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Private system Funding = private health ins., personal out of pocket, industrial health related services, philanthropy
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Public Healthcare funding = federal, state & local funding (medicare/medicaid); department of defense healthcare; department of veteran affairs
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TJC, the Joint Commission, accreditation for acute care hospitals, home health agencies, long-term care, ambulatory care, and psychiatric facilities
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Allied Health = professions that function to assist physicians and specialists
- physical therapy
- Health Information management
- emergency medical technology,
- etc
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Hospital =
1) organized medical staff
2) permanent inpatient beds
3) 24hr nursing services
4) diagnostic and therapeutic services
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Managed Care Plans = healthcare reimbursement systems
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Medicine= the science of disease prevention, diagnosis, alleviation, and cure
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Greek "pharmakos" = remedy and poison
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In 1885 Louis Pasteur invented vaccine for rabies
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1865 Lister used carbolic acid to prevent infection in wounds
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1895 Wilhelm Roentgen xray technology
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1876 Amercian Association of Medical Colleges (AAMC)
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There are 24 medical specialties.
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Ambulatory Care:
Preventative/corrective healthcare provided in practitioner's office, clinic, freestanding diagnostic or surgical center, or a hospital on an outpatient basis.
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Community based ambulatory care services not affiliated with a hospital include:
flu vaccination clinic, health fairs, mammography programs, cancer screening programs, neonatal classes
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Subacute care (Home Health & Adult Daycare):
- nursing homes
- home care providers
- rehab facilities
The level of skilled care needed by complex conditions, typically elderly patients with multiple problems.
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Home Healthcare is the fastest growing sector of medicare, because of economic pressure from third party payers
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Primary Care: First point of contact in outpatient (ambulatory) setting
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5 definitions of primary care:
- 1) Primary Care
- 2) Primary Care Practice
- 3) Primary Care Physician
- 4) Non Primary Care Physicians providing primary care services
- 5) Non physician primary care providers
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Managed Care:
Generic term for system that manages cost, quality, and access to services. Manages cost by restricting services, preauthorization, presetting amounts
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How managed care delivery systems manage costs:
- -implementing financial incentives for providers
- - promoting healthy lifestyles
- - identifying risk factors and illnesses early in disease processes
- - providing patient education
- - preauthorization/utilization review
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Average patients may are well under managed care, but chronically ill elderly and poor patients show worse outcomes
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Purpose of manage care: To provide affordable high quality healthcare
Managed care merges clinical, financial and administration to manage access, cost, and quality of care
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Managed Care Organizations (MCOs) benefits and characteristics:
MCO= healthcare plans that attempt to manage care
Balanced Budget Act 1997= "coordinated care plans"
- - physician services (in & out patient)
- - inpatient care
- - preventative wellness, immunization, well check, adult exams, pap smears
- - prenatal care
- - emergency services
- - diagnostic/laboratory tests
- - certain home health care
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Types of Managed Care Organizations:
- HMO: health maintenance organization
- PPO: preferred provider organization
- POS: point of service plan (open ended HMO)
- EPO: exclusive provider organization
- Medicare Advantage/Medicare part C
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Medical Home Model as defined by AAMC:
- - round the clock access to consultation
- - cultural and religious beliefs
- - comprehensive/coordinated approach to care through providers and and community services
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EHR Collaborative: joint collaboration involving AHIMA, AMA, American Medical Informatics Association (AMIA), College of Healthcare Information Management Executives (CHIME), HIMSS, NAHIT
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IHE: an initiative to improve how computer systems share information.
- Promotes DICOM and HL7
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ACHE: American College of Health Executives
- International society whose goal is to improve health status by advancing leadership and management.
- - Health information confidentiality
- - organ donation
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AHIMA - American Health Information Management Association
- - For managers of health record services and healthcare information
- - coding professionals are members
- - "quality healthcare through quality information"
- - RHITs (2yrs)
- - RHIA (bachelor)
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AHA - American Hospital Association
* Originally Association of Hospital Superintendents
- - Today's mission is to advance the health of individuals and communities
- - Houses central office on ICD9 coding
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AMA - American Medical Association
* largest medical professional association
* to promote art and science of medicine and better health
- - accreditation body for medical schools and residency programs
- - CPT, current procedural terminology coding system
- - Journal of American Medical Association
- - Code of Medical Ethics
- - CPT Assistant, monthly newsletter
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IOM - Institute of Medicine
* works outside government to ensure scientific analysis and independent guidance
- serves as adviser to the nation to improve health
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NCQA - National Committee for Quality Assurance
* provides report cards and accreditation to healthcare plans
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HIPPA coding systems:
- - HCPCS (ancillary services)
- - CPT4 (physicians procedures)
- - CDT (dental terminology)
- - ICD9 (diagnosis and hospital inpatient)
- - ICD10
- - NDC (national drug codes)
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Components of QUALITY care:
- - appropriateness (right care is provided at right time)
- - technical excellence (right care is provided in the right manner)
- - accessibility (right care can be obtained when needed)
- - acceptability (patients are satisfied)
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Evaluating quality of care by IOM (institute of medicine) National Roundtable on Healthcare Quality:
- - Professional accountability: self regulated relationships among physicians, etc
- - Market accountability: rests on informed choices by employers and consumers
- - Regulatory accountability: relies on government remedy to correct any of these failures
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Professional Accountability:
- -Continuous Quality Improvement (CQI) processes
- -Emphasis on Patient Focused Care
- - Peer Review
- - Quality Management Programs
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Market Accountability:
- - Collection of Information and Date on Quality of Healthcare
- - Nationa Business Coalition on Health (NBCH)
- - Employer Coalitions and Market Accountability
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Regulatory Accountability: (Federal Govt)
- - quality of care/malpractice issue
- - National Practitioner Data Bank (NPDB)
- -- Moderate incidence of malpractice
- -- weed out incompetents
- -- improve timeliness on malpractice
- - HHS, through OIG, created Healthcare Integrity and Protection data Bank (HIPDB) to combat fraud and abuse of insurance
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