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