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Exam 2 Flashcards

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1
Q

What is ambulatory care?

A

Healthcare services not requiring overnight hospitalization. Synonymous with outpatient care.

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2
Q

What are HPSAs?

A

Health Professional Shortage Areas

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3
Q

How many HPSAs are in Georgia?

A

232

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4
Q

What is primary care defined?

A

“Accessible, comprehensive, coordinated, and continual care delivered by accountable providers of personal health services.”

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5
Q

Which specialists are under the primary care umbrella?

A

Family Physicians, Internists, Pediatricians

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6
Q

What is the value of primary care?

A

Lower costs, better outcomes

Lower mortality, lower premature death (especially from asthma, cardiovascular disease, and pneumonia)

Increased age appropriate prevention

Reduced use of Emergency Department / hospital

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7
Q

What is a PCMH?

A

Patient Centered Medical Home

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8
Q

What are current issues with primary care?

A

Not enough physicians (it doesn’t pay as well as specialties) - only 5% of residencies match to primary care

Payment system reimburses procedures higher than face to face interaction

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9
Q

What are ACOs?

A

Accountable Care Organizations

Provider led organizations whose mission is to manage the full continuum of care and be accountable for the overall quality and costs for a defined population.

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10
Q

What are the primary principles of ACOs?

A

Local accountability for continuum of care
Pay for value
Transparent measures of system performance
Systems alignment (aligning pay with outcomes)
Incentivize better care at lower costs

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11
Q

What are the primary principles of PCMHs?

A

Introduced by American Academy of Pediatrics in 1967

Proactive, preventative, coordinated, and patient centered model (with physician directed teams)

Payment reform, enhanced access

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12
Q

What is the relation between ACOs and the ACA?

A

The ACA funded CMS ACO pilots starting in 2012

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13
Q

What are challenges for ACOs?

A

Incentives are aligned with cost savings which runs the risk of ACOs avoiding underserved populations (such as low income, minority, and disabled)

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14
Q

What are Community Health Centers?

A

An integral part of the health care safety net
Many are certified PCMHs
More than 10,000 clinical sites
Serving over 27,000 patients (most of which are low income & racial minority)

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15
Q

Does the US have a shortage of doctors?

A

Many experts state that we have enough doctors but we have unequal distribution / shortages in certain areas (specialties, demographics, and geographics)

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16
Q

How can we get more primary care doctors / doctors in rural areas?

A

Accept more students from rural areas (e.g. Mercer rural student scholarship)

More mobile avenues for primary care

Financial incentive for medical school completion

Medical school schoalrships

Requirement for placements in rural and /or low SES settings to become licensed

Fast track foreign trained physicians to work in an area with their race / ethnicity

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17
Q

Where do patients go when community health centers shut down?

A

Public hospitals (usually overwhelming them)

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18
Q

Describe the breakdown of Primary Care Physicians by practice size.

A
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19
Q

Describe the breakdown of US Healthcare spending.

A
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20
Q

What was the Hill Burton Act (1946)?

A

Hospital Survey and Construction Act

Provided federal grants to states for construction of new community hospitals
Required hospitals to provide a certain amount of charity care
Permitted hospitals to separate patients based on “separate but equal”
Conservation response to Truman’s comprehensive national insurance plan
Only codified instance of racial segregation in healthcare

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21
Q

What were the early versions of hospitals and when did the institution of hospitals arise?

A

Almshouses / poorhouses (1800s)
Hospitals become official institutions in the 1900s and all started as nonprofit
The Joint Commission (for accreditation) of 1950 helped begin the progression of for profit hospitals

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22
Q

What are the different types of hospitals?

A

Public (13%) including the VA system

Non-profit (60%)

For profit (13%)

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23
Q

How are different types of hospitals funded?

A

Public - by local taxes and CMS, Disproportionate Share Payments (DSP)

Non-profit - must demonstrate benefit to the IRS and via a Health Needs assessment for tax exemptions, government grants, and philanthropy

For profit - investors (e.g. Tenet, Hospital Corporation of America)

Hospitals get more funds for being Teaching Hospitals

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24
Q

What are Disproportionate Share Payments / Adjustments?

A

A payment adjustment under Medicare’s PPS for Medicaid utilization at hospitals that serve a relatively large volume of low-income patients, pregnant patients or other patients under the Medicaid program.

