Healthcare Models and Constituents Overview

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Questions and Answers

What is the first phase of the GE Change Acceleration Process (CAP) Model?

Improved State

Current State (correct)

Future State

Transition State

Which component is NOT included in the foundational components of change?

Making Change Last

Setting a Budget (correct)

Shaping a Vision

Leading Change

What is the purpose of mobilizing commitment in the change management process?

To evaluate financial impact

To establish a timeline for change

To analyze market trends

To achieve stakeholder buy-in (correct)

Which type of recruitment service is specifically aimed at medical positions?

Medical Staff Recruitment Signup and view all the answers

What does the 'Improved State' represent in the GE Change Acceleration Process (CAP) Model?

The desired outcome after successful changes Signup and view all the answers

Which position is responsible for overseeing compliance in a healthcare organization?

Chief Compliance Officer Signup and view all the answers

What is a primary responsibility of a Compliance Specialist?

Writing and maintaining policies Signup and view all the answers

Which of the following laws is NOT typically associated with healthcare compliance?

The Federal Acquisition Regulation Signup and view all the answers

In 2024, which of the following is a key focus area for healthcare compliance?

Artificial Intelligence Signup and view all the answers

What is a common task performed by legal teams in healthcare organizations?

Drafting and reviewing contracts Signup and view all the answers

Which of the following is NOT a common reason for lawsuits against healthcare organizations?

Breach of contract Signup and view all the answers

Which agency is primarily responsible for accreditation in healthcare organizations?

The Joint Commission Signup and view all the answers

What is the main goal of for-profit healthcare organizations?

Maximize profits Signup and view all the answers

Which of the following financial management processes involves managing reimbursements?

Revenue Cycle Signup and view all the answers

What type of reimbursement is determined after the delivery of care?

Retrospective reimbursement Signup and view all the answers

Which of the following is NOT a component of the governance structure in healthcare organizations?

Board of Investors Signup and view all the answers

What is the primary focus of the governance structure in a healthcare organization?

Setting direction and financial oversight Signup and view all the answers

In the context of finance, what does the Supply Chain refer to?

Clinical and non-clinical goods inventory Signup and view all the answers

Which healthcare model relies exclusively on government funding through income taxes?

Beveridge Model Signup and view all the answers

What is a primary goal of The Triple Aim in healthcare management?

Improve the health of the population Signup and view all the answers

Which component is NOT a constituent of healthcare in the United States?

Foreign Governments Signup and view all the answers

Which source of coverage does the Out-of-pocket model primarily rely on?

Individuals Signup and view all the answers

What does the 80/20 rule in The Affordable Care Act require from insurers?

Spend 80% of premiums on care Signup and view all the answers

What is the primary role of the Chief Operating Officer (COO) in healthcare organizations?

Overseeing the delivery of care strategy Signup and view all the answers

Which of the following is NOT a feature of the National Health Insurance (NHI) model in Canada?

Employee payroll deductions Signup and view all the answers

Which leadership role is directly responsible for fulfilling job responsibilities within an organization?

Manager Signup and view all the answers

In which healthcare model are individuals primarily responsible for their own health care funding?

Out-of-pocket Model Signup and view all the answers

Which type of healthcare provider is not typically included in frontline staff?

Clinical Managers Signup and view all the answers

What is a common challenge faced by healthcare leaders in managing clinical operations?

Reducing burnout and fatigue among staff Signup and view all the answers

Medicare primarily serves which group of individuals?

Seniors aged 65 and older Signup and view all the answers

Which healthcare model is characterized by multi-payer coverage dependent on employment status?

Bismarck Model Signup and view all the answers

What is a key function of the Human Resources department within healthcare management?

Managing payroll and benefits Signup and view all the answers

Study Notes

Constituents of Healthcare

Patients: Individuals receiving healthcare services.
Insurers (Payers): Entities that pay for healthcare services.
Providers: Individuals or organizations that deliver healthcare services (e.g., doctors, hospitals).
Government: Regulates and often funds healthcare services.

Factors Behind Healthcare Models

Number of Sources of Coverage:
- Single-payer Model: One entity (usually the government) pays for healthcare services.
- Multi-payer Model: Multiple entities (government, private insurance companies) pay for healthcare services.
Source of Coverage: Determines who is responsible for paying for health services.
- Government: Funded through taxes.
- Insurance Companies: Funded through premiums.
- Individually: Funded by the individual patient.
Source of Funding: How the healthcare system is financed.
- Taxpayers/Government: Funded through taxes.
- The Individual Receiving Care: Paid for by the patient.
- Employer + Employee: Funded through contributions from both employers and employees.
Delivery of Care: Where and how healthcare is provided.
- Private Sector: Privately owned and operated healthcare facilities.
- Public Sector: Publicly owned and operated healthcare facilities.

