Health Policy 2 – Flashcards
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Nation's three largest health professions
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Nurses Physicians Pharmacists
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In the United States, approximately 873,000 physicians are professionally active
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1/3 of the physicians are in primary care 2/3 of the physicians are in non-primary care fields
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Primary activity for physicians that have completed residency:
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90% patient care
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Licensing
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Licensing of all types of healthcare professionals is a state jurisdiction
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1st Medical School in the United States
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University of Pennsylvania 1765
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Early Medical Training Could be achieved through an apprenticeship or going to a medical school
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Modern Era: Medical Training In 1893, John Hopkins University's School of Medicine started a new era of medical education Implemented many features that are still a standard in medical education
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John Hopkins University's School of Medicine
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Implemented standards for medical education: 4 year course of study at the graduate school level Competitive selection of students Emphasis on the scientific paradigm of clinical and laboratory science Close link between a medical schools and medical center hospital Cultivation of academically renowned faculty
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Flexner report **********
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Extremely influential More than 30 medical schools closed Academic standards for medical schools became more stringent Only schools meeting the standards of the Licensing Council on Medical education (LCME) were allowed to award MD degrees LCME private agency operating under the authority of medical professional organizations LCME-accredited schools became known as allopathic medical schools
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Osteopathy
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Alternative medical tradition Carries the rank of physician Developed by Andrew Still (1890s) Emphasizes medical manipulation of the body as a therapeutic maneuver Schools of osteopathy award DO degrees and have their own accrediting organization Most state licensing boards grant physicians with MD and DO degrees equivalent scopes of practice and prescription authority
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MD versus DO
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2010 Allopathic (MD) schools had 16,838 graduates while osteopathic (DO) schools had 3,3631
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Postdoctoral Education: MD
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At least one formal year of education after medical school is required for licensure in most states 1st year of post-doctoral training referred to as an internship with subsequent years referred to as residency Residency training: 3 years - generalist field (i.e. family medicine) 4 to 5 years - specialty training (i.e. surgery & ob-gyn) Accreditation Council for Graduate Medical Education (ACGME) accredits allopathic (MD) residency training programs
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Board Certification
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American Board of Medical Specialties Once physicians have completed their residency training at one of the ACGME training programs they must pass a test to achieve certification Certification is not required for state licensure
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Financing Medical Education
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Who pays for the cost of medical education in the United States? Approximately ½ of U.S. medical schools are public state institutions State tax revenues help subsidize medical school education U.S. Federal Government: Plays a minor role in financing medical school education Major source of funding to support residency training
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Financing Medical Education for MD Medicare
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Allocates "graduate medical education" funding to hospitals that support residency programs Amounts to $9.5 billion annually Includes direct education payments for resident stipends and faculty salaries a education and indirect education payments to defray other costs associated with a teaching hospital
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Financing Medical Education For MD Medicaid
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Contributes another $3 billion annually to residency education
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Physician Assistants (PA)
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Originated in the United States in 1965 Duke University established the 1st physician assistant (PA) program Work in close collaboration with a physician PAs usually work in the primary care field Training Usually 20 to 36 months About 136 accredited PA schools, 70% award a master's degree, required applicants to have a bachelor's degree Licensing State boards Pas must work under the "delegated authority" of a physician Scope of Practice PA's scope of practice is about 80% of the scope of work of a primary care physician
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Registered Nurses (RN)
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Represent the largest portion of the healthcare workers in the United States Approximately 80% of the RNs are actively employed in nursing jobs 62% of nurses work in hospitals (primary employment setting) 25% work in ambulatory care or community-based setting 5% in long-term facilities Licensing Exam Administered by National Council of State Boards of Nursing Non-profit organization composed of representatives from each of the state boards of nursing
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Registered Nurse - Education
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Historically Nurses received their education in vocational programs administered by hospitals These programs awarded diplomas Over time nursing education shifted into academic institutions: Associate degree programs Baccalaureate degree programs
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2008 Active nurses
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20% - Received their basic nursing training in diploma programs 45% - Associate degree programs 24% Baccalaureate degree programs Call for Nursing Education Transformation Nursing leaders calling to move all nursing education to the baccalaureate level Studies find that patient have better outcomes when hospitals are staffed by baccalaureate prepared nurses
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American Association of Colleges of Nursing ****go through the link for 9 essentials will be on test.
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The Essentials of a Baccalaureate Education Published in 2008 http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf Contains 9 "Essentials" Liberal Education Basic Organizational & Systems Leadership Scholarship for EBP Information Management Healthcare Policy Interprofessional Communication & Collaboration for Improving patient Outcomes Clinical Prevention & Population Health Professionalism and Professional Values Baccalaureate Generalist Nursing Practice
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Enrollment in Nursing Schools Cyclical pattern
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Correspond to perception of surpluses and shortages in the labor market for RNs Graduation rates Twice as many nurses graduate with an Associate degree than from a BSN program NCLEX Number of U.S. educated nurses taking the exam increased by 50% from 1990 to 1995
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Physician versus Nursing Education
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Training Unlike physicians, international nursing school graduates do not have to undergo training in the United States to become eligible for licensure International nursing school graduates may sit for licensure Once they pass the NCLEX, they may apply for a visa to work as a nurse U.S. known as the largest importer of nurses 1/3 of internationally educated nurses come from the Philippines
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Nurse Practitioners (NPs)
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8% of RNs in the U.S. have completed advanced practice education Advanced practice nurses include: Clinical nurse specialists Nurse anesthetists Clinical nurse midwives Nurse practitioners Nurse Practitioners Approximately 140,000 active nurse practitioners Largest group of advanced practice nurses
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NP's program is how long?
