HLST 1010 Study Guide - Final Guide: Health Human Resources

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15 Dec 2017

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Saskatchewan strike, there were many limits on who would be able to practice medicine, allowed into medical school, and who was ultimately allowed access to any medical knowledge. This profession was mainly given to wealthy men and when women did gain access to medical school, they would feel uncomfortable as there was continuous harassment and very few female role models. After the inclusion of medicare, there were many efforts to reshape the healthcare division such as female nurses, and female health professions began to rise. The three health human resources address problems in the healthcare. The first is, problem with supply, which is the low number of healthcare professionals who can provide services to a population. The second is, problems with mix which the number of healthcare professionals who can provide specialty services such as specialists in certain fields like skin care. The third is, problems with distribution, which is the location of healthcare professionals across geographic areas.

Related Questions

PROVIDE A RESPONSE OR STATEMENT TO THIS STUDENTS DISCUSSION:

1 - Please share your experience on selecting a managed care plan. Please discuss the advantages and disadvantages of your MCO plan.

Up until about ten years ago my company offered an HMO MCO plan option managed by Kaiser Permanente. This plan was less expensive in my paycheck deduction and offered $10 co-pays for every office visit and 100% hospitalization. In 1992 as a single young man in my twenties I found this option very attractive. I ended up getting married early that year, had a flu episode and a bout of food poisoning. My wife ended up with a hospitalization as well. What looked good on paper ended up being a very restricted healthcare experience. My office visits were restricted to only one clinic where the health care professional point of contact were physicians assistants under the supervision of an MD which we never saw. All of the prescriptions were for generic medicines and when my wife was hospitalized she was not allowed branded medicines either. We also thought she was discharged too early. The advantages of this type of plan are costs and simplicity. If we had not been sick that year we probably would have signed back up for it. The disadvantages were that our level of care was reduced to a less skilled health care professional and the attending physician who cared for my wife in the hospital discharged my wife early due to a time limit the HMO had placed on the length of stay for her illness code. That was the first and last year I chose an MCO plan for my health coverage.

2 - Many argue that there is no consistent, direct correlation between the cost of care and its quality in a managed care program. Do you agree or disagree?

In my personal experience managed care plans attempt to lower the primary care contact to non MD health care professionals such as Nurse Practioners and Physicians Assistants. While these clinicians are well trained and certainly have their appropriate place in medicine, they do not have the extensive medical training that MDs and DOs spend a minimum of 8 years mastering. These clinicians cost less than MDs and are very attractive way to reduce staffing costs. As a patient however I prefer the highest skilled level clinician caring for me and my family and am willing to pay more for this higher level of care. In my opinion Kaiser Permanente may have saved money but I was not happy with the level of care and medicines provided. They may have saved money that year but they lost me as a customer. Epstein et al, (2014) compared Accountable Care Organization (ACO) patients with non ACO patients and while they found that there were many differences in spending, age, and severity of illness, there was no difference in quality metrics despite non ACO members costing more overall. It would seem that in this example costs can be lowered without affecting quality outcomes. However ACO participants had access to significantly more participating clinicians and hospitals. What is missing from this study is a patient survey comparing the satisfaction of ACO and non-ACO patients.

3 - Do you think patients' choice of provider and access to care will be limited under ACOs?

In my personal experience and through observations of managed care offices and hospitals as a pharmaceutical representative, ACOs not only restrict the choice of provider and access to hospitals they utilize lesser trained medical professionals in Primary Care, Specialty and Hospitals in addition to restricting access to branded medications. This observation is in agreement with Epstein et al, (2014) in which ACO members cost less but had less access and choice of participating access points and clinicians.

4 - In what ways can an ACO succeed in both delivering high-quality care and spending health care dollars more wisely?

ACOs can be very useful in curbing costs. For those with limited health care budgets or those patients who receive public assistance an ACO model whether public or private. However Lewis et al, (2014) found that even though there was an almost even split between ACOs contracting for private and public contracts in the U.S.A., public contracts were less profitable than private ones due to public patients costing more to manage per capita than private ones. Quality was not examined. It would seem that an ACO would be ideal when faced with limited resources but ACOs may be reluctant to engage in contracts that are less profitable.

