A 3-4 page case study paper dealing with the Affordable Care Act. I have attached the powerpoints for some references of the reading for the chapters this paper is based on. Please ensure that you have read the instructions carefully
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C
ase Study: Chapters 7 and 8.
Objective: The students will complete a Case study assignments that give the opportunity to synthesize and apply the thoughts learned in this and previous coursework to examine a real-world scenario. This scenario will illustrate through example the practical importance and implications of various roles and functions of a Health Care
A
dministrator. The investigative trainings will advance students’ understanding and ability to contemplate critically about the public relations process, and their problem-solving skills. As a result of this assignment, students will be better able to comprehend, scrutinize and assess respectable superiority and performance by all institutional employees.
ASSIGNMENT GUI
D
ELINES (
10%
):
Students will critically measure the readings from Chapters 7 and 8 in your textbook. This assignment is planned to help you examination, evaluation, and apply the readings and strategies to your Health Care organization, and new reform act.
You need to read the chapters assigned for week 4 and develop a 3-4 page paper reproducing your understanding and capability to apply the readings to your Health Care organization and finance. Each paper must be typewritten with 12-point font and double-spaced with standard margins.
F
ollow APA style 7th edition format when referring to the selected articles and include a reference page.
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EACH PAPER SHOULD INCLUDE THE FOLLOWING:
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1.
Introduction
(
25%
)
Provide a brief synopsis of the meaning (not a description) of each Chapter and articles you read, in your own words that will apply to the case study presented.
2.
Your Critique (
50%
):
Case Study
This is the first of a two-part series about the impact of health care reform on a Texas-based small business, Software Advice, and how the CEO, Don Fornes, plans to keep providing quality benefits while controlling costs.
When the Affordable Care Act (ACA) was passed, I thought it was just a watered-down version of health care reform. However, our health insurance broker recently briefed me on how it will impact our business when we renew our coverage. The majority of the ACA’s provisions go into effect in 2014 — and they are much more onerous than I expected.
The bottom line: We are expecting price increases of anywhere from six percent to 40 percent per employee next year. That’s a big variation, right? I’ll explain why we’re facing such uncertainty.
Dramatic changes to health insurance pricing
The ACA’s first major impact is a shift toward “community rating.” Starting in 2014, insurance carriers will no longer be able to price small group coverage based on employees’ health status and claims history. They will use only four factors: age, gender, tobacco use and ZIP code. That means other employee populations in your area will affect your insurance rates.
Community rating is a dramatic change, and it will result in substantial inflation for small groups that had previously enjoyed low rates based on younger, exceptionally healthy employee populations — like ours.
Expanded coverage requirements
The ACA introduces broader requirements on what an employer’s health care plan must cover. For example, small groups’ coverage must now provide for essential health benefits, such as pediatric services, maternity care and substance abuse treatment, and is subject to maximum deductible and out-of-pocket limits. Large groups’ plans must provide “affordable coverage” — that is, the employer must cover at least 60 percent of the actuarial value of health care costs, and employee contributions must not exceed 9.5 percent of their income, whereas previously there was no such coverage quota.
B
ecause our business has always been relatively healthy, we’ve been able to provide coverage that meets or exceeds these requirements, but I empathize with employers whose profit margins don’t easily afford the provision of high-quality coverage. They will be the most significantly impacted by the new requirements.
As I examined all this information, I came to a conundrum: Are we a small group, or not? Under current Texas law, a small group is one with two to 50 employees. However, pending legislation — Texas State Senate Bill 85 — could expand that to companies of up to 100, if passed. We just hired our fifty-fifth employee.
Large group pros and cons
Many companies have been fearful of the “large group” label when it comes to health care reform, carefully keeping their staff numbers under 50. But we found that being a large group is actually beneficial to us. As a large group, we are exempt from community ratings and maximum deductible limits. We also don’t have to provide essential health benefits — though we already do. And the expected increase in health care costs for large groups in 2014 is relatively low — six to eight percent.
Potential drawbacks of being a large group: We are subject to the “pay or play” rule — provide coverage that meets the requirements, or pay a penalty– as well as automatic employee enrollment upon hire and at renewal. For companies with a tighter bottom line, these rules may prove challenging. For our business, they are less relevant; we are already providing quality coverage, and we want everyone to have it.
Small group pros and cons
Small groups are exempt from pay or play. They don’t have to provide coverage to their employees. If we were, say, a small pizza shop, this would be a relief. But we’re not. We want to remain competitive in hiring — and can afford to keep doing so.
