1 4 Working in Today's Healthcare EnvironmentJournal 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 EnvironmentMajor 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 EnvironmentFixed-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 (PPOPatient 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 ProgramsMedicare 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 ProgramsDiagnostic 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 ProgramsDiagnostic Related Groups (DRGs) Discourages treatment of severely ill patients Patients often are discharged before ready

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

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

14 Ethical Considerations of Managed CareSome 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 CareBait-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 1986Passed out of concern about medical malpractice Protects whistleblowers National Practitioner Data Bank (NPDB) Information not disclosed to general public

17 Types of Medical PracticeSolo 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 PracticeGroup 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 PracticeProfessional corporation Managed by board of directors Shareholders Protection of individual assets and liability

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

21 Ethics of Fee SplittingFranchise 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 BoardsSeek 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 BoardsAmerican College of Surgeons Fellow of American College of Surgeons (FACS) American College of Physicians Fellow of American College of Physicians (FACP)

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

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

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

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