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Access to Care M 6920 November 13, 2001 Access to Care M 6920 November 13, 2001

Definition of Access l l Care when YOU want it Care you can afford Definition of Access l l Care when YOU want it Care you can afford without undercutting other needs Care you are comfortable with Care which adds to your health status Columbia University School of Nursing M 6920, Fall, 2001

Columbia University School of Nursing M 6920, Fall, 2001 Columbia University School of Nursing M 6920, Fall, 2001

Columbia University School of Nursing M 6920, Fall, 2001 Columbia University School of Nursing M 6920, Fall, 2001

Columbia University School of Nursing M 6920, Fall, 2001 Columbia University School of Nursing M 6920, Fall, 2001

Columbia University School of Nursing M 6920, Fall, 2001 Columbia University School of Nursing M 6920, Fall, 2001

Barriers for Vulnerable Populations Columbia University School of Nursing M 6920, Fall, 2001 Barriers for Vulnerable Populations Columbia University School of Nursing M 6920, Fall, 2001

Timing of care l l symptoms occur you can get to it • missing Timing of care l l symptoms occur you can get to it • missing work • transportation l an authority figure says so • parent • employer • practitioner Columbia University School of Nursing M 6920, Fall, 2001

Affordability of care l l l insurance coverage out of pocket expenses for the Affordability of care l l l insurance coverage out of pocket expenses for the care collateral expenses • prescriptions • supportive aids • assistance l lost opportunity costs Columbia University School of Nursing M 6920, Fall, 2001

Uninsured midlife adults Columbia University School of Nursing Commonwealth Fund 1999 National Survey of Uninsured midlife adults Columbia University School of Nursing Commonwealth Fund 1999 National Survey of Workers’ Health Insurance M 6920, Fall, 2001

Medicare Recipients with Income $10, 000/yr. Columbia University School of Nursing M 6920, Fall, Medicare Recipients with Income $10, 000/yr. Columbia University School of Nursing M 6920, Fall, 2001

Insured, but how? for Studying Health System Center Change Issue Brief #30 Columbia University Insured, but how? for Studying Health System Center Change Issue Brief #30 Columbia University School of Nursing M 6920, Fall, 2001

Who are the uninsured? l l l Contingent workers Part-time workers Small/individual businesses Early Who are the uninsured? l l l Contingent workers Part-time workers Small/individual businesses Early retirees High-cost individual insurees Un-enrolled Medicare/Medicaid eligibles Columbia University School of Nursing M 6920, Fall, 2001

Individual insurance costs l l l Hypothetical individuals submitted to 19 companies in 8 Individual insurance costs l l l Hypothetical individuals submitted to 19 companies in 8 markets (60 person) Asked to underwrite a policy with $500 deductible and $20 co-pay per office visit response might be • • “clean offer” = standard coverage and rate coverage with restrictions in a rider coverage at a higher rate refused coverage Columbia University School of Nursing Kaiser Family Foundation #3133 M 6920, Fall, 2001

Case 1 l 24 yo with hay fever • rejected 5 times • 46 Case 1 l 24 yo with hay fever • rejected 5 times • 46 of 55 limitation • range $408 -$4, 596/ year Columbia University School of Nursing M 6920, Fall, 2001

Case 2 l 36 yo 10 yr post knee repair • rejected 7 times Case 2 l 36 yo 10 yr post knee repair • rejected 7 times • 15 clean offers • range $588 -$5, 112/ year Columbia University School of Nursing M 6920, Fall, 2001

Case 3 l 48 yo 7 yr breast CA survivor • 26 rejections • Case 3 l 48 yo 7 yr breast CA survivor • 26 rejections • 11 clean offers • range $1, 464 -/416, 344/year Columbia University School of Nursing M 6920, Fall, 2001

Case 4 l Family (36 yo parents, 10 yo, 12 yo with asthma and Case 4 l Family (36 yo parents, 10 yo, 12 yo with asthma and Otitis Media) • 9 offers excluded 12 yo • many riders/increases • range $1, 692 -$15, 444/year Columbia University School of Nursing M 6920, Fall, 2001

Case 5 l 62 yo overweight smoker • rejected 33 times • 2 clean Case 5 l 62 yo overweight smoker • rejected 33 times • 2 clean offers • range $9, 936 -$20, 048/year Columbia University School of Nursing M 6920, Fall, 2001

Case 6 l 36 yo HIV positive • rejected 60 times Columbia University School Case 6 l 36 yo HIV positive • rejected 60 times Columbia University School of Nursing Kaiser Family Foundation #3133 M 6920, Fall, 2001

%Uninsured by race, ethnicity Columbia University School of Nursing United Hospital Fund, March, 2000 %Uninsured by race, ethnicity Columbia University School of Nursing United Hospital Fund, March, 2000 M 6920, Fall, 2001