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Typically 2-year master's degree program Education emphasizes: Primary care Prevention Health promotion Scope of practice 50% to 60% work in primary care settings Enrollment Doubled between 1992 to 1997 Graduates have decreased in recent years
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NP Licensing & Regulation
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Less uniformed across states than for physicians, physician assistants and registered nurses Most states require a Master's degree but some accept less training Scope of practice per state varies Most states require NPs to work with a physician 11 states permit NPs to practice with complete independence from a physician 10 states require physicians to directly supervise NPs Work In primary care settings, NPs perform approximately 80% of the tasks performed by physicians
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Pharmacists
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3rd largest health care profession 2010 Approximately 250,000 pharmacists actively practicing 2004 All pharmacy programs required to extend training by 1 to 2 years and award Doctorate of Pharmacy degrees Work environment Approximately 60% work in retail pharmacies Hospitals second largest employers
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Social Workers
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Training Assessment skills Diagnostic impressions Psychosocial support to patient and families Assist patients with navigation of healthcare system Education Minimum bachelor's degree Most work positions require a master's degree in social work plus state licensure Licensed clinical social workers (LCSWs) Must have a minimum of a master's degree plus 2 years of academic and practical experience in the filed
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Supply, Demand, & Need
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Supply between 1975 to 2005: Registered nurses doubled Physician increased by 75% Pharmacists increased by 50% Perceptions Surplus versus shortages Reduction of enrollment in nursing schools Intensity of work Changes in hospital care created the need for more highly trained RNs. Increased vacancy rates Demand for RNs increased wages
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Physician Supply & Patient Outcomes
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Low supply of physicians is associated with higher mortality Once physician supply is evened, there is little further survival benefit Medicare Beneficiaries residing in areas with high physician supply do not report better access to physicians or higher satisfaction with care and do not receive better quality of care
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Gender & Health Professions
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Physicians & Pharmacists Mostly males Pharmacists: Demographics (Women) 13% (1970) More than half (2010) 61% in pharmacy school (2010) Physicians: Demographics (Women) 8% women (1970) More than 30% (2010) 47% of medical students (2010) Nurses Mostly females 10% of the workforce were men (2008)
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Gender & Health professions
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Women On the average work fewer hours per week More likely to work part-time Female physicians attract more female patients Female physicians deliver more preventive services than male physicians Female physicians appear to communicate differently with their patients More likely to discuss lifestyle and social concerns To give more information and explanations Involve patients in medical decision-making
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Minorities & Health professions
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United States a nation of growing racial and ethnic diversity 2010 U.S. Census: African Americans, Latinos, Native Americans make-up 1/3 of the population Health professions Fail to reflect U.S. racial and ethnic diversity Diversity in Healthcare Workforce 10% pharmacists 9% physicians 8% physician assistants 10% nurses
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Increasing Minority Representation in healthcare
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Nursing schools Minority enrollment in BSN programs Increased from 12.2% (1991) to 18.1% (2005) Medical schools Increased from 1991(12.2%) to 1997 (15.5%) Decreased to 15.5% (2005) Pharmacy Little net increase from 1990 to 2010 Policy concern Minorities communities experience poorer health and access to health care compared to non-Latino whites
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Minority Healthcare Professionals
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More likely to practice to: Serve in underserved communities Serve disadvantaged patients Uninsured Medicaid Research Minority healthcare professionals and minority populations Patients with limited English proficiency have better patient outcomes and experiences when healthcare services are provided by minority professionals Reduction in medication errors
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Healthcare & Patient Outcomes
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United States Each year, millions of patients receive care at hospitals, private medical offices and outpatient clinics Some patients receive excellent care; others are not so fortunate Institute of Medicine's report To Err is Human: Building a Safer Healthcare System (1999) http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf An estimated 44,000 to 98,000 patients die each year in hospitals due to preventable medical errors
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Institute of Medicine Medical errors
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Can be defined as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" (Institute of Medicine [IOM], 1999). Examples of medical errors include: Adverse drug events Improper infusions Pressure ulcers Suicides Restraint-related injuries or death Mistaken patient identities Falls
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Medical Error & Nursing
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Statistics on Medical Malpractice Payouts & Lawsuits Medical Malpractice Payouts Dollars in payouts: $3.6 billion (3.4 percent less than in 2011) Total payouts for medical malpractice: 12,142 (one every 43 minutes) Payouts resulting from judgments: 5 percent Payouts resulting from settlements: 93 percent
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Top 5 States for Medical Malpractice Payouts
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New York - $763,088,250 Pennsylvania - $316, 167,500 California - $222,926,200 New Jersey - $206,668,250 Florida - $203,671,100
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According to the Institute of Medicine (1999):
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Variety of factors contribute to medical errors Fragmented health care delivery system Lack of access to complete information Failure to investigate broken system Current lack of quality and safety in U.S. healthcare system violates healthcare's mandate of "Do No Harm." Medical errors do not result from "one bad apple" rather they are caused by bad processes, systems, and conditions that lead people to make mistakes or fail to prevent mistakes
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Strategies for Improvement
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Institute of Medicine (1999) recommends: Establishing a national focus "Center for Patient Safety." Developing a national public mandatory reporting system and encouraging organizations and practitioners to report voluntary. Setting and raising performance standards and expectations for patient safety. Implementing safety systems in healthcare organizations to ensure a "culture of safety."
