1. 4 Working in Today's Healthcare Environment
Journal Topic: What are the main differences between Medicare and Medicaid.

2. 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

3. 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

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

5. 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

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

7. 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

8. 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)

9. 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

10. 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

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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

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

21. 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

22. 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

23. 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)

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

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

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

27. 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