Comfort with care l language • care through trained translators • family translators l Comfort with care l language • care through trained translators • family translators l l culture style • formality/informality • "charity" attitude Columbia University School of Nursing M 6920, Fall, 2001

Language barriers Baker et al, JAMA 275: 10, Pg. 783 -88 Columbia University School Language barriers Baker et al, JAMA 275: 10, Pg. 783 -88 Columbia University School of Nursing M 6920, Fall, 2001

Care which adds to health l l l minimize excess access increase access to Care which adds to health l l l minimize excess access increase access to prevention/screening fill particular gaps, such as mental health services Columbia University School of Nursing ++++++ M 6920, Fall, 2001

Hepatitis B and Hepatoma l l “Attention must be paid. Life must be prolonged” Hepatitis B and Hepatoma l l “Attention must be paid. Life must be prolonged” All the support and encouragement you can muster: • CDC web site: www. cdc. gov • WHO web sit: www. who. int • Hepatitis Central web site: www. hepatitiscentral. com • American Liver Foundation web site: Columbia University gi. uscf. edu/alf. html School of Nursing M 6920, Fall, 2001

Infergen®-Consensus Interferon l l l Infergen®: has Triple the success rate of Combination therapies Infergen®-Consensus Interferon l l l Infergen®: has Triple the success rate of Combination therapies in Consensus Interferon Trials Infergen® Testing of Maxamine™ and Infergen® Package Insert for Patients Columbia University School of Nursing M 6920, Fall, 2001

Liversupport. com l You are here because you or someone you care about has Liversupport. com l You are here because you or someone you care about has a liver disease or concern and you want to learn what you can do about it. • What you discover on this site will definitely help you. • To begin with, a scientifically-proven nutritional supplement you will read about here is actually prescribed by doctors in Europe. Columbia University School of Nursing M 6920, Fall, 2001

Liversupport. com l European physicians routinely prescribe this substance specifically to help protect and Liversupport. com l European physicians routinely prescribe this substance specifically to help protect and support liver function in patients with serious liver concerns (including chronic hepatitis and cirrhosis). Columbia University School of Nursing M 6920, Fall, 2001

Liversupport. com l Now, in the USA, you can get the most powerful form Liversupport. com l Now, in the USA, you can get the most powerful form of this valuable substance without a doctor's prescription, and we will tell you how. • Click here to learn more about this safe and powerful liver protector along with other helpful information for liver patients l www. Liver. Support. com © Columbia University School of Nursing M 6920, Fall, 2001

The preceding brought to you by l l Olympus microscopes Smith. Kline Beecham pharmaceuticals The preceding brought to you by l l Olympus microscopes Smith. Kline Beecham pharmaceuticals Columbia University School of Nursing M 6920, Fall, 2001

According to CDC analysis l l For treatment of hepatitis C, interferon alone is According to CDC analysis l l For treatment of hepatitis C, interferon alone is 7 -10% effective In combination treatment, persistent effectiveness is at the 15% level. Columbia University School of Nursing M 6920, Fall, 2001

Access to care by those with significant problems Columbia University School of Nursing Health Access to care by those with significant problems Columbia University School of Nursing Health Affairs Summer, 1996 Datawatch M 6920, Fall, 2001

Ways to achieve a policy outcome l l State preference and hope? Legal requirements/sanctions Ways to achieve a policy outcome l l State preference and hope? Legal requirements/sanctions • Economic sanctions • Business sanctions Contractual incentives l Contractual commitments • Pay if you do • Withhold pay if you don’t Columbia University School of Nursing M 6920, Fall, 2001

Potential actions l l l Provider Standards Fee for service License requirements Capitation contracts Potential actions l l l Provider Standards Fee for service License requirements Capitation contracts Penalty for failure to meet goals Columbia University School of Nursing l l Patient education Reduced rates for response Reduced co-pays or deductible Material rewards for participation M 6920, Fall, 2001

Actions to increase access l Financial access • expansion of Medicaid • Oregon Plan Actions to increase access l Financial access • expansion of Medicaid • Oregon Plan • Raising limits for prenatal to 300% (1990) • COBRA (1987) • Medical Savings Accounts (1996) • CHIP (1997) Columbia University School of Nursing M 6920, Fall, 2001

CHIP plans by state Columbia University School of Nursing Red: separate plan Yellow: Medicaid CHIP plans by state Columbia University School of Nursing Red: separate plan Yellow: Medicaid Turquoise: Combined M 6920, Fall, 2001

Negative impact of welfare reform l l l In 1995, 88% of poor children Negative impact of welfare reform l l l In 1995, 88% of poor children received food stamps Medicaid and food stamp eligibility have not changed with welfare reform In 1998, 70% of poor children received food stamps Columbia University School of Nursing M 6920, Fall, 2001

Increasing access, cont. l geography • Hill Burton Hospitals l geography/finances • OEO Neighborhood Increasing access, cont. l geography • Hill Burton Hospitals l geography/finances • OEO Neighborhood health centers • 330 Migrant Community Health Centers • Community mental health centers Columbia University School of Nursing M 6920, Fall, 2001

