HEALTH SYSTEMSTypes Of Health Insurance Plans:HMO: Health Maintenance Organizatios, an HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:The least freedom to choose your health care providersThe least amount of paperwork compared to other plansA primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist.
PPO:Preffered provider organizations, with a PPO, you may have: A moderate amount of freedom to choose your health care providers — more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.Higher out-of-pocket costs if you see out-of-network doctors vs. in-network providersMore paperwork than with other plans if you see out-of-network providers.HSA: Health Savings Account, This is an investment account that grows tax-free over the years. You put money in the account before you have to pay any taxes on it. You don’t pay a tax when you spend it, either, as long as you spend HSA money on qualified health expenses health care or products on an IRS-approved list.Effective Process Management in Healthcare: In health care, awareness of the need for better management of systems and processes is finally starting to take root.
Leaders are keen to become familiar with examples of how institutions achieve it in practice.Limit the Number of Strategies and Metrics:Senior leaders often create a dizzying array of strategies and metrics that confuse frontline workers. I recently visited a health care system in North Carolina that had 242 strategic initiatives. Its leaders explained to me how important each initiative was. What they didn’t see was that when physicians and nurses try to meet the goals of so many initiatives, they have less time to solve real problems and improve processes that directly affect patients.Penetrate the Daily Work: To be effective at implementing change, executives and senior mangers must become familiar with frontline workers’ daily challenges.
At Zuckerberg San Francisco General Hospital, a large safety-net hospital, the chief operating officer has a daily 10-minute conversation with her direct reports, to familiarize herself with that day’s problems.Health Systems- Organize and Service Delivery:The concept of the organization of health care services includes both the entire structure of health care delivery as well as individual health care facilities such as hospitals, traditional healers working out of their homes, midwives, and shop keepers selling over the counter medications. It is useful to think about the “macro” organization of health service delivery as well as the “micro” organization.There are four key characteristics in the organization of service delivery:The mix of organizations that provide health-care services; The division of activities among these organizations;The interactions among these organizations and their relationship with the rest of the political and economic environment—especially how they get the resources they need to continue to exist; andThe internal administrative and management structures and processes of these organizations.
Three Principles of Improving Healthcare:Success in health care delivery is predicated on very principled processes. For instance, why is cardiopulmonary resuscitation successful? Because it is highly codified, taught with high consistency, team-based, and everybody knows their roles — in this way it is similar to space flight. Sometimes the greatest threat to proper procedure in a cardiac arrest is the temptation for fellows and residents to defer to authority when an attending arrives rather than to rely on the role-based processes they have been rigorously taught.Interdependence must take precedence over the fragmentation of “silos.” As part of VHA’s current reorganization, we are taking apart entrenched silo structures and rebuilding them as logical associations. For example, we have long been a very data-rich organization, but we had multiple data systems, in addition to VistA, across the organization.
As a result, if you were to ask the same question of different parts of the organization, you could get different answers. Bringing all the data and analytical capability together became crucial in ensuring both consistency and the capability to transform data into effective information. . Health care must change from being about the encounter to being about a sustained relationship. This is a fundamental goal in transforming the VA health care system.
When we achieve this, we will have built a foundation of prevention and wellness for the trusted supporting relationship that is crucial when people become ill or are injured.Keys to efficient and effective healthcare delivery:The first key to improving efficiency and effectiveness in healthcare delivery is defining and examining core, supporting and driving processes. When a team comes together with the intention of documenting strategic direction and associated workflow processes, process consultants can assist the team with techniques on how to better align expectations, reduce unnecessary re-work and unnecessary wait time, and make more effective use tools and technology.Another key is leveraging tools and technology.
Each year millions of dollars are spent on Electronic Medical Record systems and Integrated Healthcare Management systems. These technologies offer tools to manage and share healthcare data with high-speed computer networks and mobile devices to ensure favorable treatment outcomes and improve care delivery on a case-by-case basis. The third and most important key is understanding the appetite of the current culture for change. Otherwise, all of the money and effort spent on a new process or new technology will be wasted. Many tools exist to understand leadership styles, communication and learning preferences. Integrating human resource values such as involving folks in decisions that impact them, requires clinical leadership to integrate the voice of the employees within leadership strategies.