Global Healthcare Models

Beveridge Model (Universal Care):
- Found in the UK.
- Single-payer model.
- Government is the source of coverage and it's funded through income taxes.
- Public delivery of care.
National Health Insurance (NHI) Model (Universal Care):
- Found in Canada.
- Single-payer model.
- Government is the source of coverage and it's funded through income taxes.
- Private delivery of care.
Bismarck Model (Universal Care):
- Found in Germany.
- Multi-payer model.
- Government is the source of coverage and it's funded through employee payroll deductions.
- Private delivery of care.
Out-of-pocket Model:
- Primarily found in developing countries.
- Private-payer model.
- Individuals directly pay for health services.
- Private delivery of care.

United States Healthcare System

Coverage is dependent on the patient population.
- Veterans:
  - Veterans'Health Administration (VHA) provides care.
  - Government funded.
- Medicare & Medicaid:
  - Medicare provides coverage for those 65+, individuals with certain disabilities, and those with end-stage renal disease.
  - Medicaid provides coverage for low-income individuals.
  - Government funded with a mix of public and private delivery of care.
- Uninsured & Under-insured:
  - Individuals pay for care out-of-pocket or healthcare systems "write it off" for unpaid bills.
  - Approximately 30 million American citizens lack health insurance.
- Insured by Employer:
  - Employees and employers contribute to cover healthcare costs.
  - Provided through private delivery.

The Affordable Care Act (ACA)

Signed into law in 2010.
Provides many benefits, including:
- Children under 26 can stay on their parents' insurance.
- A healthcare marketplace was created for individuals to shop for coverage.
- Insurance equality for men and women.
- Prevention of denial of coverage for people with pre-existing conditions.
- Coverage for preventative care.
- 80/20 rule mandates insurers spend 80% of premiums on care.
- Expanded Medicaid coverage.

The Triple Aim

Aims to:
- Reduce the cost of care.
- Improve the patient experience.
- Improve the health of the population.

Definition: Healthcare Leader

Individuals responsible for driving organizational success and ensuring the delivery of quality care.

Healthcare Leaders Drive:

Organizational Culture:
- Mission: The organization's purpose and reason for existence.
- Vision: Where the organization wants to go in the future.
- Values: The principles that guide the organization's actions and decisions.
Talent Development:
- Recruitment: Attracting qualified candidates.
- Retention: Keeping valuable employees.
- Employee Engagement: Fostering employee motivation and commitment.
Strategic Planning: Developing a plan for the future success of the organization.
Performance Management: Ensuring employees are performing their job responsibilities effectively.
Development & Succession Planning: Identifying and developing future leaders within the organization.
Change Management & Innovation: Implementing positive changes and adapting to new advancements.
Policy: Understanding, following and implementing organizational policies.

Leadership Hierarchy

Chief Executive Officer (CEO): The top leader of an organization.
C-Suite/Senior Vice President: High-level executives responsible for various departments.
Vice President/Executive Director: Responsible for managing a department and its operations.
Director: Responsible for overseeing a specific area or function within a department.
Manager: Responsible for a team of employees and their day-to-day work.
Supervisor: Responsible for overseeing the work of a small group of employees.
Lead: May have some supervisory responsibilities and often provides guidance and support to team members.

Definition: Clinical Operations

The process of managing the provision of care to patients in a healthcare setting.

Org Chart:

Chief Operating Officer (COO)/Medical Chief Operating Officer:
- Responsibilities include setting strategic direction, improving efficiency, monitoring performance and driving innovation within clinical operations.
Vice President/ Medical Vice President:
- Provides strategic direction, manages resources, and oversees day-to-day operations of clinical departments.
Clinical Operations Director/ Department Chair:
- Responsible for aligning department activities with organizational goals, promoting efficiency, and ensuring quality standards.
Clinical Manager/ Section Chair/ Advanced Practice Care (APC) Lead:
- Manages day-to-day operations, ensures department goals are met, and focuses on the patient experience.
Clinical Supervisor:
- Oversees day-to-day operations within a specific clinical area, providing support and guidance to staff.
Frontline Staff (RN, MA, CNA, etc.)/ Physicians (MD, DO, OD, etc.) & Clinicians (PA, NP, CRNA, etc.):
- Provide direct patient care.

Definition: Human Resources Management (HRM)

The process of managing and developing an organization's workforce.