CASE STUDY 7 **** WHAT DID YOU LEARN FROM THE CASE STUDY? ( ****basically just summarize what the case study is about)

Transforming the Clinical Process at Farmington Endoscopy Center William C. Kinney

Transforming the clinical work process in healthcare is not going to be a simple task, as many of todayâs work solutions are rooted in decades-long and even century-old autonomous and hierarchical structures. As mentioned in the chapter, Paul Starrâs The Social Transformation of American Medicine explained how US healthcare evolved into a system that separates the business side and clinical side of care delivery. Separating the two functions ultimately created two diverging approaches, leaving the patient caught in the middle. Regulations from both the insurance industry and federal government are trying to bring the two sides together in the interest of what is best for the healthcare system as a whole.

The IOMâs reports on medical quality highlighted the inefficiencies and mistakes that resulted from the increased complexity of healthcare. Although IT exists to change the system, it has lacked the leadership and skills needed to bring about a redesign that, in turn, could transform existing processes and structures. The IOM reports and subsequent analyses have highlighted IT as a tool to improve quality and efficiency. Clinical decision support system (CDSS), in particular, has been identified as a priority health IT, as it pushes evidence-based health recommendations that lead not only to better clinical processes, quality, and outcomes but also to lower healthcare costs. The challenge in adopting CDSS is determining where and how to apply the evidence.

This case highlights the use of health IT to transform the clinical and business processes. Readers should take note of who the relevant players are, the information needs in care delivery, and the method of leveraging information to make care delivery more efficient and effective.

Farmington Endoscopy Center

Farmington is a Midwest college town with a population of more than 100,000 and a large and productive medical community supported by a local medical school. The medical community serves not only the residents of Farmington but also the residents of the surrounding rural communities, some of whom drive more than two hours to get to their respective clinic or hospital. The limited number of primary care physicians who work in rural settings, lack of supporting facilities, and varying socioeconomic backgrounds all add to the complexities of rural medicine. Rural communities also have few manufacturers and corporations that hire employees and provide employer-sponsored, private health insurance. This leaves many rural patients no choice but to enroll in government- supported healthcare programs. Farmington Endoscopy Center (FEC) is a freestanding, physician- owned endoscopy facility that serves both adult and pediatric patients. The main proceduresâesophagogastroduodenoscopy (EGD) and colonoscopyâare performed by six gastroenterologist (the owners). Last year, it completed almost 5,000 cases, and this year it is anticipating a 5 percent growth in volume by adding a new physician. FEC is owned and managed by the physicians, but a full-time administrator is in charge of day-to-day operations, compliance with state and federal safety/account- ability standards, billing and collections, and staffing. Rounding out the staff are eight nurses, four receptionists, one billing specialist, and one certified registered nurse anesthetist (CRNA).

Patients are referred to FEC for an endoscopy procedure by the six physicians, each of whom runs a separate outpatient clinic, or by independent primary care or specialty physicians. The independent primary or specialty care physician assumes patient-management responsibilities for the results of the endoscopy, so the gastroenterologist who performs the procedure is essentially a technician whose responsibility to the patient ends at the completion of the procedure. Both EGD and colonoscopy are not painful, but they are uncomfortable and thus require sedation. Administered by the CRNA, sedation techniques range from applying topical anesthetic to running an intravenous line of light anesthesia (where the patient stays awake and can communicate) or a heavy dose of anesthesia (where the patient is unconscious and could stop breathing and may need respiratory support). The CRNA is licensed by the state but cannot act as an independent provider and must be under the close supervision of the gastroenterologist. Throughout the procedure, the gastroenterologist is ultimately responsible for the patientâs well being.

Areas of Improvement

Susan Michaels, the FEC administrator, is reviewing last yearâs reports to find ways to increase volume. Both private and public insurance have changed their rules, resulting in lower reimbursements. Meanwhile, healthcare costs continue to rise, further cutting into profits. Needless to say, the FEC physician owners are concerned. Susan identifies two problem areas in the reports:

1. The center has a day-of-procedure cancellation rate of 8 to 12 per- cent. These patients show up for their scheduled procedure only to be cancelled by the clinic because of some factors that were not known before their arrival. The top-five factors are blood-thinner usage, unidentified cardiovascular risk, failure to adhere to NPO (latin for ânil per os,â which means no food or drink hours before a procedure), improper guardianship, and lack of bowel prep.

