4 Working in Today's Healthcare Environment Journal Topic: What are the main differences between Medicare and Medicaid.

Learning Objectives Define all key terms. Describe today’s healthcare environment. Discuss the similarities and differences among health maintenance organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider organizations (EPOs). continued on next slide

Learning Objectives Describe five types of medical practice. Discuss the term diplomat as it relates to medical specialty boards. Identify three categories of licensed nurses and describe their educational requirements. Describe five categories of certified healthcare professionals. continued on next slide

Learning Objectives Describe the diagnostic related group (DRG) system of classification. State the differences between Medicare and Medicaid.

Today's Health Care Environment Major changes since 1965 with Medicare and Medicaid Increased life expectancy = more older adults Technological discoveries Preventative care and patient education stressed (but not funded) Government legislation continued on next slide

Today's Health Care Environment Fixed-payment plans Medical care for a fixed monthly fee Third-party payers

Managed Care Managed Care Organization (MCO) Gatekeeper Health Maintenance Organization (HMO) Offers a wide range of services to members for a predetermined fee by a limited group of providers Capitation rate continued on next slide

Managed Care Preferred Provider Organization (PPO Patient must use a medical provider who is under contract with the insurer for an agreed-upon fee Copayment Exclusive Provider Organization (EPO) Combines the concepts of HMO and PPO Fee-for-service (FFS)

Federal Assistance Programs Medicare Health care coverage for elderly or seriously disabled, or with end stage renal disease, or other debilitating ailments, regardless of wealth or income Rationing of health care

Federal Assistance Programs Diagnostic Related Groups (DRGs) Classifies each Medicare patient by illness into a category Hospitals receive a preset sum for treatment of an illness category Regardless of "bed days" used continued on next slide

Federal Assistance Programs Diagnostic Related Groups (DRGs) Discourages treatment of severely ill patients Patients often are discharged before ready

Medicaid A joint Federal–State program Federal government pays 57% of expenditures Federal program implemented by individual states continued on next slide

Medicaid Financial assistance to insure poor and indigent Rationing takes place Not all providers accept Medicaid coverage Individual states enact their own legislation regarding spending

Ethical Considerations of Managed Care Some physicians will not treat Medicare patients Must provide minimum standard of care to everyone Patients must be fully informed of consequences of obtaining health care elsewhere continued on next slide

Ethical Considerations of Managed Care Bait-and-switch Profit may be more important than patient's health Wealthy may have greater access to care and treatment than poor patients

Health Care Quality Improvement Act (HCQIA) of 1986 Passed out of concern about medical malpractice Protects whistleblowers National Practitioner Data Bank (NPDB) Information not disclosed to general public

Types of Medical Practice Solo practice Sole proprietorship Partnership Shared responsibility for financial and legal matters Associate practice Shared facility, but not accounting or legal responsibility continued on next slide

Types of Medical Practice Group practice Three or more physicians Share same facility Practice medicine together Can be designated as HMO or IPA continued on next slide

Types of Medical Practice Professional corporation Managed by board of directors Shareholders Protection of individual assets and liability

Ethics of Fee Splitting One physician offers to pay another for referral (unethical and illegal) Fee splitting vs. referrals continued on next slide

Ethics of Fee Splitting Franchise Business run by individual to whom franchisor grants exclusive right to market product or service in certain market area (ethical) Franchisees Persons or companies that hold a franchise

Medical Specialty Boards Seek to improve quality of medical care Encourage physicians to further education and training Evaluate candidates who apply and pass exam Board-certify those who pass continued on next slide

Medical Specialty Boards American College of Surgeons Fellow of American College of Surgeons (FACS) American College of Physicians Fellow of American College of Physicians (FACP)

Allied Health Professionals Licensed personnel include: Registered nurse Nurse practitioner Licensed practical nurse Pharmacist continued on next slide

Allied Health Professionals Certified personnel include: Physician assistant Medical assistant Medical transcriptionist Lab technician Lab technologist continued on next slide

Allied Health Professionals Registered personnel include: Nurses Medical assistants Medical technologists Phlebotomists American Medical Technologists (AMT) association

Conscience Clause Enacted by several states Employees may have a moral or religious objection to assisting with certain procedures (sterilization, abortion) Employee cannot be discriminated against under the state's statute