The requirement to provide for essential health benefits could be problematic for cash-strapped companies and might raise carrier costs.
The biggest downsides if we’re a small group: we’d be subject to detrimental community ratings, and maximum deductible and out-of-pocket limits would drive up costs across the board. As a small group, we would face a whopping 30 to 40 percent increase in health care costs for 2014.
The outcome
One thing we will do is push our renewal date out to December 2018, so that our new plan won’t take effect until January 2019. That’s because the government may actually change or delay implementation of some ACA provisions. Pushing out our renewal delays the new requirements as long as possible and allows us to keep a plan we like, while giving us a chance to see if the government backpedals.
CASE STUDY CHALLENGE
1. Describe hoe some changes in the health service delivery system have led to a decline in hospital inpatient days and growth in ambulatory services.
2. All primary care is ambulatory, but not all ambulatory services represent primary care. Discuss.
3. As hospital evolved from rudimentary custodial and quarantine facilities to their current state, how their purpose did and function changes.
3.
Conclusion
(
15%
)
Briefly summarize your thoughts & conclusion to your critique of the case study and provide a possible outcome for the Health Care Center. How did these articles and Chapters influence your opinions about Health Care and new reform act?
Evaluation will be based on how clearly you respond to the above, in particular:
a) The clarity with which you critique the case study;
b) The depth, scope, and organization of your paper; and,
c) Your conclusions, including a description of the impact of these Case study on any Health Care Setting, and inpatient facilities.
ASSIGNMENT RUBRICS
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Assignments Guidelines
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1 Points
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10%
|
|
Introduction
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2.
5 Points
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25%
|
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Your Case Study Critique: Challenges
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5 Points
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50%
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Conclusion
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1.5 Points
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15%
|
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Total
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11 points
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100%
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ASSIGNMENT GRADING SYSTEM
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A
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90% – 100%
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|
B+
|
85% – 89%
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B
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80% – 84%
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C+
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75% – 79%
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|
C
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70% – 74%
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D
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60% – 69%
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F
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50% – 59% Or less.
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Chapter 8
Inpatient Facilities and Services
1
Learning Objectives (1 of 2)
Perspective on hospital evolution
Factors contributing to hospital growth prior to the 1980s
Reasons for the decline of hospitals and their utilization
Measures pertaining to hospital operations and inpatient utilization
Compare utilization measures in U.S. hospitals to other countries
2
Learning Objectives (2 of 2)
Differentiate among various types of hospitals
How the ACA affected physician-owned specialty hospitals and nonprofit hospitals
Basic concepts in hospital governance
Understand licensure, certification, and accreditation and the Magnet Recognition Program
Get a perspective on ethical issues
3
Introduction
Inpatient requires overnight stay in a facility
Hospital
Institution with at least six beds
Delivers services including diagnostics and treatment
Evolved from institutions of refuge for homeless and poor
Ultramodern facilities providing advanced services
4
Hospital Transformation in the U.S.
Five functions in the evolution of hospitals
Primitive institutions of social welfare
Distinct institutions of care for the sick
Organized institutions of medical practice
Advanced medical training and research
Consolidated systems of health services delivery
5
Expansion Phase: Late 1800s to Mid-1980s
Development of professional nursing
Growth of private health insurance
Role of government
Hill-Burton Act
Public health insurance
6
Figure 8-1: Trends in the number of U.S. community hospital beds per 1,000 resident population.
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 281; National Center for Health Statistics. 2016. Health, United
States, 2015. Hyattsville, MD: U.S. Department of Health and Human
Services. p. 289.
7
Downsizing Phase: Mid-1980s Onward
Average hospital has become smaller.
Shift from inpatient to outpatient care.
Changes in reimbursement.
Impact of managed care.
Hospital closures
Since 2000 many government-run hospitals closed.
8
Figure 8-3: Ratio of hospital outpatient visits to inpatient days for all U.S. hospitals, 1980–2013 (selected years).
Data from National Center for Health Statistics. 2002. Health, United
States, 2002. Hyattsville, MD: Department of Health and Human Services.
p. 110; National Center for Health Statistics. 2013. Health, United States,
2012. Hyattsville, MD: Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015.
Hyattsville, MD: Department of Health and Human Services. p. 281.
9
Some Key Utilization Measures and Operational Concepts
Discharges
Inpatient days
Average length of stay
Hospital access and utilization: comparative data
Capacity
Average daily census
Occupancy rate
10
Table 8-2: Ratio of hospital outpatient visits to inpatient days for all U.S. hospitals, 1980–2013 (selected years).
