Introduction to Healthcare Management Study Guide (Week 1-6) PDF
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Uploaded by WellBeingChiasmus
University of Wisconsin - La Crosse
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Summary
This document is a study guide for a healthcare management course. It covers various aspects of healthcare, including constituents of healthcare, factors behind healthcare models, global healthcare models, and the United States healthcare system.
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**MGT 350 -- Introduction to Healthcare Management** **Study Guide \| Weeks 1 -- 6** **[Week 1: Healthcare in the United States]** - **Constituents of Healthcare:** - Patients - Insurers (Payers) - Providers - Government - **Factors Behind Healthcare Models**...
**MGT 350 -- Introduction to Healthcare Management** **Study Guide \| Weeks 1 -- 6** **[Week 1: Healthcare in the United States]** - **Constituents of Healthcare:** - Patients - Insurers (Payers) - Providers - Government - **Factors Behind Healthcare Models** - Number of Sources of Coverage - Single-payer Model - Multi-payer Model - Source of Coverage - Government - Insurance Companies - Individually - Source of Funding - Taxpayers/ Government - The Individual Receiving Care - Employer + Employee - Delivery of Care - Private Sector (Privately Owned, Privately Employed) - Public Sector (Publicly Owned, Publicly Employed) - **Global Healthcare Models** - Beveridge Model (Universal Care) -- UK - Number of Sources of Coverage -- Single-payer - Source of Coverage -- Government - Source of Funding -- Income Taxes - Delivery of Care -- Public - National Health Insurance (NHI) Model (Universal Care) -- Canada - Number of Sources of Coverage -- Single-payer - Source of Coverage -- Government - Source of Funding -- Income Taxes - Delivery of Care -- Private - Bismarck Model (Universal Care -- Dependent on employment status) -- Germany - Number of Sources of Coverage -- Multi-payer - Source of Coverage -- Government - Source of Funding -- Employee Payroll Deduction - Delivery of Care -- Private - Out-of-pocket Model - Number of Sources of Coverage -- Private-payer - Source of Coverage -- Individual - Source of Funding -- Individual - Delivery of Care -- Private - **United States Healthcare System** - Coverage is dependent on the patient population - Veterans - Veterans' Health Administration (VHA) - Government funded - Medicare &Medicaid - Medicare -- Seniors 65+, Certain Disabilities, End-stage renal disease - Medicaid -- For those with lower income and resources - Government funded - Publicly & privately delivered - Uninsured & Under-insured - Privately paid -- the individual pays for their care or the health system writes it off - Roughly 30 million American citizens lack health insurance - Insured by Employer - Coverage paid for by employee and employer - Private delivery - **The Affordable Care Act (ACA)** - Signed into law in 2010 - Many benefits: - Children under 26 can stay on their parents insurance - Introduced a marketplace where individuals could shop for coverage - Equality -- women wouldn't pay more than men for health insurance - Insurers couldn't deny coverage to those with pre-existing conditions - Insurance would cover preventative care (annual exams, flu shot, etc.) - 80/20 rule -- Insurers need to spend 80% of premiums on care - Expanded Medicaid - **The Triple Aim** - Reduce the cost of care - Improve the patient experience - Improve the health of the population **[Week 2: Clinical Operations]** - **Definition -- Healthcare Leader:** - Healthcare Leaders Drive: - Organizational Culture - Mission, Vision & Values - Talent Development - Recruitment, Retention & Employee Engagement - Strategic Planning - Direction to support the organization - Performance Management - Fulfilling job responsibilities - Development & Succession Planning - New Leaders & Cross Training - Change Management & Innovation - Staying competitive & taking the team with you - Policy - Following & execution - **Leadership Hierarchy:** - Chief Executive Officer - C-Suite/ Senior Vice President - Vice President/ Executive Director - Director - Manager - Supervisor - Lead - **Definition -- Clinical Operations** - Org Chart: - Chief Operating Officer (COO)/ Medical Chief Operating Officer - Several years of leadership experience - Ultimately responsible for the delivery of care - Sets the direction and strategy for AOR as well as the organization - External scan of industry -- competitive advantage - Relies on data for decision making - LARGE stakeholder audience - Reducing burnout and fatigue - Vice President/ Medical Vice President - Several years of leadership experience - Ultimately responsible for the delivery of care - Sets the direction and strategy for AOR as well as the organization - External scan of industry -- competitive advantage - Relies on data for decision making - LARGE stakeholder audience - Reducing burnout and fatigue - Clinical Operations Director/ Department Chair - Typically have some direct patient care experience - Natural path for Clinical Managers, Section Chairs and APC Leads - Several years of formal people management - Aligning to the organizations strategic plan - Set the direction for their departments - Involved in larger organizational process improvement - Coordination's with leaders and staff at all different levels - Reducing burnout and fatigue - Clinical Manager/ Section Chair/ Advanced Practice Care (APC) Lead - Typically have some direct patient care experience - Oversee day-to-day operations - Assist with projects the impact day-to-day operations - Employee performance management - Ensures department goals/ objectives are met - Enforces regulatory standards and adherence to policy - Focus on the patient experience - Reducing burnout and fatigue - Clinical Supervisor - Typically have some direct patient care experience - Oversee day-to-day operations - Assist with projects the impact day-to-day operations - Employee performance management - Ensures department goals/ objectives are met - Enforces regulatory standards and adherence to policy - Focus on the patient experience - Reducing burnout and fatigue - Frontline Staff (RN, MA, CNA, etc.)