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25
When did Medicare develop Diagnostic Related Groups (DRGs) and how did they affect hospitals?
1983; this changed reimbursement to hospitals based on patients' admitting diagnoses. This led to increased care and discharge management (payment was set based on diagnosis, not length of care which incentivized quicker discharge and led to fewer hospital beds)
26
What were factors that led to reduced numbers of hospital beds?
Diagnostic Related Group reimbursements (and similar funding changes in private insurance plans) Moving procedures and surgeries out of hospitals Developing hospitals into larger systems (like Wellstar and Emory) "Certificate of Need" in Georgia (needed to build new hospital or provide more beds)
27
What are Rural / Critical Access Hospitals?
Similar to public hospitals but are often required to provide 24 hour emergency services (this rule was waived in Georgia) to justify funding. They are paid similarly to public hospitals but can also get cost-plus reimbursement due to increased costs of maintaining high level of services to a small population.
28
Why have DSPs lowered?
Assumptions that all states would expand Medicaid (which did not happen).
29
What is Health Care Quality defined?
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
30
What are the three major issues with quality in healthcare?
Overuse Underuse Misuse
31
What is the Institute of Medicine Framework of Quality in Medicine?
Patient experience Functioning of Microsystems Functioning of organizations that house microsystems Environment of policy, payment, regulation, accreditation, etc.
32
What are the 6 IOM Aims for Healthcare Improvement?
Safe Effective Patient Centered Timely Efficient Equitable
33
What is the Triple Aim of Improving Healthcare?
Improving Patient Experience of Care Improving the Health of Populations Reducing per capita cost of healthcare
34
What are the three aims of improving healthcare?
Better Care Healthy People / Healthy Communities Affordable Care
35
What are the three long term goals of making care safer?
Reducing preventable hospitalizations Reducing adverse health care associated conditions Reducing harm from inappropriate or unnecessary care
36
What are some examples of CMS Hospital Quality Measures?
* Percentage of surgery patients with surgical complications or postoperative infection. * Rates at which patients fall and incur injury during a hospital stay. * Use of electronic systems for entering medication orders. * Patient mortality rates by type of condition (e.g., heart attack, hip fracture, pneumonia) or by type of procedure (e.g., coronary artery bypass graft surgeries, valve surgeries, hip replacement). * Percentage of patients receiving recommended hospital care for specific conditions such as heart attack, pneumonia care, and prevention of surgical infection. * Patients’ reports on the care and service they received from the hospital. * Provision of care instructions upon hospital discharge for certain conditions. * Patients’ reports on the timeliness of care and service they received from the hospital. * Utilization of hospital services or procedures as measured by the hospital discharge rate or average length of stay. * Number of beds and the types of services available. * Whether the hospital is accredited or has other types of specialty certification. * The use of electronic patient medical records or prescription ordering systems. * Percentage of physicians who are board-certified. * Nurse-to-patient staffing ratios.
37
What hospital system components failed during Covid?
Individual: misinformation, long wait times for mental health services, lack of equitable care, displaced trauma care, missed screenings and wellness visits Microsystems: Travel nurses and increased payments de-incentivized staying loyal to a local hospital for nurses, poor staff care & retention, staff displacement into other departments, Macro system: supply chain issues, lack of clear protocol (CDC findings always changing), poor crisis planning, lack of hospital beds, poor research on depth of disease (especially airborne capabilities), Medicaid dropping 3.9 million after the public health emergency "ended"
38
Describe recent trends in Healthcare Quality Improvement
39
What do long term supports and services (LTSS) include?
Nursing home care Adult daycare Home health aide Personal care services transportation supported employment assistance by family caregiver
40
How is the aging population in the US growing?
The 65 and over population will double and the 85 and over population will triple by 2050
41
What was the ADA (1990)?
Americans with Disabilities Act - a civil rights law that prohibited discrimination against individuals with disabilities
42
What was the Olmstead Decision (1999)?
Unjustified institutionalization of disabled individuals is illegal discrimination to "administer services, programs, and activities in the most integrated setting appropriate" with "reasonable accommodation" and "fundamental alteration"
43
How did the Olmstead Decision affect Medicaid?
Shift to community based services, preference for integrated settings, supported employment, elimination of disability discriminatory practices Avoidance of institutionalization
44
Who is the primary payer for LTSS?
Medicaid
45
What are common reasonings to remove the elderly from their homes?
Inability to manage medication No family caregiver to manage needs Physical injury
46
How do we make the elderly healthier?
Encourage regular wellness visits and coordinated care from younger ages Adhere to treatment and/or medication regimen / management (especially for diabetes and hypertension)
47
What are conditions of eligibility for hospice care?
Condition is terminal There is no treatment for future cause of death (only provision of comfort) Life expectancy of months or less
48
How does the ACA help with advanced directives?
It provides billing assistance for end-of-life discussions and planning
49
What are advanced directives?
a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.
50
How many US consumers complete advanced directives prior to age 66?
29.3%
51
What is a health disparity?
a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage they affect those who have systematically experienced greater obstacles to health / been historically linked to discrimination or exclusion
52
What was the typical annual cost of nursing home care in 2016?
82,000 (over three times the income of most seniors)
53
What is health equity?
the idea that everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential
54
How do we achieve health equity?
We must: value everyone equally match resources to needs address historical and contemporary injustices
55
What are health care disparities?