Accountable Care Organizations(ACOs):Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. Health Maintenance Organization(HMOs):HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The HMO is paid monthly premiums or capitated rates by the payers, which include employers, insurance companies, government agencies, and other groups representing covered lives. The HMO must meet the specifications of the federal HMO act as well as meeting many rules and regulations required at the state level. There are 4 basic models: group model, individual practice association, network model and staff model.
An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionalsHOW IT WORKS(EXAMPLE):An HMO develops its network by contracting primary care physicians (for example, internists and family doctors), specialists (for example, cardiologists and ophthalmologists), and clinical facilities (for example, hospitals and specialty clinics). The HMO agrees to pay these parties specific levels of compensation for a range of services they provide to its subscribers.In return for a monthly fee, or premium, subscribers are granted access to providers inside the network at no additional cost. Subscribers may access services outside the network with the HMO’s approval but may need to pay for part of the services.List Of HMO Insurance Plans:HMO Plans offer a wide range of healthcare services through a network of providers who agree to supply services to members.
With an HMO you’ll likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.Aetna,Anthem Blue Cross,Blue Shield,Cigna,Health Net.San Francisco Health Plan,Sutter Health Plus,UnitedHealthcareMedicare Shared Savings Program by ACOs:The Medicare Shared Savings Program (Shared Savings Program) is committed to achieving better health for individuals, better population health, and lowering growth in expenditures.
The Shared Savings Program is an alternative payment model that:Promotes accountability for a patient population.Coordinates items and services for Medicare FFS beneficiaries.Encourages investment in high quality and efficient services.Medicare ACOs continue to improve quality,some reducing costs:Medicare ACOs continue to improve significantly on overall quality scores. Both Pioneer ACOs and MSSPs have been able to attain higher average performance than quality benchmarks and better performance than Medicare fee-for-service on measures with data, such as colorectal screening, tobacco cessation, and depression screening.Future of Accountability in Healthcare Industries:A more sustainable model based more on patient care than profitability will, in the long term, gain the respect and loyalty of patients and staff.
Building a community with trust and concentrating on the patient’s care, cure and satisfaction is the future of healthcare. Hospitals will gain a healthy and profitable model by ensuring their patients feel like they are important and cared about rather than being simply one more patient.Managing Change in Healthcare:Being ready for change is a necessary, but not sufficient, prerequisite to changing your organization’s approach to fall prevention. Even when a health care organization is armed with the best evidence-based information, willing staff members, and good intentions, the implementation of new clinical and operational practices still requires additional careful organizational planning.
Once you have established organizational readiness, the next practice change step is completing a thoughtful assessment of your organization’s current practices and knowledge about fall prevention.Your timeline should balance the need to act systematically and thoughtfully with the need to move quickly enough to maintain momentum by demonstrating progress. This section is designed to help you manage change at the organizational level. New Structure, New Roles for Healthcare:Centralizing and professionalizing the board. Governance is evolving. “Today, boards in large health systems are starting to look more like corporate boards in other industries, comprised of senior business leaders who can help guide the organization on how to make investments and where to allocate capital.Establishing physicians in leadership roles. The makeup of the C-suite also is evolving.
“The most material leadership change I see is that more organizations are putting clinicians in senior executive positions,” Welter says. “In particular, physicians are being asked to lead care model transformation, clinical informatics, and population health management initiatives.”Hiring leaders to support innovation and transformation. As part of its restructuring, Jefferson has hired a new chief innovation officer who is committed to commercializing products and services and to establishing joint ventures with other organizations.
The chief innovation officer also works with leaders in the academic pillar to create an appointments, promotions, and tenure committee based on entrepreneurship, which will provide a new career track for entrepreneurial faculty.Building and reassessing partnerships. In the past two years, Jefferson has grown from a $1.5 billion, three-hospital academic medical center to a $4 billion, eight-hospital system, largely due to a merger with Abington Jefferson Health, Abington, Pa. Jefferson also has signed definitive agreements to merge with Philadelphia-based Aria Health and with Kennedy Health, based in Cherry Hill, N.J.
“We have abandoned the traditional hub-and-spoke model of care delivery because nobody really wants to be a spoke,” Klasko says. “Instead, we have adopted a ‘hub-and-hub’ model, in which most care is delivered out in the communities.”