11
Modified from Weiss, A. J., and A. Elixhauser. 2014. Overview of hospital stays in the United States, 2012 (Statistical Brief #180). Rockville, MD: Agency
for Healthcare Research and Quality. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012 .
Accessed May 2017.
12
Figure 8-5: Average lengths of stay by U.S. hospital ownership (selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 307;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 281.
13
Figure 8-6: Breakdown of U.S. community hospitals by size, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
14
Figure 8-7: Change in occupancy rates in U.S. community hospitals, 1960–2013 (selected years).
Data from National Center for Health Statistics. 2013. Health, United States, 2012. Hyattsville, MD: U.S. Department of Health and Human Services. p. 314;
National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
15
Factors That Affect Hospital Employment
Hospitals accounted for largest number of jobs in the health care industry in 2013.
Workforce represented roughly 39% of total health care employment.
More than 6 million people are employed by U.S. hospitals.
Changes in reimbursement policy can affect employment.
Cannot outsource health care jobs because they generally require personal interaction.
16
Hospital Costs
Inpatient hospital services are the largest share of total U.S. health care expenditures.
Medicare and Medicaid payments.
Rise in bad debts.
International cost comparisons.
17
Figure 8-8 Proportion of total U.S. hospitals by type of hospital, 2014.
Data from Health Forum. 2016. Fast facts on U.S. hospitals. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed October 30, 2016.
18
Types of Hospitals (1 of 4)
Classification by ownership
Public hospitals
Private nonprofit hospitals
Private for-profit hospitals
Classification by public access
Classification by multiunit affiliation
19
Figure 8-9: Breakdown of U.S. community hospitals by types of ownership, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
20
Table 8-6: The Largest U.S. Multihospital Chains, 2014
Data from Sanofi-Aventis. 2016. Managed care digest series: Hospital/systems digest, 2016. Bridgewater, NJ: Author.
21
Types of Hospitals (2 of 4)
Classification by type of service
General hospitals
Specialty hospitals
Physician-owned specialty hospitals
Psychiatric hospitals
Rehabilitation hospitals
Children’s hospitals
22
Types of Hospitals (3 of 4)
Classification by length of stay
Short-stay hospitals
Long-term care hospitals
Classification by location
Swing-bed hospitals
Critical access hospitals
Other rural designations
23
Types of Hospitals (4 of 4)
Classification by size
Other types of hospitals
Teaching hospitals
Church-affiliated hospitals
Osteopathic hospitals
Figure 8-6 Breakdown of U.S. community hospitals by size, 2013.
Data from National Center for Health Statistics. 2016. Health, United States,
2015. Hyattsville, MD: U.S. Department of Health and Human Services. p. 288.
24
Expectations for Nonprofit Hospitals (1 of 2)
Internal Revenue Code, Section 501(c)(3)
Grants tax-exempt status to nonprofit organizations
Institutions are exempt from federal, state, and local taxes
Nonprofit organizations
Provide some defined public good
Do not distribute any profits to any individuals
25
Expectations for Nonprofit Hospitals (2 of 2)
Nonprofit institutions face new ACA demands
Establish written financial assistance and emergency care policies.
Limit charges for those eligible for assistance under hospital’s financial assistance policy.
Limit billing and collection actions against those within the guidelines of financial assistance.
Conduct a community health needs assessment.
26
Some Management Concepts
Hospital’s organizational structure differs from other large business organizations.
Hospital governance
See Figure 8-10
Board of trustees
Chief executive officer
Medical staff
27
Licensure, Certification, and Accreditation
State governments oversee the licensure of health care facilities.
Certification allows a hospital to participate in Medicare and Medicaid programs.
Accreditation is designed to ensure facilities meet certain basic standards.
28
Magnet Recognition Program
Designation conferred by the American Nurses Credentialing Center
Affiliate of the American Nurses Association
Recognizes
Quality patient care
Nursing excellence
Innovations in professional nursing practice in hospitals
29
Ethical and Legal Issues in Patient Care
Principles of ethics
Legal rights
Bill of rights and informed consent
Advance directives
DNR
Living will
Durable power of attorney
Mechanisms for ethical decision making
30
Summary
Almshouses and pesthouses evolved into public hospitals to serve the poor.
Key measures of inpatient utilization.
Hospitals are classified in numerous ways.
ACA restrictions.
Ethical decision making has been a special area of concern for hospitals.
