-Outpatient existed before hospitals and nursing homes
-Hospitals major player in outpatient services
-Hospitals capitalized on technology to compete on an outpatient basis
-Hospital labs and diagnostic better equipped
-Solo practices consolidated to cope
-Outpatient helps serve underserved population
-Community health centers receive federal and state money to serve rural and inner cities
-“Outpatient” is more comprehensive
-Ambulatory care more diagnostic and therapeutic to the “walking” (ambulatory)
-Outpatient and Ambulatory care used interchangeably
What are outpatient and primary care services?
100
- an institution with at least 6 beds whose function is to deliver patient services that include diagnostics and treatment
must be licensed
have an organized physician staff
provide continuous nursing services supervised by RNs
-Other Characteristics:
a governing body is legally responsible for hospital conduct
a CEO is responsible for operations
medical records on each patient
pharmacy services supervised by a registered pharmacist
food services to meet nutritional needs
What is a hospital?
100
-Discharges
-Inpatient Days
-Average Length of Stay
-Capacity
-Average Daily Census
-Occupancy Rate
What are the utilization measures and operational concepts that impact hospitals?
100
- The National Committee for Quality Assurance (NCQA)
- Participation is voluntary, but about half are accredited
- A national committee of physicians supervises the accreditation process
- A rating system assigns 6 status categories
What does the accreditation of MCOs include?
100
Prospective UR
Concurrent UR and discharge planning
Retrospective UR
What are the 3 types of utilization review?
200
- Plays a central role in a health care delivery system
- Focus on the type or level of services,
prevention
diagnostic
therapeutic services
health education
counseling, and
minor surgery
- Coordination of care
Delivery of health services between the patient and the different components of the delivery system
Refer patients to sources of specialized care
Give advice regarding various diagnosis and therapies
Discuss treatment options
Provide continuing care of chronic conditions
What is primary care or primary care services?
200
These consume the biggest share of national health spending; hence, were the first to be targeted with PPS.
Subsequently, outpatient services mushroomed.
What are hospitals?
200
-Over half are private nonprofit (voluntary)
-State and local government owned are the next largest group
-For-profit or investor-owned come next
-Federal hospitals are the fewest in number
-Numerous ways to classify
-Classifications are not mutually exclusive
What are types of hospitals?
200
- Healthcare Effectiveness Data and Information Set (HEDIS)
- HEDIS results are used by employers, the general public, public insurers, and regulators
- Over 90% of health plans use HEDIS
- 2013 HEDIS has 80 measures in 5 domains:
Care effectiveness
Access to and availability of certain services
Client experience of care
Utilization and resource use
Information on the health plan
What does quality assessment in MCOs include?
200
Staff
Group
Network
Independent practice associations (IPAs)
What are HMO models?
300
True or False? All primary care is outpatient, but not all outpatient care is primary care.
Give examples
What is True?
Examples: emergency room, urgent care treatment, outpatient surgery, rehabilitation, renal dialysis, chemotherapy
300
1. Social welfare
almshouses and pesthouses
2. Care for the sick
public and voluntary institutions
3. Medical practice
medical science and technology
hospital administration, organization, efficiency
4. Medical training and research
collaboration between hospitals and universities
5. Consolidated systems
organizational integration
service diversification
What are the 5 dominant functions that impacted the evolution of hospital transformation in the U.S.?
300
Public (Government ownership)
Private nonprofit
Private for-profit (Proprietary)
What are hospital classification by ownership type?
300
Two main factors:
Flaws in fee for service
Weakened economic position of providers
What are the factors that have impacted growth of managed care?
300
Personal care—basic ADL assistance (e.g., bathing)
Custodial care—nonmedical care to maintain function and prevent decline
Restorative care—help regain or improve function; professional therapies
Skilled nursing care—clinical care provided by licensed nurses under the direction of a physician
Subacute care—postacute, technically complex services
What are the levels of long-term continuum?
400
-Changes in reimbursement
constraining inpatient services
favoring outpatient services
-Fewer payment restrictions
surgery, dialysis, chemotherapy
paid as fee-for-service
- Development of New Technology
less invasive procedure
quicker recuperation from surgery
- Utilization Controls
Managed care restriction on utilization, quicker discharge
prior authorization (precertification)
utilization review
- Social Factors
Preference for obtaining services at home or in community based settings, especially long term care
What are reasons for growth in outpatient primary care services?
400
1) advances in medical science
2) development of specialized technology and surgical services
3) advances in medical education
4) development of professional nursing
5) growth of health insurance
6) role of government
What are the 6 main factors that have led to the in the growth of hospitals from the Late 1800s to Mid-1980s?
What are the types of service for hospital classifications?
400
Choice restriction
Gatekeeping
Case management
Disease management
Pharmaceutical management
Utilization review
Practice profiling
What are the cost control methods for MCOs?
400
Home health care
Adult day care
Adult foster care
Senior centers
Home-delivered and congregate meals
Homemaker services
Continuing Care at Home
Case management
What are the types of community-based LTC services?
500
1. Clinical Services: Special consultation
2. Surgical Services
3. Emergency Services for Acute Services
- Emergent require immediate attention
- Urgent require attention within a few hours
- Non urgent, non emergency (used by mostly uninsured as a substitute for primary care)
4. Home Health Care
5. Women’s Health Center
- Women are major users of health care due to a female majority
Change in culture towards women’s equality
A national priority
What are the 5 main types of hospital based outpatient care services?
500
- Changes in Reimbursement
From cost-plus to PPS
Decrease in inpatient utilization
- Impact of Managed Care
Emphasis on cost containment
Efficient utilization of resources (care in alternative settings)
- Hospital Closures
Economic constraints
Many rural and urban hospitals had to close
Other hospitals closed wings or used them for alternative purposes
What are the reasons for hospital downsizing from the mid 1980s onward?
500
1) ?
- A hospital must be licensed to operate
- State government oversees w/ own set of standards
- Emphasizes physical plant compliance with:
building codes
fire safety
climate control
space allocations
sanitation
2) ?
- Not mandatory (required only if a hospital wants to participate in Medicare and Medicaid—most do)
- A federal function
- Hospitals must comply with the conditions of participation—federal standards for health, safety, and quality
- Currently revised conditions focus on quality of care delivered and the outcomes of that care
3) ?
- Joint Commission or American Osteopathic Association
- Accreditation is a private undertaking
- It is voluntary for the hospital
- It confers deemed status on hospitals
- Deemed status is not conferred on nursing homes
What are licensure, certification and accreditation?
500
Three main strategies:
Drug formularies
Tiered cost sharing
Pharmacy benefits management companies
What are the 3 main strategies for MCOs pharmaceutical management?
500
- Brokerage model—Case managers are freestanding agents who assess client needs and make referrals; minimal coordination and monitoring
Medicaid Preadmission Screening and Resident Review (PASRR)
- Managed care model—Services are delivered through a social managed care plan. All services are received through the MCO.
Have been shown to postpone institutionalization
But, only 4 such programs participate in Medicare
- Integrated care model—PACE — focused on frail elderly already certified for nursing home placement under Medicare and/or Medicaid