2. Regulations have doubled the amount of required paperwork to be completed for each patient. Explanation of patient rights and privacy policies, medication-reconciliation process, deep venous thrombosis evaluation, and complication reporting are just some of the tasks or forms that must be completed before a case can be closed. The planned addition of another physician to the practice would increase the number of cases, exacerbating the paperwork problem. Susan is considering hiring another nurse to help the existing staff with the workload, a move that would enable the FEC to accommodate more patients and complete the paperwork quicker. Fortunately, Susan just returned

Fortunately, Susan just returned from a health IT workshop that presented a new logic and tools for how to define the dimensions of a problem and derive workable solutions.

Information Needs

Evaluating and managing patient health needs is about acquiring information and making a decision based on that information. A wise physician once stated that 90 percent of the information a physician consults to arrive at a diagnosis is contained in the patientâs medical history. Much of todayâs health IT efforts pay attention to the physicianâs information needs for two reasons: (1) The doctor is ultimately responsible for health- care evaluation and management, and (2) the doctor gets paid based on a certain level of information she gathers. A careful review of current EMRs shows that information is maintained in vertical silos or âbucketsâ and based on billing and collection needs. Information is compartmentalized and cannot be shared easily among all players in the care delivery process. Compartmentalization also hinders the use of the information and masks the time-sensitive value of that information. Time, in this case, is chronologic and pertains to information that must be gathered and acted upon before an event.

In the case of scheduled procedures, decisions need to be made days before the encounter. Anticoagulation therapy, for example, is information that must be relayed before a patientâs appointed surgery or intervention. Appropriately managing anticoagulation is not necessarily straightforward, and a new healthcare player (e.g., a cardiologist) may need more information or guidance. CDSS can ensure that relevant patient information, research evidence, and best practice are available at the right time, a system that is infinitely valuable to a freestanding endoscopy center or ambulatory surgery center.

Information Gathering Process for an Integrated IT

Susan decides to use IT to address FECâs two problems. She identifies the information needs of each player (i.e., physicians, CRNA, and nurses), and then she breaks down the problems into components to better under- stand the clinical processes and find ways to integrate them to improve efficiencies and patient satisfaction. The ultimate goal is to create a sophisticated data-capture and management IT with an integrated CDSS. The steps she takes are as follows:

1. List each team member involved in an endoscopy procedure. Does the team composition change according to who initiated the patient referral? What steps do the physicians follow to refer patients to FEC? The referring physiciansâ information needs must be considered so that a better request-for-procedure ordering process can be developed.

2. List the information needs of each team member, including the supporting players who perform billing, collections, and other administrative tasks. Here are a few examples of these needs:

- The gastroenterologist needs to know why the patient is there. Is this a screening colonoscopy because of a family history of colon cancer? Is this a patient with anemia and guaiac-positive stools?

- The nurse needs to know if the patient had surgery in the last 30 days, as this increases the patientâs risk of deep venous thrombosis. The nurse also needs a current list of medications to complete the medication-reconciliation process.

The CRNA needs to know if the patient is taking an angiotensin- converting enzyme inhibitor. Current recommendations are for patients to not take this medication on the morning of a procedure. The CRNA must know the patientâs cardiac history and be able to identify potential risk factors that would affect the patientâs choice of sedation.

The referring physician needs a system for telling the FEC gastroenterologist, nurses, and CRNA information on the patient, including tests, medications, and risk factors, that could affect the patientâs ability to receive the procedure on the day it is scheduled.

Scheduling needs to know which patients are scheduled for what procedure and how long the procedure is estimated to take. Scheduling staff is responsible for reminding the patient of the appointment time, date, and any preparation (such as the NPO).

Registration needs to know the patientâs demographic and social status. Is the patient a minor? Who will be present to sign the consent? If the child is in foster care, does FEC need to obtain a court order to do the procedure? If the patient is an adult, is he of sound mind and body, or does he have a legal guardian?