/ Physicians (MD, DO, OD, etc.) & Clinicians (PA, NP, CRNA, etc.) **[Week 3: Human Resources]** - **Definition: Human Resources Management** - **Departments under the HR umbrella:** - Payroll & Benefits - Operational arm of HR - Administer benefits (medical, dental, vision, etc) - Compensation (pay bands, hourly vs. salary, etc.) - Payroll (Frequency, taxes, etc.) - Employee & Labor Relations - Governing body around policies - Go-to resource for staff and leaders - Conflict resolution - Union negotiations (if there are unionized positions at the organization) - Recruitment Services - Two types - Recruitment Services (non-medical positions) - Medical Staff Recruitment (medical positions) - Talent seekers, interview experts, people connectors - Organizational Development/ Corporate Learning - Staff Development - Leadership Development - Employee Engagement - **Definition: Change Management** - GE Change Acceleration Process (CAP) Model: - Phases of Change: - Current State: This is where we are before the change starts - Transition State: This is where we are when we're working through the change - Improved State: This is where we want to be after the change - Foundational Components of Change: - Leading Change: Do we have the right people to lead the change? Do all impacted areas have a voice/ champion? - Changing Systems & Structures: Do we have the equipment, positions, software, etc. - Individual Components of Change: - Creating a Shared Need: Framing the need for change. Why are we doing this? - Shaping a Vision: What will success look like, sound like, etc. - Mobilizing Commitment: Achieving stakeholder buy-in - Making Change Last: Is the change sustainable? - Monitoring Progress: Are we tracking the right metrics? **[Week 4: Compliance]** - **Definition: Healthcare Compliance** - **Positions that fall under the Compliance umbrella:** - Chief Compliance Officer (CCO) - Policy Analyst - Compliance Specialist - Manager of Compliance - Director of Compliance - **A day in the life of a Compliance Specialist:** - Writing & maintaining policies - Procedures & standards of conduct - Oversight & participation in compliance office and committees - Training & education - Effective lines of communication - Enforcement of standards through well publicized disciplinary guidelines - Auditing & monitoring - Responding to offences - **Compliance Specialists need to have a strong understanding of the following:** - 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** - Artificial Intelligence - Virtual Care - Data Collection - Mergers & Acquisitions - COVID Response & Disruption - Remote Workforce **[Week 5: Legal]** - **Legal teams in the healthcare space primarily focus on the following:** - Drafting & Reviewing Contracts - HCOs have hundreds if not thousands of contracts that are regularly reviewed - Purchased services, NDAs, physician contacts, media contracts, etc. - Goal is to find a win-win scenario for the HCO and vendor - Providing counsel on lawsuits that are brought against the healthcare organization - Common reasons for lawsuits include negligence, intentional torts (assault & battery, invasion of privacy) and infliction of mental distress - Advising on regulatory compliance - Legal and compliance work together very closely - There are many regulatory and accrediting agencies that collaborate with HCOs - 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 - Accreditation Commission for Healthcare **[Week 6: Finance]** - **Definition: Financial Management** - **There are two types of HCOs:** - For-profit - Owned by investors - Required to pay taxes - Typically physician practices & skilled nursing facilities - Goal is to maximize profits - Not-for-profit - Privately and publicly owned - Tax-exempt - Goal is to take care of everyone. Pour profits back into the community - **Regardless of tax status, there's still a governance structure:** - Governance structure - Board of Directors - Board of Trustees - CEO, CFO, COO - Focus of a governance structure is to help set the direction, strategic planning, financial oversight, *supervising* the CEO and service on various committees - **Departments that fall under the finance umbrella:** - Revenue Cycle -- The process of managing reimbursements from patients and third party payers - Retrospective reimbursement -- Amount is determined after the delivery of care - Prospective reimbursement -- Amount is determined before the delivery of care - Coding plays a SIGNIFICANT role when it comes to reimbursement - Supply Chain -- Refers to the process of managing clinical and non-clinical goods and inventory purchased for the organization. - Delivery of care - Cost control - Profitability - Financial Planning - Accounting - Accounts Payable - Treasury - **Every leader contributes to the organization's financial performance.** - Budgeting - Forecasting