Chapter 2 the health care delivery system

Professional Standards review organizations (PSRO) - Created by the federal government to review the quality, quantity, and cost of hospital care Who is the biggest consumer of health care? - The federal government which pays for Medicare and Medicaid Utilization review (UR) committees - Review the admissions and to identify and eliminate overuse of diagnostic and treatment services ordered by physicians caring for patients on Medicare. Prospective payment system (PPS) - Established by Congress in 1983, eliminated cost-based reimbursement. Grouped inpatient hospital services for medicare into DRGs. Diagnosis related groups (DRGs) - Grouped inpatient hospital services for Medicare patients. Each group has a fixed reimbursement amount with adjustments based on case severity, rural/urban/regional costs, and teaching costs. Hospital receive a set dollar amount for each patient based on the assigned DRG, regardless of the patient's length of stay or use of services. capitation - Providers receive a fixed amount per patient or enrollee of a healthcare plan. Aims to build a payment plan for select diagnoses or surgical procedures that consists of the best standards of care at the lowest cost Resource utilization groups - Health care providers try to manage cost so that organizations remain profitable. adds more pressure to ensure that patients are managed effectively and discharged as soon as possible. Managed care - Describes healthcare systems in which the provider or healthcare system receives a predetermined capitated payment for each patient enrolled in the program Integrated delivery networks (IDNs) - Include a set of providers and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting. Reduces duplication of services across the levels or settings of care to ensure that patients receive care in the most appropriate settings Primary health care - Health promotion. Focuses on improved health outcomes for an entire population. It includes primary care and health education, proper nutrition, maternal/child health care, family planning, immunizations, and control of diseases. What are some examples of primary care ? - Prenatal and well baby care, nutrition counseling, family planning, and exercise classes What are some examples of preventive care? - Blood pressure and cancer screening, immunization, mental health counseling and crisis prevention, Community legislation - seat belts, air bags, bike helmets What are some examples of secondary acute care - Emergency care, acute medical - surgical care, radiological procedures for acute problems - x-rays, CT scans What are some examples of tertiary care ? - Intensive care and subacute car