IOM: "racial or ethnic differences in the quality of health care that are not due to access related factors or clinical needs, preferences, or appropriateness of intervention" Agency for Healthcare Research and Quality: "the differences or gaps in care experienced by one population compared with another population"
56
What are historical benchmarks in health care equity?
The Heckler Report / Secretary's Task Force on Black & Minority Health (1985) Establishment of the Office of Minority Health (1986) IOM Unequal Treatment Report (2002) National Partnership for Action to End Health Disparities (2007)
57
What did the Heckler Report (1985) find?
The Heckler Report documented persistent health disparities that accounted for 60,000 excess deaths each year and synthesized ways to advance health equity.
58
What were major study caveats of health equity?
Access (insurance status, ability to pay for healthcare) is the most important predictor of quality of healthcare across racial and ethnic groups
59
What are potential sources of disparities in care?
health systems level: financing, structure of care, cultural / linguistic barriers, policies; geographical limits to care and medication patient level (unlikely to be a major source of disparity) : patient preferences, refusal of treatment, poor adherence, biological differences clinical encounters (patient / provider interaction): clinical uncertainty, bias / prejudice, stereotypes, and lack of time / resources
60
What are examples of cultural & linguistic barriers to healthcare?
difficulty accessing translation lack of stable relationships with primary care providers financial incentives to limit services emergency services over / misuse health care fragmentation
61
Are disparities a result of sociocenomic differences?
The majority of studies, however, find that racial and ethnic disparities remain even after adjustment for socioeconomic differences and other healthcare accessrelated factors (for more extensive reviews of this literature, see Kressin and Petersen, 2001; Geiger, this volume; and Mayberry, Mili, and Ofili, 2000).
62
How does the Institute of Medicine recommend we address health disparities?
Recommendation 5-7: Structure payment systems to ensure an adequate supply of services to minority patients and limit provider incentives that may promote disparities. Recommendation 5-8: Enhance patient-provider communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice. Recommendation 5-12: Implement patient education programs to increase patients’ knowledge of how to best access care and participate in treatment decisions.
63
Do racial health disparities only affect patients?
No, it also affects racial minority health care workers
64
What were some of Dr. Camara Jones' allegories concerning racial health disparities?
The Restaurant Saga (Dual Reality) Japanese Lanterns (Colored Perceptions) A Gardener's Tale (Levels of Racism) The Conveyor Belt (Motivation to Act)
65
Describe what factors drive health disparities
66
Describe the context of health disparities
67
Describe how health outcomes differ among different groups versus white people
68
Describe the continuum of unequal treatment
69
Describe redlining in Atlanta
70
What is health policy defined?
laws, regulations, procedures, administrative actions, and funding priorities advanced by governmental and other authoritative bodies that directly or indirectly impact health, public health, or health care
71
What is the Iron Triangle?
Congress / Legislative, Bureaucracy (Administration) / Executive, and Interest Group (Stakeholders)
72
What were the main goals of the ACA?
Increased access / quality / equity & decreased costs
73
Describe expanded access via the ACA
Medicaid Expansion to <138% FPL Development of the Health Insurance Marketplace and subsidies for the working poor (100-400% FPL)
74
How many benefit from the development of the health insurance marketplace?
Over 11 million Americans signed up for a policy and 89% received a subsidy 20 million uninsured gained coverage Less than 10% are now uninsured (lowest reduction in over 40 years)
75
Describe ACA provisions for cost control
Limited insurance premium increases Stipulated that over 80% of premium dollars must be spent on care Reduces payments for preventable medical errors & hospital acquired conditions Supports quality initiatives Center for Medicare and Medicaid Innovation (piloted ACOs and PCMHs) Rate of cost growth has slowed
76
Describe ACA provisions for quality improvement
Supports payment and delivery system redesign (especially incentives and penalties based on quality and safety) Promotes prevention by eliminating cost sharing for preventative services and establishing National Prevention Council & Prevention & Public Health Fund Promotes primary care (improved reimbursement, support for community health centers, medical home pilots)
77
What is the National Health Service Corps?
a program which puts primary care doctors in underserved communities in exchange for loan forgiveness, support for medical homes, and through improved reimbursement for primary care services
78
What was a major safety provision of the ACA?
Preventing CMS hospital readmission within 30 days (disincentivizing discharge planning)
79
What were the health equity specific provisions of the ACA?
Data collection with focus on racial and ethnic minority (new federal standards) Support for workforce diversity Cultural competence training Civil rights protection
80
What are state level challenges of the ACA?
State versus federal health insurance marketplace Medicaid expansion (states who have not expanded have a coverage gap for 38% to 100% FPL - no subsidies and ineligible for medicaid)
81
What is Health in All Policies?
a collaborative approach to improving the health of all people by incorporating health considerations into decision making across sectors and policy areas
82
What are the major tenets of Health in All Policies?
Promote health, equity, and sustainability Support collaboration Benefit multiple partners Engage stakeholders Create structural change
83
Describe the Iron Triangle of Policy (government version)
84
Describe the Medicaid Gap
85
Describe the CDC Policy Process
86
Describe the Iron Triangle of Inequality
87
Describe equality versus equity versus justice
88
How does Medicaid cover LTSS?
Medicaid covers 6 in 10 nursing home residents 50% of seniors receiving LTSS are in nursing homes 70% of seniors' Medicaid expenses are in LTSS $55 billion spent on LTSS by Medicaid in 2015
89
What are factors impacting growth of hospitals?
Specialization / technology Demographics Payment reform (including DRGs, Managed Care, inpatient vs outpatient, emergency / trauma services, payer mix) Integration of services (certificate of need)

Health Policy (2 decks)

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