Fundamentals of Healthcare - Exam I

Health Care Systems Where people go for health care services. Inpatient Settings Admitted to the hospital Stay at least 24 hours 00:01 01:31 Outpatient Settings Only receives treatment for a few hours Does not stay overnight Observation Status Not admitted to the hospital, although is staying overnight More common in inpatient hospitals Ownership - Public Federal Federal Government agencies operate the hospital Department of Veterans Affairs - VA Medical Center Indian Health Services for Native Americans Public - State/Local Long term psychiatric patients Beatrice State Hospital Public - Prison Can be administered by Federal, State or Local governments Private - Non Profit Stem from charity institutions Profit is re-invested in the hospital or community Government doesn't require them to pay taxes Local Examples: CHI (Immanuel, Lakeside, Bergan Mercy, etc) Private - For Profit Owned by private corporations Profit is given to the shareholders Required to pay taxes General Services Have a variety of services they offer: ED (Emergency Department), OB/GYN, Oncology, Medical-Surgical, etc Teaching Services Connected with medical schools that have residency programs Academic Medical Centers UNMC - University of Nebraska Medical Center CUMC - Creighton University Medical Center Specialty Services Focus on a single specialty Children's Hospital Lasting Hope/Richard Young Nebraska Orthopedic Hospital Methodist Woman's Hospital Networks of Hospitals A network is a organization that owns and operates multiple hospitals and/or outpatient facilities. Horizontal Network multiple institutions of the same type Shriners Hospital Vertical Network contains different types of services Kaiser Permanente Board of Director/Trustees Set the vision of the hospital/clinic oversees the financial status of the hospital Administrative Services CEO, VP, Departments Leads Run the day-to-day operations Therapeutic Services Physician, Pharmacy, PT/OT/SLP, SW, etc Diagnostic Services Informational Services Informational Services Lab, Testing, Imaging (CT, Xray, etc) Medical Records, Billing, HR, etc Support Services Food Services, Supply Management, Housekeeping Committees Infection Control, Falls, Quality Assurance Skilled Nursing Facilities (SNF) 24 hr nursing care Residents may range from younger to elderly depending on the disability and/or diagnosis Most are heavily funded through Medicare/Medicaid Long Term Acute Care Hospitals Need hospital level of care for weeks/months Inpatient Rehab Facilities (IRF) Need medical management as well as comprehensive rehabilitation Outpatient Known as "ambulatory care" because most patients walk in/out for services provided. Examples: PT/OT appointments Mammogram Lab testing Types of Outpatient Settings Private Practice Owned and operated by the professionals that work in the clinic Hospital/Health Care Network Affiliated with the hospital and have a direct relationship with the network Community Health Center (CHC) Government supported for low-cost care to undeserved and low income populations Local Examples: Charles Drew, One World Free/Charitable Clinic Also for underserved and low income, although are operated by private not-for-profit organizations Local Government County Health Departments Local Examples: Douglas County Hospital Emergency Department (ED) Patients have not yet been admitted to the hospital Urgent Care Center The in-between step from primary care doctor and ED Are not able to handle trauma cases Local Examples: Urgent Care of Papillion, Midwest Minor Medical Retail Clinic Convenient locations, quick care Minor conditions: strep throat, flu shot, school physical, etc Ambulatory Surgery Center May be located in the hospital Minor procedures: colonoscopies, cataract sx Home Care Patients receive care in their home PT/OT/SLP, SW, Nursing, Bath aide Need to be HOME BOUND!! Hospice Care is focused on quality vs quantity of life, majority have a terminal illness To provide comfort for their symptoms Typically have 6 months or less to live May be provided in the home, or at a facility Non-Physician Services Dentist, Chiropractors, Podiatrist, Optometrist, etc Complementary and Alternative Medicine Herbal and Natural Products (acupuncture, homeopathic care) Most patients have to pay out-of-pocket for this type of treatment Boutique/Concierge Practice High level of service, patients pay an annual membership fee Issues in Health Care The issue health care faces Shortage of Primary Care MDs Most have a specialty area Changing Models of Care Solo Practice vs Group Practice Hospital-Physician Relationship Patient Centered Medical Homes (PCMH) Financing health care by creating a single center where all the pt's care is coordinated with bundled payments. Uncompensated Care Orgs Charity care: hospital gives away care and doesn't expect to recover Bad debt: tries to recover from the patient Under compensated care orgs Typicially what Medicare covers for services and private insurances follow suit May make allowances to "shift" Directly affects other areas of operation Hospital-Physician Relationship ... Independent Contractors Primarily in OP settings and can admit patients to one or more hospitals Medical Group Contract with the group to provide care in their hospital Speciality groups: Local Examples: GIKK, Hematology/Oncology Consultants, Heartland Cardiac Medical School or Academic Physician Organization Nebraska Medicine, Creighton University Medical Center Hospitalist House physician that rounds on patients that are inpatient only and does not follow their care upon discharge. insurances have Patients/Consumers Providers (MD, RN, therapists, etc) Payors Information Asymmetry Once side of a transaction has more information than the other side. Influences many interactions in the health care system. Ex: insurance co wants the policy holder to incur fewer costs so the company will not have to pay as much Moral Hazard The trend toward risky behaviors when you know you won't end up having to cover the full cost. Ex: smoking and neglecting to get regular check-ups Adverse Selection covering those who aren't covered enough. Insurance exists to spread costs among even those who end up incurring them. Key reason for the individual mandate Behavior Economics Study of the human behavior and psychology to understand various health issues Beneficiary: The individual whom is enrolled in the health insurance plan/policy Subscriber Person who purchases the insurance May be the same person as the beneficiary Dependents Other people who are on the policy (spouse/children) Insurance Premium The monthly fee to maintain the insurance Cost-Sharing When a service is provided and insurance pays for a portion of the bill, the beneficiary is responsible for paying the difference Deductible Fixed dollar amount that the beneficiary must pay out of pocket. Amounts vary for each policy Co-Payment Fixed dollar amount that the beneficiary pays for certain services: Office visit, ED visit Amount may vary based on the type of visit