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Patient Outcomes
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In addition to medical errors that lead to patient deaths, inappropriate patient care has also led to negative patient outcomes. An estimated 57,000 people died for not receiving appropriate care for high blood pressure or elevated cholesterol
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High-Quality Care
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What is high-quality healthcare? Helps healthy people stay healthy Cures acute illnesses Allows chronically ill patients to live as long as possible Components of high-quality healthcare include: Access to care Adequate scientific knowledge Competent health care providers Separation of financial and clinical decisions Organization of healthcare institutions to maximize quality
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High-Quality Care: Components
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Access to Care People must have access to care. People with reduced access to care have poor health outcomes than those with access to care. Adequate Scientific Knowledge Physicians must have a body of knowledge at their disposal that distinguishes between effective and ineffective care. Competent Healthcare Providers All healthcare providers must have the skills to diagnose problems and to choose the appropriate treatments. Incompetent healthcare providers result in poor quality care and poor patient outcomes.
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Medical Negligence & Patient Outcomes
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Medical Negligence Defined as "failure to meet the standard of practice of an average qualified physician practicing in the same specialty" (Bodenheimer & Grumbach, 2012). Harvard study 28% of medical injuries were due to negligence Most common injuries were: Drug reactions (19%) Wound infections (14%) Failure to diagnose a condition (8%) Can negligence be equated with incompetence?
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Money & Quality of Care Impact of financial consideration on the quantity of medical care
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Fee-for-service versus capitation Fee-for-service encourages providers to perform more services Capitation payments rewards providers who perform less medical services Most surgeons in the United States are compensated via fee-for-service Bunker (1970) study found that the U.S. performed twice as many surgical procedures as Great Britain. Bunker speculated that the number was due to the way physicians in the U.S. (fee-for-service) were paid versus Great Britain (salary). Thus many of the surgical procedures in the U.S. may be unnecessary
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Commercialization of Medicine
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The introduction of technology and the increase of physician business ventures. In Florida, 40% of practicing physicians owned services to which they referred their patients to. In Florida, physicians owned or partially owned services include: 93% of diagnostic imaging facilities 76% of ambulatory surgery centers 60% of clinical laboratories
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Impact of medical services on patient outcomes
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According to Bodenheimer and Grumbach (2012), "The quantity and quality of medical care are inextricably interrelated. Too much or too little can be injurious."
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How a healthcare facility or system is organized strongly impacts patient outcomes.
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Example: hospitals with more RNs have lower surgical complication rates and lower mortality rates (Bodenheimer & Grumbach, 1999). Quality of care also improves with experience.
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Crossing the Quality Chasm (2001) Six Core Dimensions of Quality
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Safe Avoiding injuries to patients from care that is suppose to help them Effective Providing services based on scientific knowledge and refraining from services that are not likely to produce a benefit Patient-centered Providing care that is respectful of and responsive to the patient Timely Reducing delays that can be harmful to patient Efficient Avoiding waste of equipment, supplies, ideas & energy Equitable Providing the same quality of care to everyone
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Improving Quality
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Continuous quality improvement model (CQI) Shifts the focus from "one bad apple" to one that "seeks to enhance the clinical performance of all systems of care, not just the outliers with fragrant poor quality of care"
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Joint Commission & Patient Safety
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2014 Hospital National Patient Safety Goals The goal is to improve patient safety The Patient Safety Goals include: http://www.jointcommission.org/assets/1/6/2014_HAP_NPSG_E.pdf Identify patients correctly*** Improve staff communication*** Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery
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The Role of Licensure, Accreditation & Peer Review
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Licensing Pros All healthcare providers go through training and special licensing exams to ensure they have at least a basic level of knowledge and competence. Cons Not all healthcare providers that pass their licensing exams are competent. No re-examination This may point to a failure in the educational and licensing systems. Another reason may be that the healthcare provider was competent at the time of licensure but with the passage of time their skills have deteriorated. "Don't use it, you lose it" The role of CEUs Hospital competencies
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Quality and Safety Education for Nurses (QSEN)
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Project began in 2005 Funded by the Robert Wood Johnson Foundation Overall goal "To address the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare system in which they work" (Quality and Safety Education for Nurses, 2012). Website: http://qsen.org/
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QSEN: Pre-Licensure KSAS
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Using the Institute of Medicine's competencies, the QSEN faculty developed a list of pre-licensure knowledge, skills and attitudes future nurses need to acquire before graduating: Patient-Centered Care Teamwork and Collaboration Evidenced-Based Practice (EBP) Quality Improvement (QI) Safety Informatics
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The Role of Licensure, Accreditation & Peer Review
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Certification agencies Require periodic re-examinations to maintain active specialty certification Peer Reviews Traditional approach to quality assurance Evaluation conducted by healthcare providers on fellow peers to determine appropriateness and quality of services Joint Commission requires hospital medical staff to set-up peer review committees for the purpose of maintaining quality of care in their facilities. Joint Commission can terminate hospitals from the Medicare program
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What is the Joint Commission?
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An independent, not-for-profit organization, that accredits and certifies more than 20,500 health care organizations and programs in the United States Mission To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
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Performance Measurement Core Measures
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Core Measures Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Pregnancy and Related Conditions (PR) Childrens' Asthma Care (CAC) Surgical Care Improvement Project (SCIP) Hospital-Based Inpatient Psychiatric Services (HBIPS) Hospital Outpatient Department (OP) Stroke (STK) Venous Thromboembolism (VTE
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What is a core measure?