Departments under the HR Umbrella:

Payroll & Benefits: Administers employee benefits, salary compensation, and payroll processes.
Employee & Labor Relations: Addresses employee concerns, resolves conflict, and negotiates with unions.
Recruitment Services: Identifies and attracts qualified candidates for open positions.
Organizational Development/ Corporate Learning: Provides training and development opportunities for employees.

Definition: Change Management

The process of managing and implementing organizational changes.

GE Change Acceleration Process (CAP) Model:

Phases of Change:
- Current State: Represents where the organization is before change occurs.
- Transition State: The period during which the change is implemented.
- Improved State: The desired outcome of the change process.
Foundational Components of Change:
- Leading Change: Ensures effective leadership during the change process.
- Changing Systems & Structures: Adjusting systems and processes to support the change.
- Individual Components of Change:
  - Creating a Shared Need: Communicating the rationale behind the change.
  - Shaping a Vision: Establishing a clear understanding of what the change will achieve.
  - Mobilizing Commitment: Securing stakeholder buy-in.
  - Making Change Last: Ensuring the change is sustainable.
  - Monitoring Progress: Tracking progress and measuring the impact of the change.

Definition: Healthcare Compliance

The process of ensuring that healthcare organizations comply with all applicable laws and regulations.

Positions that fall under the Compliance Umbrella:

Chief Compliance Officer (CCO): Oversees the compliance program.
Policy Analyst: Develops and maintains compliance policies.
Compliance Specialist: Implements and monitors compliance programs.
Manager of Compliance: Leads a team of compliance specialists.
Director of Compliance: Oversees the entire compliance department.

A Day in the Life of a Compliance Specialist:

Writes and maintains compliance policies, procedures, and standards of conduct.
Oversees and participates in compliance committees.
Provides training and education on compliance-related topics.
Communicates effectively about compliance matters.
Enforces compliance standards through disciplinary guidelines.
Audits and monitors compliance activities.
Responds to compliance violations.

Compliance Specialists need a strong understanding of:

Fraud, waste, and abuse
The False Claims Act
Anti-Kickback Statute
The Stark Law
The Social Security Act
Civil Monetary Penalties Law
The Emergency Medical Treatment and Active Labor Law

Compliance in 2024

Emerging trends in healthcare compliance include:
- Artificial Intelligence
- Virtual Care
- Data Collection
- Mergers & Acquisitions
- COVID Response & Disruption
- Remote Workforce

Legal Teams in the Healthcare Space Primarily Focus On:

Drafting & Reviewing Contracts:
- Healthcare organizations have numerous contracts that require regular review.
- Example contracts include NDAs, purchase agreements for services, and physician contracts.
- The goal is to ensure favorable terms for both the HCO and vendor.
Providing Counsel on Lawsuits:
- Healthcare organizations are commonly sued.
- Common reasons for lawsuits include negligence, intentional torts like assault & battery, invasion of privacy, and infliction of mental distress.
- Legal teams provide guidance during legal proceedings.
Advising on Regulatory Compliance:
- Legal and Compliance departments work closely to ensure adherence to regulations.
- Relevant agencies include:
  - The Joint Commission
  - The National Committee on Quality Assurance
  - Center for Disease Control and Prevention
  - Department of Health and Human Services
  - Centers for Medicare and Medicaid Services
  - Accreditation Commission for Healthcare

Definition: Financial Management

The process of managing the financial resources of a healthcare organization.

Two Types of HCOs:

For-profit:
- Owned by investors.
- Required to pay taxes.
- Common examples include physician practices and skilled nursing facilities.
- Goal is to maximize profits.
Not-for-profit:
- Privately or publicly owned.
- Tax-exempt.
- Goal is to provide care to everyone and pour profits back into the community.

Regardless of Tax Status There's Still a Governance Structure:

Governance structures are present in both for-profit and not-for-profit organizations.
Governance structures include:
- Board of Directors
- Board of Trustees
- CEO, CFO, COO
The focus of a governance structure is:
- Setting strategic direction.
- Financial oversight.
- Supervising the CEO.
- Serving on various committees.

Departments that Fall Under the Finance Umbrella:

Revenue Cycle: Manages reimbursements for services from patients and third-party payers.
- Retrospective reimbursement: The amount is determined after the delivery of care.
- Prospective reimbursement: The amount is determined before the delivery of care.
- Coding plays a significant role in reimbursement.
Supply Chain: Manages the procurement and inventory of clinical and non-clinical goods for the organization.

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Description

Explore the key constituents of healthcare including patients, insurers, providers, and government entities. Understand the different healthcare models based on sources of coverage and funding mechanisms. This quiz will test your knowledge of the complex factors that shape healthcare systems.