Procedure room nurses need to know the capability of supplies and equipment to meet the needs of the patient. Is the patient wheelchair bound, and if so, should more time be added to the schedule? Does the patient have an artificial joint, as this will affect where the electrocautery-grounding pad is placed?

Construct a timeline of the information needs across the encounter. Identify overlapping information needs between players.

As a final step, Susan determines the time component of each information need to ensure that it is available at the appropriate time, which could reduce cancellations. Susan considers available consumer technology, such as the Internet, smart phones, and apps, to enhance the IT option. Susan also looks into outsourcing.

A successful health IT solution for FEC results in a significant reduction in cancellation rates and in a faster or same-day completion of the administrative, regulatory, and nursing paperwork. Such improvements enable FEC to schedule more patients and complete more procedures.

lemongnat674

The CEO of St. Sebastian Health System, a moderate-sized hospital system in a mid-sized, Midwest city has hired you to help turn things around. The CFO is projecting a $3.7 million operating loss this year, which will be more than offset by non-operating income. However, the board has made it clear that the situation must improve. If the system cannot produce a positive operating margin in 2017, someone else is going to be the CEO. The CEO and CFO have asked you to recommend strategic approaches to sell their services in the community that will help turn the financial ship around.

Your Health System

St. Sebastian is a community-based health system. The senior management team has an average tenure of 17 years. The exception is the Chief Medical Officer (CMO). She has been in her position for two years and is the fourth CMO in that role in the past ten years. The CEO and COO have each been in their current roles for ten years. The system is comprised of the following:

Two large, acute care hospitals

Two long term care facilities

Two skilled nursing facilities

One long-term acute-care hospital (LTAC)

Four geographically distributed outpatient centers

Four Urgent Care Centers

Two free-standing ambulatory surgery centers (ASCs)

A 400 member employed physician group that includes 180 Primary Care Providers (PCPs). All 28

PCP practices are certified Level III Patient-Centered Medical Homes by NCQA.

The remainder of the 1,000 members medical staff is generally comprised of large, independent groups who have varying degrees of loyalty to the system. The Radiology and Emergency groups, for example, do 100% of their work at St. Sebastian and have no ownership of any outside facilities. The Gastroenterology Group, on the other hand, does work at the hospital but also owns its own, freestanding endoscopy center. The orthopedic group does 75% of their work at St. Sebastian but maintains privileges at other facilities. They do not own their own ASC.

In the current year, St. Sebastian is projecting 220,000 patient visits (combined IP and OP) with an average cost per visit of $1,727. They have an average charge per visit of $4,545.

Over the past ten years, St. Sebastian has been active in pursuing many different strategic projects including:

They have established clinical institutes in cardiovascular, orthopedic, oncology, maternity, and neurologic care. Each of these has been built through a co-management agreement between the system and the internal or external physician group who would be most logical. Each institute is led by a dyad of an administrator and medical director.

Five years ago, they consolidated maternity programs to one facility, a move that justified investing in a Level III Neonatal Intensive Care Unit (NICU)

They have established a research division in the hopes of working with national pharmaceutical companies and/or tertiary care hospitals in the Midwest.

They have established a Physician Hospital Organization (PHO) and intend to become an Accountable Care Organization (ACO) that can participate in the Medicare Shared Savings

Program (MSSP) and/or enter into global risk contracts with third-party payers. The PHO is currently evaluating whether or not they should purchase an insurance license so that they could offer commercial, Medicare Advantage, and Managed Medicaid insurance products.

5. They have established a Business Health division to service the corporate health needs of the employers in the region. This would include things like EAP programs, on-site wellness, drug screening, on-site clinics, etc. This division also recently built two large, full-service fitness centers.

The competition The community is currently served by three other major health providers:

Mercy is the competitor acute care system in town and has two hospitals and various outpatient centers. They have not been active in physician employment they employ a group of 60 PCPs, but no specialists. Similarly, they have not been engaged in branching out with different strategic initiatives, preferring instead to focus on cost-efficient care. They do not have clinical institutes, research divisions, a PHO, or a Business Health division. They have 230,000 visits per year, with an average cost of $1,435 per visit and an average charge of $4,348.