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Per the Joint Commission, all health care organizations, regardless of what vendor they use, are implementing the measures in the same standardized way, and therefore, these data are comparable across vendors. The Joint Commission calculates national comparison group data based on the hospital-level data submitted by our listed measurement system vendors on behalf of our accredited hospitals.
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Joint Commission: Accountability Measure List
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Go to http://www.jointcommission.org/assets/1/18/2013_Accountability_Measures.pdf to read full list Acute Myocardial Infarction (AMI) AMI-1 Aspirin at Arrival AMI-2 Aspirin Prescribed at Discharge AMI-3 ACEI or ARB for LVSD AMI-5 1Beta-Blocker Prescribed at Discharge AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI-8a Primary Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival AMI-10 Statin Prescribed at Discharge
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Clinical Practice Guidelines Agency for Healthcare Research and Quality also known as AHRQ
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Established by U.S. Congress in 1989 Goal is to improve quality of care by developing practice guidelines. Practice guidelines are produced by a panel of experts that make specific recommendations to physicians on how to treat clinical conditions such as diabetes. More than 2000 guidelines exist To access "National Guideline Clearinghouse" got to http://www.guideline.gov/
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Clinical Practice Guidelines
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Practice guidelines can assist but do not replace clinical judgment and are not always appropriate. They can be useful when used in computer systems to remind physicians what services should be included in certain diagnoses. Example CPOE or Computerized Physician Order Entry
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Measuring Practice Patterns
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Central to the continuous quality improvement (CQI) model is the need for regular monitoring of healthcare providers. Two basic types of indicators used to evaluate clinical performance: Process measures Outcomes measures
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Clinical Performance Indicators
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Process measures Refer to types of services delivered by caregivers Example: Prescribing aspirin to patients with coronary heart disease Turning immobile patients in hospital beds to prevent bed sores To be considered a valid indicator of quality, must show that process influence patient outcomes Outcomes measures Include death, symptoms, mental health, physical functioning, and related aspects of health status. Maybe impacted by severity of illness and other patient characteristics and not just quality of care. Must be risk adjusted More challenging to use outcomes measures to evaluate quality than process measures
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Continuous Quality Improvement (CQI)
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CQI involves the identification of concrete problems AND the formation of interdisciplinary teams to gather data and propose and implement solutions to the problems. The Institute for Healthcare improvement (IHI) has led efforts to spread CQI by sponsoring collaboratives. Collaboratives are 10 to 12 month programs were teams from various organizations work with each other and IHI faculty to rapidly test and implement changes that lead to lasting improvement
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Electronic Medical Records (EMRs)
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Improve care Can create list of patients Generate reminders for physicians and patients Reduce medical errors due to drug prescriptions Computer programs can alert physicians about inappropriate medication doses or medication allergies Have not proven to significantly improve quality
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Public Reporting of Quality
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Release of quality of care measures to the public Commonly referred to as "report cards" Goal is to empower healthcare consumers to select higher quality providers and institutions by providing information to them.
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New York State Department of Health
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Report Cards Initiated in 1990 Data released by the New York State of Department of Health indicated: Patients did not switch from hospitals with high-mortality to low-mortality In 4 years, overall risk-adjusted coronary artery bypass mortality dropped by 41%
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Pay for Reporting
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Medicare program Initiated reporting for hospitals in 2003 Program called the Hospital Quality Initiative It is voluntary Non-participating hospitals receive a reduction in their Medicare payments Since program started some measures have improved Measures included: Heart attack Heart failure Pneumonia The public can access the hospital reports at www.hospitalcompare.hhs.gov
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Pay for Performance (P4P)
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Goes beyond reporting Physicians or hospitals receive more money if their quality measures exceed certain benchmarks or if their measures improve from year to year (Bodenheimer & Grumbach, 2012). Examples: Integrated Healthcare Association (IHA)
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Integrated Healthcare Association
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One of the largest pay for performance programs Set of uniform performance measures Consists of 7 health plans, 221 physician organizations involving 35,000 physicians and 10 million patients In 2010, health plans paid $49 million to physicians in performance-based bonuses. IHA program unique All major health plan collaborated in choosing measures Most physicians in California belong to a large medical group pr independent practice association
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Critics of pay for performance argue:
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That P4P programs could encourage physicians and hospitals to avoid high-risk patients. Another issue with P4P is that many patients see many physicians for different types of problems making it impossible to determine which physician should get the bonus. Examples: Cardiologist, Endocrinologist, Nephrologists, etc) P4P could increase disparities in quality by rewarding physicians and hospitals that care for higher-income patients and have more resources than institutions that care for vulnerable populations and are resource-poor
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Malpractice Reform Goals of malpractice system:
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To financially compensate people who in the course of seeking medical care have suffered medial injuries To prevent physicians and other healthcare personnel from negligently causing harm to their patients Harvard Medical Practice study Only 2% of patients who suffer adverse events caused by medical negligence file malpractice claims
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Malpractice Reform
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As many of 40% of malpractice claims do not involve true medical errors 25% of these inappropriate claims result in patient receiving monetary compensation "Malpractice system is burdened with expensive, unfounded litigation that harass physicians who have done nothing wrong while failing to discipline or educate most physicians that commit actual medical negligence and to compensate most true victims
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Malpractice Reform Options
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Tort reform Placing limits on malpractice awards to paid patients Alternative dispute resolution Substituting mediation and arbitration for jury trials Use of practice guidelines Improving the ability to determine whether a physician was negligent No-fault reform Providing compensation to patients suffering medical injury regardless of whether the injury is due to negligence Enterprise liability Making institutions responsible for compensating medical injuries on a no-fault basis, thereby creating incentives for institutions to improve quality of care provided
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U.S. Healthcare System
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U.S. Healthcare System is a 2.5 trillion dollar system. Four important players: purchasers, Insurers, Providers and suppliers
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U.S. Healthcare System (purchasers)
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Include: individuals, employers, & government Purchasers supply the funds. They include individual consumers, businesses that pay for health insurance for their employees, government public programs (Medicare and Medicaid).