31
Chapter 7
Outpatient and Primary Care Services
1
Learning Objectives
Outpatient, ambulatory, and primary care
Principles behind patient-centered medical homes and community-based primary care
Reasons for dramatic growth in outpatient services
Various types of outpatient settings and services
Role of complementary and alternative medicine
Primary care delivery in other countries
Impact of ACA on primary care
2
Introduction
The terms outpatient and ambulatory are used interchangeably.
Hospitals provided majority of outpatient care.
Independent providers faced capital constraints.
Consumer demand fueled growth of complementary and alternative medicine.
ACA addresses access for poor and vulnerable.
3
What Is Outpatient Care?
Outpatient services or ambulatory care
Ambulatory care
Diagnostic and therapeutic services for the walking patient
Used synonymously with community medicine
Outpatient services
Services not provided with an overnight stay
4
Scope of Outpatient Services
Primary care is the foundation for ambulatory health services.
Services other than primary care are an integral part of outpatient services.
Technological advances allow treatments to be provided in ambulatory care settings.
5
Table 7-1: Owners, Providers, and Settings for Ambulatory Care Services
Data from Barr, K. W., and C. L. Breindel. 2004. Ambulatory care. In: Health care administration: Planning, implementing, and managing organized
delivery systems. L. F. Wolper, ed. 4th ed. Burlington, MA: Jones & Bartlett Learning. pp. 507–546.
6
Primary Care
Plays a central role in a health care delivery system.
Distinguished from secondary and tertiary care by duration, frequency, and intensity.
Secondary and tertiary care are more complex and specialized.
7
Secondary Care
Usually short term
Sporadic consultation from a specialist
Includes hospitalization
Routine surgery
Specialty consultation
Rehabilitation
8
Tertiary Care
Most complex level of care
Uncommon conditions
Institution based
Highly specialized
Technology-driven
Rendered in large teaching hospitals
9
Health Care Service Frequency
Primary care
75−85% of population requires only primary care
Secondary care
10−12% requires referral to short-term secondary care
Tertiary care
5−10% require tertiary care
10
World Health Organization Definition
World Health Organization (WHO, 1978)
Three elements for understanding primary care
Point of entry
Coordination of care
Essential care
11
Institute of Medicine Definition
IOM defined primary care
Comprehensively addresses any health problem at any stage of patient’s life
Coordination ensures a combination of health services to best meet the patient’s needs
Continuity of care administered over time
Emphasizes accessibility and accountability
12
Primary Care and the Affordable Care Act
Four primary care provisions
Increased Medicare and Medicaid payments
New incentives for primary care providers working in underserved areas
Expansion of the health center program and strengthening of the capacity of health centers
Creation of additional training programs
13
New Directions in Primary Care (1 of 2)
Patient-centered medical homes (PCMH)
Team-oriented approach for special-needs children requiring constant care coordination
Initially consisted of an interdisciplinary team of physicians and allied health professionals
Studies demonstrated a positive impact
PCMH assessment tools
14
New Directions in Primary Care (2 of 2)
Community-oriented primary care elements
Reducing exclusion and social disparities
Organizing health services around people’s needs
Integrating health into all sectors
Pursuing collaborative models of policy dialogue
Increasing stakeholder participation
15
Primary Care Providers
U.S. primary care practitioners
Not restricted to physicians trained in general and family practice
Includes internal medicine, pediatrics, and obstetrics and gynecology
Nonphysician practitioners (NPPs)
Nurse practitioners (NPs), physician assistants (PAs), and certified nurse-midwives (CNMs)
16
Growth in Outpatient Services
Reimbursement
Technological factors
Utilization control factors
Physician practice factors
Social factors
17
Figure 7-2: Percentage of total surgeries performed in outpatient departments of U.S. community hospitals, 1980–2013.
Data from National Center for Health Statistics. 2016. Health, United States, 2015. U.S. Department of Health and Human Services. p. 281.
18
Types of Outpatient Care Settings and Methods of Delivery (1 of 6)
Private practice
Hospital-based services
Clinical services
Surgical services
Emergency services
Home health care
Women’s services
19
Types of Outpatient Care Settings and Methods of Delivery (2 of 6)
Figure 7-3 Growth in the number of medical group practices in the United States.
Data from Medical Group Management Association. Medical group fast
facts. Available at: http://www.mgma.com/uploadedFiles/Store_Content
/Surveys_and_Benchmarking/8523-Table-of-Content-MGMA
-Performance-and-Practices-of-Successful-Medical-Groups ; SK&A
. 2016. Medical group practice list. http://www.skainfo.com/databases
/medical-group-practice-list. Accessed January 2016; VHA Inc. and Deloitte
& Touche. 1997. Environmental assessment: Redesigning health care for the
millennium. Irving, TX: VHA Inc.; SMG Solutions. 2000. Report and directory:
Medical group practices. Chicago, IL: SMG Solutions.
