care organizations  Primary care physicians, nurses, ancillary services, EG lab and radiology  After hours, non-emergency; location- 55% suburban; 25% urban; 20% rural  Episodic care w/emphasis on primary care physician relationship  Since 1997, American Board of Urgent Care Medicine certifies, after taking an exam, created primary care specialists in the field of urgent care  So you can specialize in urgent care Contentious issues  Hospitals: cull paying patients, leave the poorest for hospital emergency departments and clinics  Physicians: discourage/impede relationship with primary physician and continuity of care  Consumers: Urgent care responds quickly, efficiently, effectively w/lowest cost Retail Clinics  First in 2000; Minneapolis/ St. Paul grocery stores; 1,200 retail site by 2010 (like the little clinic in kroger)  Operated in pharmacies and supermarkets  CVS, Walmart, Walgreens, Kroger, Target  2007-2009: number of retail clinics quadrupled: visits exploded from 1.5 M to 6M  Entrepreneurial response to consumers' needs  Strong insurer and employer acceptance; some insurers waive/lower co-pays  Market forecasts doubling numbers to 2,800 by 2018  American Academy of Family Practice Physicians recognized retail clinic need and creates primary physician opportunities; opposes expansion beyond minor illnesses; clinics can be a component of PCMH (patient-centered medical homes) Retail Clinic Issues  AMA (American Medical Assoc.) 2007: urged investigation for conflicts of interest (RX, other sales), disruption of physicians/patient relationships, co-pay waiver unfair to physicians still required to collect Ambulatory Surgery Centers  Established in the 1970s  Anesthesia advances: primary drivers  New operation technologies  34.7 M annual visits  2008: 5,149 Medicare-certified centers; 2000-2007: 7.3% increase in numbers  96% full or partial physician-ownership; 25% have hospital ownership interest; 2% entirely hospital owned  Medicare and private insurer mandates pushed development  Created hospital opportunities for profitable space conversions Benefits of Ambulatory Surgery and Quality  Patients: access, fewer complications, quicker recovery  Physicians: convenient staffing and scheduling, less competition for facilities  Accreditation: Medicare, Joint Commission reviews, Accreditation Association for Ambulatory Health Care reviews, American Association for the Accreditation of Ambulatory Surgery Facilities reviews; 43 states require licensure Federally Qualifies Community Health Centers (FQHCs)  1960s: US Office of Economic Opportunity; both urban and rural locations- Pres. Johnsons war on poverty  2008: received a $1.9 Billion grant, administered by Health Resources Services Admin. Of the Dept. of HHs  2011: Served 20.2 M patients in 1,200 centers with 8,500 sites in all states, DC, Puerto Rico, US Virgin Islands  Multidisciplinary care teams; provide education, translation, pharmacy, transportation, etc.  Link, refer: WIC, social work, public assistance, legal services  2/3 of patients uninsured or Medicaid  Revenue: Medicare, Medicaid, private insurance; Medicaid patients increased 39% 2007-2011 while Medicaid reimbursement declined  Administering organizations for FQHC: local government health departments, units of community organizations, stand-alone not-for-profit agencies  2009: $600M American Recovery Reinvestment Act created Funds to expand 85 centers; support HER, other technology  2010: ACA (affordable care act) funds expansions, new sites, 3-year PCMH (Patient-centered Medical Homes) pilot for Medicare beneficiaries Public Health Ambulatory Services History  Originated in charitable tradition of community responsibility by municipalities and states, colonial period-1800s developed as almshouses and "poor- houses"  State and local governments' increased roles providing welfare and public health developments led to tax- supported departments of health in late 19th, early 20th centuries  Public health success in controlling childhood and other communicable diseases gave way to expanded medical care focus on chronic illness with a resources shift from prevention to treatment  New public health demands to promote lifestyles, provide safety-net services, expand regulatory oversight to medical industries  Current public health services range across a spectrum of city, county, state: immunizations well- baby care, tobacco control, disease screenings , education, personal services through health centers; infectious disease case-finding and control  Staffing: physicians, nurses, aides, social workers, sanitarians, educators, community health workers, support staff  2010 NACCHO (National Assoc. of County and City Health Officials), findings of Nations Survey of Local Health Departments (2,107/2,565 responses)  Most common ambulatory services  92%: childhood immunizations  75%: tuberculosis treatment  59% treatments for STIs  55% Family planning Public Health Ambulatory Services: Emergency Preparedness  2001 terrorist attacks  $5 billion to states to strengthen infrastructure accompanied by many new demands amid state budget crises; did little but fill gaps  2009 H1N1 threat  Public health response of state variable in local level performance; reports identify Internet access, staffing constraints, media use patterns as causes of variability Not-For-Profit Agencies  Not For Profit organizations, governed by volunteer boards of directors  Cause- related, often grass-roots in origins  Disease and/or cause specific Missions  Usually tax-exempt, 501© 3  501 C 3 is just a tax code that references an organization being tax exempt  Education, counseling, medical care, advocacy  Ex: planned parenthood, Alzheimer's Association  Single corporations or affiliates of national organizations  Funding: government and private foundation grants, private donations, Medicare, Medicaid, private insurance, sliding fee scale  Serve as repositories of community values and charity, fill gaps for special need populations and cause advocacy Continues Future Expansion and Experimentation  Shift from hospitals to freestanding facilities will continue with medical care advances, cost-reduction initiatives, consumer demands; ambulatory surgery, urgent care and retail clinic use will grow  PCMH (patient centered medical homes), ACO models' study finding will inform practitioners and policymakers about future refinements tin improve quality and reduce costs


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