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U.S. Healthcare System (Insurers)
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Insurers receive money from the purchasers (individuals and businesses) and reimburse the providers when the policyholders require medical care. Some insurers are the same as purchasers (ie. Medicare and Medicaid programs).
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U.S. Healthcare System (Providers)
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Include: hospitals, nursing homes, home care agencies, physicians, pharmacies, etc. In the past purchasers viewed the expenses of the insurers, providers, and suppliers as an investment into better healthcare. Today there is a conflict- the purchasers want the healthcare industry (insurers, suppliers and providers) to reduce spending and the suppliers want to increase the amount spent on healthcare
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U.S. Healthcare System (Suppliers)
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Medical & pharmaceutical suppliers, computer equipment ing this time period, independent hospitals and small private physician offices populated the U.S. health delivery system Some large institutions combined hospital and physician care. Examples: Kaiser-Permanente system & Mayo Clinic A defining feature of the healthcare industry at this time was an alliance between insurers and providers. The provider-Insurer pact was created when Blue Cross and Blue Shields formed an alliance. At the time, Blue Cross was formed by the American Hospital Association and Blue Shield was run by the state medical societies affiliated with the American Medical Association.
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1945-1970: The Provider-Insurer Pact
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Health care inflated at a rapid rate since reimbursement rules were formulated by physicians, hospitals, and Blue Shield Medicare and Medicaid programs (enacted in 1965) had the same reimbursement provisions as private patients during this period.
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1945-1970: The Provider-Insurer Pact Results:
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The development of many independent hospitals and many small private practices Many private insurers Providers tended to dominate the insurers Purchasers had little power Reimbursement for providers was generous
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Purchaser disinterest was due to a
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healthy economy since U.S. businesses controlled domestic and foreign markets. Labor unions had generous wages and benefits. Business could afford these costs since the economic growth was robust and profits were high. In addition there was a tax subsidy for health insurance since payments for employees health were tax-deductable business expenses. No "brakes" on cost for a system that equated proliferation of biomedical breakthroughs with health improvements in people's lives.
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1970s - Tensions Develop
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Conflict between providers and insurers Purchasers (especially government) concerned about costs of health care In early 1970s, the U.S. fell from it position of postwar economic dominance. Western Europe and Japan start to gain ground in the world markets. U.S. industrial production dropped from 60% in the 1950s to 30% in 1980. Insurers begin to question generous reimbursements to providers
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1970s - Tensions Develop Result:
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Federal government established a network of health planning agencies to slow growth of hospitals. Peer and Utilization reviews were established to monitor appropriateness of MD services under Medicare and the glut of unused hospital beds and reduce length of stay. State governments started to regulate hospital construction and hospital rate regulation. Insurers demanded that services be provided at lower costs. Blue Cross legally separated from the American Hospital Association in 1972.
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1980s: Revolt of the Purchasers
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Late 1980s produced a severe shock: employer-sponsored health plans increased Many large corporations started to self-insured Purchasers (businesses now joining government) very concerned about health costs - cutting into their profits Reduction in heath costs through: Medicare DRGs (1983) Fee schedules HMOs (Managed care plans become dominant) Selective contracting by purchasers and insurers
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Businesses profits are adversely affected since
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the percentage of total payroll spent on employee health benefits almost doubled from 5% (1976) to 9.7% (1988). 40% of businesses have employer-sponsored health benefits (self-insured plans). With the troubled economy, rising health costs, and self-insurance plans, big businesses got into the center of the health policy debate! Businesses advocate for managed care (especially HMOs) as a cost-control device. The shift from fee-for-service to capitated reimbursement which transfers health expenditure risk from the purchaser and insurer to providers.
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1990s: The Breakup of the Provider-Insurer Pact
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Selective contracting tended to disorganize rather than organize medical care patterns MDs were forced to admit patients from one HMO to one hospital and those from another HMO to a different hospital. Labs and other contracted specialties were sometimes across town. With selective contracting, insurers and purchasers start to have more input into reimbursement rates. Independent hospitals begin to merge into hospital systems.
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HMOs lost enrollees if their premiums were too high
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HMOs lost enrollees if their premiums were too high. Providers who demanded high payments from HMOs were cut out and therefore lost patients. Large integrated health networks (HMOs)are formed and compete with private insurance, Medicare, or Medicaid Large physician groups develop Insurance companies dominate manage care markets For-profit hospitals increase in importance
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Insurers gain power over providers Period of purchaser dominance (especially employers) in healthcare
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Government stops Medicare inflation through the Balanced Budget Act of 1997 (expenditures actually declined) HMO enrollees expand from 40 million in 1990 to 80 million in 1999
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The New Millennium: Provider Power Reemerges
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Consolidation in the Health Care Market (Insurers, MDs, Hospitals) Growing Power of Specialists and Specialty for profit service centers Increasing Physician-Hospital tensions (MDs taking business away) For profit- a threat to traditional professionalism and community service ( economic motivation clash with the professional commitment to patient welfare.)