General Pediatric is a pediatric teaching hospital. Five years ago, they signed an affiliation agreement with Johns Hopkins to gain access to clinical and research capabilities that would have been beyond their reach, given their size. The employee essentially all of the pediatric subspecialists and have a PHO, which includes 75% of the region's primary care pediatricians. They will have 200,000 visits this year, with an average cost of $2,100 per visit and an average charge of $5,000 per visit.

General University is an adult teaching hospital affiliated with the local university's medical school. They staff the region's free-care clinics and historically, have been the region's hospital for indigent/uninsured patients. They are the region's Level I trauma center and are well regarded for intensive services like trauma, stroke, and cancer care. However, their location and reputation for taking indigent patients mean that they are not preferred for normal medical care by commercially insured or Medicare patients. Besides the community health centers, they own an inpatient rehab hospital, but no other facilities. They have explored affiliations with national leaders in academic medicine, but so far have not signed any such agreements. They see 180,000 visits per year with an average cost of $1,833 and an average charge of $5,556 per visit.

There are no other hospitals currently operating, though there are 23 skilled nursing facilities (SNFs) and 3 inpatient rehab facilities throughout the region. They are independent actors and for the most part, are struggling to stay profitable. Several single-specialty physician groups operate ambulatory surgery centers and one chain of independent diagnostic treatment facilities (IDTFs). Three years ago, there was a significant change in the state government, and that resulted in the long-time Certificate of Need (CON) program is all but scrapped (Skilled Nursing Facilities are still heavily regulated). Several for-profit hospital companies have recently done some analysis around entering your market, but have not done so yet.

The community is a Midwest city and surrounding suburbs in the midst of a transition from a manufacturing employment base, which unfortunately accelerated with the 2008 economic downturn. The hospitals have seen this over the past several years in a tightening of benefits offered by local employers. Benefits continue to be offered, but increasingly are likely to have a significant deductible associated with them. Unemployment has been above the national average and is projected

to remain that way. This means that the average wage in the region is actually below where it was in 2008 when the last recession hit. The number of Medicare-age residents is projected to rise over the next 10-20 years while working-age patients are projected to stay flat or fall slightly. Similarly, birth rates are expected to fall slightly over the coming decade.

The community is 60 miles south, 45 miles east, and 50 miles north of other, similarly-sized cities. Until 20 years ago, that made this city effectively an island unto itself. Increasingly, however, the suburbs of each of these communities have become very close to each other. As that has happened, providers in each community have followed and established practice sites and free-standing outpatient centers.

The community has a normal looking mix of Commercial, Medicare, and Medicaid patients. Because the state's governor was fiercely against the Affordable Care Act, the Medicaid expansion that happened in other states hasn't happened here. Thus, the community also has a sizable population without insurance today. As you'd expect, different hospitals see a different mix of these patients. The local health council was able to provide you with the most recent years payer mix by hospital below:

Patient visits	Commercial	Medicare	Medicaid	Uninsured/Self-pay
Mercy	80,500	105,800	23,000	20,700
St. Sebastian	99,000	101,200	11,000	8,800
Gen. Pediatric	70,000	4,000	110,000	16,000
Gen. University	63,000	45,000	45,000	27,000
Community Total	312,500	256,000	189,000	72,500

Reimbursement the CFO was able to supply you with their best estimate for what various payers are reimbursing for services. In general, the commercial plans are paying 50% of charges, regardless of location, except at General Pediatric. There, the monopoly on pediatric services has allowed them to negotiate rates of 80% of charge, but only for the commercial plans. Medicare currently pays 30% of charges at all hospitals, and Medicaid pays 25% of charges everywhere. Uninsured patients are generally paying 2% of charges.

refer back to St. Sebastian and the facts laid out in the background reading and Case #1and consider:

What products are in this industry vs. part of another distinct group?

What is the geographic scope of competition?

Identify the participants and segment them. Who are,

The buyers and buyer groups?

Suppliers and supplier groups?

The competitors?

The substitutes?

The potential entrants?

Which of these forces is strong/weak and why?

If possible, analyze the industry structure.

Why is the level of profitability what it is?

Which are the controlling forces for profitability?

What are the recent and likely future changes in each force, both positive and negative?

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HLST 1010 Study Guide - Final Guide: Health Human Resources

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