Increasing access, cont. l geography/culture • 330 neighborhood board approach • Increasing access, cont. l geography/culture • 330 neighborhood board approach • "community health workers"--IHS • requirements for translation services l disability • Handicapped access laws • Americans with Disabilities Act Columbia University School of Nursing M 6920, Fall, 2001

Average Hours in Charity Care in Previous Month Columbia University School of Nursing M Average Hours in Charity Care in Previous Month Columbia University School of Nursing M 6920, Fall, 2001

Changes in charity care Center for Studying Health System Change Columbia University School of Changes in charity care Center for Studying Health System Change Columbia University School of Nursing * p not significant **P significant at <. 001 M 6920, Fall, 2001

Managed care for uninsured* Columbia University School of Nursing *Center for Studying Health System Managed care for uninsured* Columbia University School of Nursing *Center for Studying Health System Change Issue Brief #25 (Jan, 2000) M 6920, Fall, 2001

HIPPA l l l Made insurance l portable from one job to another Limited HIPPA l l l Made insurance l portable from one job to another Limited use of ‘preexisting conditions Limits exclusions to conditions or treatments, if done uniformly Columbia University School of Nursing Cannot deny or charge more based on • • health status medical history medical condition claims experience receipt of health care genetic information evidence of uninsurab. disability M 6920, Fall, 2001

Programs for the uninsured l l l Boston Health. Net & Network Health Hospitalization, Programs for the uninsured l l l Boston Health. Net & Network Health Hospitalization, OP, ER, dental, vision, MH, pharmacy Below 200% poverty get free Enrollment 73, 000 $ from state uncompensated care pool Providers paid fee for service Columbia University School of Nursing M 6920, Fall, 2001

Uninsured, cont. l l l Wishard Advantage, Indianapolis Hospitalization, OP, ER, pharmacy, MH Free Uninsured, cont. l l l Wishard Advantage, Indianapolis Hospitalization, OP, ER, pharmacy, MH Free below 150% FPL; shared up to 200% FPL Enrollment 20, 000 $56 Million city/county property tax Primary care capitated $15/mo Columbia University School of Nursing M 6920, Fall, 2001

Uninsured, cont. l l l Ingham Health Plan, Lansing, Mich OP, pharmacy Free below Uninsured, cont. l l l Ingham Health Plan, Lansing, Mich OP, pharmacy Free below 100% FPL; share to 250% Enrollment 8, 500 $3. 5 Million from state, Medicaid, county tax Providers fully capitated $24/mo Columbia University School of Nursing M 6920, Fall, 2001

Issues for the elderly l l l 50% of those over 85 need assistance Issues for the elderly l l l 50% of those over 85 need assistance Care often includes non-health components such as housing Existing finance mechanisms not designed with these issues in mind Columbia University School of Nursing M 6920, Fall, 2001

Use of assisted living 75%Female Average age: F 84. 5 M 82. 5 Columbia Use of assisted living 75%Female Average age: F 84. 5 M 82. 5 Columbia University School of Nursing M 6920, Fall, 2001

Practitioners decide, not patients l Older women with localized breast cancer have a choice Practitioners decide, not patients l Older women with localized breast cancer have a choice • Breast-conserving surgery • Mastectomy l BCS used where • highest BCS fees (9 x as likely) • belief in patient participation (6 x) • MST favored by male surgeons Columbia University School of Nursing Mandelblatt et al, Medical Care 39: 3 (228 -242) M 6920, Fall, 2001

The particular role of public hospitals* l l Inclusivity Continuity Responsiveness Visibility *Opdycke, Sandra The particular role of public hospitals* l l Inclusivity Continuity Responsiveness Visibility *Opdycke, Sandra 1999 No one was turned away: the role of public hospitals in New York City since 1900 New York: Oxford University Press Columbia University School of Nursing M 6920, Fall, 2001

Decreasing inappropriate access l l shift out of emergency rooms monitoring of high-tech procedures Decreasing inappropriate access l l shift out of emergency rooms monitoring of high-tech procedures to limit over-use control of ownership of facilities/ equipment information about alternative approaches Columbia University School of Nursing M 6920, Fall, 2001

Use of NYC emergency departments, 1998 Columbia University School of Nursing Billings et al, Use of NYC emergency departments, 1998 Columbia University School of Nursing Billings et al, Emergency Dept. Use: the NY Story. Commonwealth Fund: Nov. 2000 M 6920, Fall, 2001

Attempted use of planning l l Comprehensive health planning HSA/SHCC/SHPDA Certificate of Need Push Attempted use of planning l l Comprehensive health planning HSA/SHCC/SHPDA Certificate of Need Push to managed plans or managed competition Columbia University School of Nursing M 6920, Fall, 2001