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The Provider Counter-Revolution
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HMOs enrollments dropped from 32% to 19% of insured employees. Instead, PPO (preferred provider organization) enrollment grew from 30% to 60% of insured employees. Hospitals consolidate into hospital "systems" and demand more money from insurers. Physicians balked at tight managed care contracts Negotiation between health care providers and insurers became hostile
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Consolidation in the Health Care Market
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Intense competition stimulated consolidation among insurers and providers to improve bargaining power Large HMOs bought smaller ones In most states, three (Wellpoint, United Healthcare & Aetna)large insurance companies dominated more than 60% of the market
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Providers also consolidated
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By 2001, 65% of hospitals were members of multi-hospital systems or networks Hospital prices often rose after consolidation Specialists increasingly joined single-specialty groups Private primary care and specialty practices were being acquired by hospital systems to increase their market clout
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Consolidation went hand-in-hand with organizations converting from non-profit to for-profit status
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For -profit hospitals provide less charity care, treat fewer Medicaid patients, lower quality, and higher administrative costs due to being investor owned. Non-profit community hospitals are competing too- these hospitals are creating "specialty service lines" to attract specialist physicians and well-insured patients:
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Pharmaceutical Industry Comes Under Criticism
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Rising tensions among purchaser, insurers and providers spilled over to healthcare's major supplier: the pharmaceutical industry 1988 Prescription drugs accounted for 5.5% of national health expenditures At the time, 71% of drug costs were paid by individuals Private insurance companies only covered 18% The growing costs of drugs and the elderly became a major national issue Because of its unaffordable prices and high profits
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In the U.S., drug companies are very profitable
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Earning net profits after taxes close to 20% of revenues compared with 5% for all Fortune 500 firms Pharmaceutical companies argues that their high drug prices are justified due to the cost of research and development of new drugs Unlike many other nations, the U.S. does not regulate drug prices as a result of drug industry lobbying A 2003, Medicare law forbids the government from regulating drug prices
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Drug companies developing new brand name drugs enjoy a 20-year patent
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During this time period, no other company can produce the same drug Once the patent expires, generic drug manufacturers can compete by selling the same product at lower prices 2009 Drug companies spent $7 billion on sales representative to visit physicians to persuade them to use brand name medications and not generic equivalents
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Nursing and Policy
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Policy and politics are the ways and means that nurses can use to influence the quality, safety, and accessibility of patient care. Nurses need to be key change agents since nursing is concerned with health issues that are subject to frequent policy changes at all levels. Therefore every action and decision that influences health and the health system should be important to nurses. Understanding the policymaking process permits nurses to determine when and how to intervene to shape a policy to benefit a patient.
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Policy Making and Nursing
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Policy making is a complex, multidimensional, dynamic process; ....it encompasses the choices that a society or organization makes regarding its goals and priorities and the ways it allocates its resources to attain those goals. Politics simply means the process of influencing the allocation of scarce resources ($). Politics is often associated with "conflicting values". Nurses can improve the health of people by developing influence in four interconnected spheres: the workplace, government, professional organizations, and community
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Types of Policy
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Public Policy- Social Policy- Health Policy- Institutional Policies- Organizational Policies-
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Public Policy-
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formed by governmental bodies (ie. Legislation passed by Congress such as the ACA).
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Social Policy-
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pertains to policy decisions that promote welfare of the public (ie. A local age limit ordinance).
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Institutional Policies-
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those that govern workplaces such as hospitals. Magnet hospitals have nurses involved in decision making policies at all levels of the institution.
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Organizational Policies-
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positions taken by organizations such as the ANA, or NLN.
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Health Policy-
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decisions made to promote the health of individual citizens (ie. gov't paid smoking cessation program)
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Advocacy
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the act of pleading are arguing in favor of something such as a policy or interest active support of an idea.
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Beneficence
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Is the obligation to care for patients to the best of one's ability
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Nonmaleficence
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Is the duty of healthcare providers "to do no harm"
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Autonomy
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Is the right of a person to choose and follow his or her own plan of life and action
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Justice
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Treating everyone in a fair manner
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What is rationing?
