2-organization of care Flashcards
(48 cards)
Characteristics of the organization of health service delivery:
mix of organizations
divisions
interactions among these
organizations -how they get the resource
The internal administrative and management structures
how is British NHS – an example of regionalized care
2/3 of UK physicians are GPs.
Secondary care – specialists, usually in hospital based clinics, consultants
Tertiary care sub-specialists – immunologists, pediatric hematologists, transplant specialists
Hospitals and provider placement follows population calculations – i.e. what number of people, with particular demographics, require what number of providers, at what level.
Dispersed model in the US – less structured approach, less oversight, regulation and guidance form government.
Patients can access specialists directly.
what does the division of services look like in the US
Hospitals in US do not operate within a secondary and tertiary classifications, with many private hospital offering highly specialized services to attract patients and providers. Not efficient, or high quality.
While it may offer greater flexibility of services and convenience - top-heavy with specialists, expensive, fragmented often uncoordinated care.
what is meant by the phrase a cottage industry
nonintegrated, dedicated artisans who eschew standardization.
what are the reasons health care is fragmented in the US
peer accountability,
quality improvement infrastructure,
clinical information systems
what has lead to dispersed model of care
Biomedical model of health care -one problem one treatment
Financial incentives
Professionalism -sovereignty of physicians as pre-eminent authorities on health care
what % of care is self care
~80% of care = self care
– treatment of rare and complex disorders
Tertiary
hospital care falls under
secondary along with specialists
4 characteristics of primary care
Initial contact
Continuous care
Comprehensive
Coordination of care
what is gatekeeping
“Gatekeeping” preventing inappropriate visits to specialists or for unnecessary procedures
how can Patient incentives improve care
Patients should be given incentives to choose to receive care from high-quality, high-value delivery systems. This requires performance measurement systems that adequately distinguish among delivery systems. Payment…
how can Regulatory changes improve care
The regulatory environment should be modified to facilitate clinical integration among providers. Limit unnecessary duplication of facilities and services
Full population prepayment
a single payment for the full continuum of services for a given patient population and period of time—should be encouraged.
Global case payments for acute hospitalizations
Ideally, such payments should bundle all related medical services from the initial hospitalization to a defined period post-hospitalization (including preventable re-hospitalizations). These payments also should be risk-adjusted to avoid adverse patient selection.
APM
is a system for medical reimbursement that provides additional compensation as an incentive for the delivery of higher quality and more cost-efficient health care by providers
PPS
The Medicare Prospective Payment System (PPS)
A payment mechanism for reimbursing hospitals for inpatient health care services in which a predetermined rate is set for treatment of specific illnesses.
PPOs
– pts can see any providers, but lower costs if using in-network. Providers agree to accept payment as set by insurer.
HMO used to be
Health Maintenance Organization used to be
Prepaid Group Practice
ACO how it different from HMO
HMO only covered in HMO network
you can see ACO outside
don’t cut corners, need to track care
An ACO is not a managed care system designed by an insurance company. That would be an HMO. ACO stands for accountable care organization, and ACOs are part of Medicare.
what is risk adjustment for ACO
Risk adjustment helps to determine if a particular population of patients is sicker than another similar group. We have all heard physicians say, “My patients are sicker, and that is why they cost
Beveridge” Model
Named after William Beveridge, the social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library.
cost of the Beveridge” Model
Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge.
Countries using the Beveridge plan or variations on it include
its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong and Cuba ( purest)