Figure 7-4 Ambulatory care visits in the United States.
Data from National Center for Health Statistics. 2016. Health, United States, 2015.
U.S. Department of Health and Human Services. p. 265.
20
Types of Outpatient Care Settings and Methods of Delivery (3 of 6)
Freestanding facilities
Walk-in clinics
Urgent care centers
Surgicenters
Retail clinics
Mobile medical, diagnostic, and screenings
EMTs and paramedics
21
Types of Outpatient Care Settings and Methods of Delivery (4 of 6)
Home health care
Hospice services
Comprehensive services for terminally ill with life expectance of 6 months or less
Palliation with psychosocial and spiritual support
Specific conditions for Medicare certification
22
Figure 7-6: Demographic characteristics of U.S. home health patients, 2013.
Data from Alliance for Home Health Quality and Innovation. 2015. Home Health Chartbook 2015. Available at: http://ahhqi.org/images/uploads/AHHQI_2015_Chartbook_FINAL_October_Aug2016Update . Accessed February 2017.
23
Figure 7-7: Estimated payments for home care by payment source, 2014.
Data from National Center for Health Statistics. 2016. Health, United
States, 2015. U.S. Department of Health and Human Services. p. 298.
24
Table 7-4: Home Health and Hospice Care Patients Served at the Time of the Interview, by Agency Type and Number of Patients in the United States, 2007.
25
Reproduced from Park-Lee E.Y., and F. H. Decker. 2010. Comparison of home and hospice care agencies by organizational characteristics and services provided: United States, 2007. National Health Statistics Reports no. 30: 1–23.
26
Types of Outpatient Care Settings and Methods of Delivery (5 of 6)
Ambulatory long-term care services
Nursing homes
Case management
Adult day health care
Public health services
Community health centers
27
Types of Outpatient Care Settings and Methods of Delivery (6 of 6)
Three characteristics of free clinics
Services provided at no charge or nominal charge
Clinic not directly supported or operated by a government agency
Services delivered by trained volunteer staff
Other clinics
Telephone access
28
Complementary and Alternative Medicine (CAM) (1 of 2)
Reasons for CAM growth
Most seek CAM therapies following Western treatments that have not helped
Want to avoid/delay complex surgeries or toxic allopathic treatments
Feel in control when empowered with medical and health-related information
Want practitioners to take time to listen to them
29
Complementary and Alternative Medicine (CAM) (2 of 2)
National Center for Complementary and Alternative Medicine’s (NCCAM) objectives
Explore complementary and alternative healing practices in the context of rigorous science
Train complementary and alternative medicine researchers
Disseminate authoritative information to the public and professionals
30
Utilization of Outpatient Services (1 of 3)
Visits to physicians
Physicians in general and family practice (22.8%)
Physicians in internal medicine (13.6%)
Pediatrics (11.1%)
Obstetrics and gynecology (6.4%)
Doctors of osteopathy (6.7%)
31
Utilization of Outpatient Services (2 of 3)
32
Utilization of Outpatient Services (3 of 3)
Reproduced from Centers for Disease Control and Prevention (CDC). 2013. National Ambulatory Medical Care Survey: 2013 summary tables. Available at: https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2013_namcs_web_tables . Accessed April 2017.
33
Table 7-6: Principal Reason for Visiting a Physician
“Modified from Centers for Disease Control and Prevention (CDC). 2013. National Ambulatory Medical Care Survey: 2013 summary tables. Available at:
https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2013_namcs_web_tables . Accessed April 2017.”
34
Primary Care in Other Countries (1 of 2)
United Kingdom
Most comprehensive coverage with little or no patient cost sharing
Canada
Covers physician visits but medication coverage varies
Australia, New Zealand, and Germany
Varying degrees of cost sharing
35
Primary Care in Other Countries (2 of 2)
Australia, Canada, France, Germany, Switzerland, and the U.S.
Payers typically use fee-for-service payments
Employ performance incentives
Mostly privatized in all countries mentioned except Iceland and Sweden
36
Summary
Ambulatory services increased outside the hospital setting.
Ambulatory services transcend basic and routine primary care services.
Primary care has become specialized.
Numerous outpatient services have emerged.
A variety of settings for services have developed.
37