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General view • Rationing is limitation of medical care such that not all care expected to be beneficial is provided to all patients. • Example: Lack of intensive care beds
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Rationing within One Health Program: The Oregon Health Plan
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WORKED Rationing within one health program • 1994 (Bodenheimer & Grumbach, 2012) • Oregon added 100,000 poor uninsured to its Medicaid program • To control costs, a prioritized list of services was created • List based on how much improvement in quantity and quality of life the treatment was likely to produce • Final list contained 745 treatment pairs • State of Oregon paid for items above line 574 on the list • Condition below 574 were not covered • In addition, the state legislature of Oregon, decided what services would be covered • 2004 • Plan enrollees dropped out of the program • Rate of uninsured climbed from 11% to 17%
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The Oregon Health Plan Pros:
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• Plan more than a rationing proposal • Chief feature was to extend health care coverage • This aspect of the plan promotes justice • Attempt to prioritize medical care based on effectiveness • If rationing is needed this is a reasonable method to eliminate services
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The Oregon Health Plan Cons:
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• Some features may be viewed as negatively impacting distributive justice • 1996 • 12% of beneficiaries denied services because they were below the priority list line • Of those denied, 78% stated their health worsened • Medical services were rationed for individuals in this plan but not anyone else
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American Nurses Association's Social Policy Statement
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Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response and advocacy in the care of individuals, families, communities and populations
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• Attempts to legislate national health insurance
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1912-1919 American Association for Labor legislation (first one) 1946-1949 Wagner-Murray-Dingell bill supported by president Truman 1963-1965 Medicare and Medicaid passed as first step toward national health insurance 1970-1974 Kennedy and Nixon proposal 1991-1994 Variety of proposals introduced, including president Clinton's plan 2009-2010 Patient Protection and Affordable Care ACT signed into law by President Obama
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• The Pluralistic Reform Model: The Patient Protection and Affordable Care Act of 2010
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• Passed ACA w/o any republican vote • Obama signed the most significant health legislation (March 23.2010) since Medicare/Aid in 1965 • "Socialized medicine" and "government takeover of health care" • Financing model of ACA- Individual and employer mandates for private insurance and an expansion of the publicly financed Medicaid program • Resembled Mitt Romney's Massachusetts Health Plan of 2006
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• You need to know 4 numbers from affordable care act. When ACHA came into effect.
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1. Individual mandate: all US citizens and legal residents to have insurance coverage • Meeting federally determined "essential benefits" standard • Consequences of not purchasing insurance or don't qualify for public programs will pay tax penalty (2016) • Must pay 2.5% of their income 2. Employer mandate: employers with 50 or more employees face a financial penalty if their employees are not enrolled in an employer-sponsored health plan meeting the essential benefit standard • Any of their employees apply for federal subsidies for individually purchased insurance 3. Medicaid eligibility expansion: required to be low income and a "categorical" eligibility requirement (being a child or an adult with permanent disability) • ACA eliminated the categorical eligibility requirement and required that all states made all US citizens and legal residents below the 133% Federal Poverty Level eligible for their Medicaid program 4. Insurance market regulation: new rules on private insurance • Allow adults up to 26 yrs. old to be dependents under their parent's health insurance • Eliminates caps on total insurance benefits payouts • Prohibits denial of coverage based on pre-existing conditions • Limits the extent of experience rating to a max ratio of 3-1 between a plan's highest and lowest premium charge for same benefit package (came up with a formula)
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• The Pharmaceutical Industry Comes Under Criticism
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• Increase cost of pharmaceuticals for the elderly ---major national issue • Was becoming public enemy #1 due to unaffordable prices and high profits • High drug prices are due to its expenditures on research and development of new drugs • U.S Gov't does not impose regulated prices on drugs... result of drug industry lobbying • Medicare prescription drug coverage law passed in 2003 forbid gov't to regulate drug prices • Drug industry—largest contributor within health industry • Companies developing new brand name drug enjoy patent for 20 yrs. from date it was filed and no other company can produce the same drug • Once patent is expired, generic drug manufacturers can compete by selling same product at lower prices • Some drug companies waged legal battled to delay patent expirations on their brand name products or paid generic drug companies not to make a generic • Persuade physicians and patients to use brand names • FDA sent letters to drug manufacturers citing advertising violations (minimizing S/E and exaggerating benefits) • Physician-industry relationship cause them to prescribe the most expensive and whose safety has not been evaluated adequately • Most trials to determine efficacy of prescription drugs funded by drug's manufacturer • In 2006, 18 relatively new drugs removed from market because of serious S/E (hid them from FDA) or FDA ignored evidence • More use of generic and brand name drug companies are starting to produce generics • Generic industry booming to fewer and larger companies
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Which are the three major health insurance on the market????
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In most states, three (WellPoint, United Healthcare & Aetna) large insurance companies dominated more than 60% of the market
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• Who Provides Long-Term Care?
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• Families • Medicare • Medicaid • Private Long-term Care Insurance
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Activities requiring assistance in long-term care
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• ADL's basic human function- Feeding, dressing, bathing or showering, getting to the toilet, getting in an out of a chair or bed, Dealing with incontinence • ADL's to maintain independence-doing housework, laundry, preparing meals, shop, using transportation, Managing finances • Making and keeping appointments, taking meds, telephoning
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• Private Long-Term Care Insurance-
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The elderly is the largest market for private insurance, must be dependent for three ADL's to receive home health care. Yet many that have fewer than 3 ADL's may need long-term care. And their insurance may pay nothing. Usually, have large deductibles pay fixed daily fee then reimbursing actual charges. Insurance pays 150 a day, nursing home charges 220 a day and the patient pays 70 dollars out of pocket.
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• Medicare Long-Term Coverage
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• Medicare • Does not cover assistance with ADLs that are considered custodial services • Medicare only covers or pays for only "skilled care" • Examples of skilled care include: • Registered nurses in a hospital facility, nursing home, or home care services • RNs provide a wide variety of services: • Changing wound dressings, taking blood pressures, assessing heart and lung sounds, reviewing patient compliance with medications and providing patient education (diabetes, hypertension and heart failure). • Usually covers services after an "acute" hospitalization • Does not cover care for "chronic conditions"
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• Individual or Population -
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The medical model seeks to identify high-risk individuals and offer them individual protection often by counseling on such topics as smoking cessation and low fat diet. The public health approach seeks to reduce disease in the population as a whole, using such methods as mass education campaigns to counter drinking and driving, and taxation of tobacco to drive up prices. Labeling of foods to indicate fat and cholesterol content
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• What is Prevention?
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• Primary prevention- anti-smoking campaign • Seeks to avoid disease and injury • Examples: Immunization • Secondary prevention • Refers to early detention of disease and intervention to stop the condition from progressing • Examples: Pap smears & Mammograms
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Pay for Reporting WHEN IT STARTED WHAT IT IS NO REPORTING= NO PAY
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• Medicare program o Initiated reporting for hospitals in 2003 o Program called the Hospital Quality Initiative o It is voluntary o Non-participating hospitals receive a reduction in their Medicare payments o Since program started some measures have improved • Measures included: • Heart attack • Heart failure • Pneumonia • Surgical care and other measures have been added o Physician Quality Reporting system in 2007--- physician who report certain quality measures may receive 2% increase in Medicare fees o Physician(s) reports are not made public
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Continuous Quality Improvement
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• CQI involves the identification of concrete problems AND the formation of interdisciplinary teams to gather data and propose and implement solutions to the problems. • The Institute for Healthcare improvement (IHI) has led efforts to spread CQI by sponsoring collaborative. • Collaborative are 10 to 12 month programs were teams from various organizations work with each other and IHI faculty to rapidly test and implement changes that lead to lasting improvement (Institute of Healthcare Improvement, 2009
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Proposals for Improving Quality
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• Institute of Medicine (1999) recommends: • Establishing a national focus "Center for Patient Safety." • Developing a national public mandatory reporting system and encouraging organizations and practitioners to report voluntary. • Setting and raising performance standards and expectations for patient safety. • Implementing safety systems in healthcare organizations to ensure a "culture of safety."
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Institute of Medicine's To Err is Human
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REPORT 1999 THE WAY WE SEE HEALTH CARE AND HOW IT MANAGES IT SELF. 98,000 DIE DUE TO ERRORS • Medical errors • Can be defined as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" (Institute of Medicine [IOM], 1999). • Examples of medical errors include: • Adverse drug events • Improper infusions • Pressure ulcers • Suicides • Restraint-related injuries or death • Mistaken patient identities • Falls • Adequate Access to Care -
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• Computerized Information Systems
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HEALTH CARE • Electronic Medical Records (EMRs) • Improve care • Can create list of patients • Generate reminders for physicians and patients • Reduce medical errors due to drug prescriptions • Computer programs can alert physicians about inappropriate medication doses or medication allergies • Have not proven to significantly improve quality
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• Traditional Quality Assurance: Licensure, Accreditation, and Peer Review -ENSURE
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• Certification agencies • Require periodic re-examinations to maintain active specialty certification • Peer Reviews • Traditional approach to quality assurance • Evaluation conducted by healthcare providers on fellow peers to determine appropriateness and quality of services • Joint Commission requires hospital medical staff to set-up peer review committees for the purpose of maintaining quality of care in their facilities. • Joint Commission can terminate hospitals from the Medicare program if it finds that the hospital's quality is deficient. •
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• Regulatory Strategies
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• In a nation with tax-financed health insurance, government regulation of taxes serves as a control over public expenditures for health care. Most evident when certain tax funds are earmarked for health insurance (German health insurance plans or Medicare part A) tax hikes will anchor inflation on health care.
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• Categories of Cost Controls
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• Financing controls Regulatory limits on taxes or premiums Competitive Reimbursement Controls Price controls Regulatory Competitive Utilization controls Aggregate units of payment, capitation, diagnosis-related groups Global budgets Patient cost sharing Utilization management Supply limits Mixed controls.
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• Utilization Management
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MRI-VERY EXPENSIVE CONTROL COST THROUGH DR. PREAUTHORIZATION. Utilization management involves the surveillance of and intervention in the clinical activities of physicians for the purpose of controlling costs. • Seeks to influence physician behavior. • The mechanism is simple and direct: denial of payment for services it deems unnecessary. • UM has been criticized as a process of micro-management of clinical decisions that intrudes into the physician-patient relationship. A few case studies on UM have shown some short-term reduction in hospitalization rates and surgery BUT there is little evidence that this approach yields substantial savings • UM appears to be a "painless" form of cost control because it selectively reduces inappropriate or unnecessary care
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Patient Cost Sharing-
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Occurs at the point of purchase Examples: deductibles, copayments, and uncovered services as part of the reimbursement transaction. This method makes patients pay a share of costs at the "point of receiving health care services". The primary intent: to discourage patient demand for services. When patients have to pay a greater amount of out of pocket expenses, it tends to discourage them. Rand experiment: Evaluated the influence of cost-sharing on appropriateness of care and health outcomes ◦ Individuals were randomly assigned to health insurance plans with varying degrees of cost sharing ◦ Individuals with cost-sharing plans versus individuals with no cost-sharing plans Made about 1/3 fewer visits Hospitalized 1/3 less often ◦ Cost sharing did not reduce medically inappropriate use of services selectively but equally discouraged use of appropriate and inappropriate services Low income patients received less preventive services and had poorer HTN control than those without cost sharing Patients are less likely to purchase needed medications under cost-sharing policies (i.e. Medicare part D's "donut hole") leading to worst control of chronic diseases. This study suggest that cost sharing, which attempts to restrict health care use by influencing patient behavior, is not a painless form of cost control. This study suggest patient cost-sharing is "not painless"
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Pay for reporting benefits High-quality care components • What is high-quality healthcare?
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• o Helps healthy people stay healthy o Cures acute illnesses o Allows chronically ill patients to live as long as possible
