US Healthcare: Nursing Homes, Medical Schools & Professionals, Exams of Nursing

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MHA 707 EXAM 2 BOST CHAPTERS 2, 3, 4 and 5 Community-based care - Answer>>self and ambulatory care Hospital based care - Answer>>inpatient acute care Postacute care - Answer>>long-term care, ambulatory rehab centers, long term care hospitals Self-care (80-95% of health problems stop here) - Answer>>OTC meds, vitamins and supplements and change of habits Ambulatory healthcare - Answer>>medical services performed without admission to a hospital or other health care facility for an overnight stay Freq settings for ambulatory care - Answer>>physician offices, emergency departments, and hospital outpatient clinics Emerging and expanding ambulatory HC - Answer>>telehealth, physician home visits, retail pharmacies, diagnostic imaging and laboratory centers, ambulatory surgery centers, and urgent care centers Most freq reasons for visits - Answer>>general medical exam, routine prenatal, post op, medication, cough, well baby exams, hypertension, knee symptoms, and pre-op visit Majority of OVs in NE - Answer>>>65 and female Majority of ED - Answer>>visits occur in NFP 70.9% How many ED visits are taught IN hospitals? - Answer>>around 15% in 2016, how many patients are insured - Answer>>the majority. 85% were private ins, Medicaid and Medicare. Only 8.4% had no ins. ED functions related to providing highly technical resources for acutely ill persons - Answer>>life threatening, prompt hospitalizations, and serve as secondary private physician's office. ED functions related to restricted access to HC - Answer>>cannot reach private physician, reg clinic is not open or available, geographically isolated, or have no ins so no place to go when sick. Top 3 reasons for visits to ED - Answer>>abdominal pains, chest pain, or fever Level of urgency- Level I - Answer>>Resuscitation Level of urgency- Level II - Answer>>emergent (likely to deteriorate and/or time sensitive) Level of urgency- Level III - Answer>>urgent (stable but complex) Level of urgency- Level IV - Answer>>semi-urgent (stable, one level of diagnosis or significant pain- lacerations/pain when voiding) Level of urgency- Level V - Answer>>non-urgent Most ED visits are considered? - Answer>>level 3 or level 4 In 2016, majority of home health agencies - Answer>>were FP centers (i.e. hospice, nursing homes etc) In 2016, the minority of adult day services centers were - Answer>>for profit (FP) In 2016, majority of nursing homes and residential care communities and minority adult day service centers were - Answer>>chain-affiliated Adult day services centers - Answer>>4600 adult day services centers and 286,300 participants (safe, professional care settings for adults who need supervision outside the home during the day) Home health agencies - Answer>>provided to individuals and families in their place of residence to promote, maintain, or restore health or to maximize the level of independence while minimizing the effects of disability and illness, including terminal illness. Hospitals without walls (Home health) - Answer>>advnaces in technology allow dozens of complex illnesses, once treated almost exclusively in the hospital, to be treated at home. Hospice - Answer>>4300 hospices and 1,426,000 patients received services in 2015. Defined as a program of palliative and supportive care services that provides physical, psychological, social and spiritual care for dying persons, their families and other loved ones (usually life expectancy is <6mo) Nursing homes - Answer>>15,600 homes and 1,347,600 residents. Provide a wide range of health and personal care services- focusing on medical care more than most assisted living facilities. (rehab, physical, occupational and speech) Residential care communities - Answer>>28,900 res. care communities and 811,500 residents served. Provide level of care and supervision for people unable to live by themselves but who do not need 24-hour nursing care. Horizontal - Answer>>mergers and acquisitions vertical - Answer>>adding service lines and/or levels of care People who provide HC - Answer>>physicians, nurses, and radiology techs HC Occupations - Answer>>•Dieticians and nutritionists •Pharmacists working in retail stores •Paramedics providing ambulance services •Orthotists and prosthetists (Braces and artificial limbs) •Medical records and health information technicians •Many others Certification or licensure - Answer>>required to practice for many, although not all, HC occupations Salary and Occupational Autonomy - Answer>>both of which are highly related to the amount of education required Occupations are constantly evolving in response to changes in - Answer>>tech, health policy, HC econ, and culture Changes in HC occupation take form of - Answer>>new training criteria, new practice patterns, and different kinds of practice settings. Limentani wrote - Answer>>Ethics are not optional in medicine: they are an essential and integral part of health care A few core ideas guide HC occupations including: - Answer>>Primum non nocere (do no harm), providing care competently, maintaining confidentiality of patients and their records (HIPAA), respecting patient autonomy and primacy, and engaging with patients and fellow workers honestly. Health care workers in every occupation are a ? - Answer>>Source of economic stability in many communities HC occupations also offer a gateway to middle class life for - Answer>>unskilled workers through support positions earned in noncollege settings Nursing assistants are - Answer>>persons with only a HS diploma or equivalent, trained to assist, are carry out basic patient care, and their training can lead to more skilled and well-paying jobs. HC Occupations amount to a large and increasing portion of employed US persons - Answer>>In 2018, about 13 million people, or 8.5% of all civilians employed in nonagricultural occupations and in 2002, about 9 million, or 6.8% The Bureau of Labor Statistics has 2 major categories of HC workers - Answer>>practitioners and tech occupations and HC support Occupations. Major categories of HC occupations do NOT include - Answer>>•Medical and Health Services Managers (n = 372,670) •Health Educators (n = 58,780) •Postsecondary Health Teachers (n = 255,190), Postsecondary Health Specialties Teachers (n = 199,480), and Community Health Workers (n = 56,130) •Medical records and health information technicians (15.5%) •Nursing, psychiatric, and home health aides (35.8%) •Medical assistants (15.3%) African Americans comprise a particularly high percentage of licensed practical nurses __% and nursing, psychiatric, and home health aides __% - Answer>>30.4% and 35.8% What percent of Asian Americans make up the US employed population - Answer>>6.3% The American Asians are overrepresented in health care occupations in eight of the largest categories - Answer>>Particularly overrepresented in physicians and and surgeons (19.8%), pharmacists (23.1%), and physical therapists (14.3%) What percent of Hispanic Americans make up the US employed population? - Answer>>17.3% Hispanic Americans are overrepresented in only one of the largest health care occupations—medical assistants (28.6%) - Answer>>Particularly underrepresented in registered nurses (7.2%), physical therapists (4.3%), physicians and surgeons (8.2%), pharmacists (4.4%), nurse practitioners (2.6%), physician assistants (8.2%), and physical therapist assistants and aides (7.1%) In 2012, there were 785,000 physicians in active patient care (95%) - Answer>>•Not the largest health care occupation •However, physicians' authority, autonomy, and leadership within the health care system transcend their numbers Family and General Practitioners—117,000 General Internists—79,000 General surgeons—24,000 Anesthesiologists—31,000 Pediatricians—57,000 Obstetricians and Gynecologists—34,000 Floating in space - Answer>>440,000 In 2019, 154 fully accredited allopathic medical schools in the United States - Answer>>Allopathic (MD) medical schools in the United States and Canada accredited by a voluntary agency— Liaison Committee on Medical Education (LCME) •Comprised of representatives from the AMA and the Association of American Medical Colleges (AAMC) and their Canadian counterparts In 2019, 35 osteopathic (DO) medical schools - Answer>>DO schools accredited by the American Osteopathic Association (AOA) Most medical schools are attached to a university - Answer>>•Invariably a separate college with its own dean (or the equivalent) •Sometimes loosely linked with other health professional schools in a health sciences center •About 60% of the medical schools are part of state public universities and remainder private •All the medical schools receive substantial, although primarily indirect, financial support from the federal government Physician training regimen is long - Answer>>•Entry to U.S. medical schools usually requires a university bachelor's degree •"Undergraduate" medical education lasts another four years •"Graduate Medical Education" (GME) includes the residency experience, which last many years depending upon the specialty Admission to medical school is selective - Answer>>For the class entering in 2018-2019, there were 52,757 applicants •21,622 found places (matriculants), a ratio of about 2.4:1 (1978 3.2:1) The ratio of full-time faculty to students is very high, much higher than in virtually any other branch of education - Answer>>Number of medical school faculty actually exceeds the number of students by a ratio of close to 1.77:1 (most faculty don't teach full-time; research is a critical activity) Medical school applicants for 2018-2019 - Answer>>•51% were women •47% were white, 21% were Asian, 8% African American, and 6% Hispanic or Latino Medical school graduates for 2017-2018 - Answer>>•47% were women (%-age of women eclipsed men in 2019) •56% were white, 21% Asian, 5.7% African American, and 5.4% Hispanic or Latino •This profile of graduates is similar to the matriculants for 2018- 2019, but with a lower percent of women and a higher proportion of whites and a lower percent of African Americans and Hispanics. The proportion of women in medicine has been increasing since the 1960s. - Answer>>•In 1965, women comprised less than 10% of applicants, matriculants, and graduates •This percent began rising steeply in 1970 •By 1990, it was about 40% •From 1990 to 2009, women were about 48% of applicants, matriculants, and graduates The record for increasing the admission rates for African Americans does not match that for women - Answer>>1970s to The Profession has changed quite substantially in the last 50 years - Answer>>Less autonomous as physician practices are incorporated into HC systems, More physicians are salaried (employed), Greater oversight of physicians by health care payers like CMS and the insurance companies, and Most physicians feel their societal esteem falling (still one of most trusted professions) ** Most studies have found physician dissatisfaction growing A 2017 physician satisfaction survey conducted by the Physicians Foundation found: - Answer>>•80% of physicians reported being overextended or are at capacity, with no time to see additional patients (burnout = 42% in 2020; highest in Gen X) •48% of physicians said their time with patients is always or often limited •46.8% of physicians plan to accelerate their retirement plans •Only 6% of physicians said ICD-10 has increased efficiency in their practices About 40,000 doctors are in only in administration, research or teaching 20,000 doctors are federally-employed (most in military) Doctors per 10,000 population - Answer>>US, 1965 14.5 US, 1980 20 US, 2012 28.3 Mass 44 (highest) Idaho 18 (lowest) About ¼ U.S. physicians trained outside U.S. (IMGs) Projected physician shortfall = - Answer>>47,000 to 122,000 by 2032 Primary Care shortfall - Answer>>21,000 to 55,000 by 2032 Specialty physician shortfall - Answer>>25,000- 66,000 by 2032 Demographics - Answer>>population growth and aging are primary drivers of shortfall. Achieving population health goals - Answer>>goals (↓obesity, smoking, BP, cholesterol, glucose) would increase demand by 34,000 FTEs; *Also achieving universal access* Ø2:5 currently active physicians will be >65 y.o. within next decade Trend towards fewer weekly hours worked per physician; > younger; > female - Answer>>equates with 21,000 fewer active physicians by 2032 Within nursing, Registered Nurses (RNs) are the largest category - Answer>>In 2018, 2.95 million active RNs, up from 2.2 million in 2001 Nursing includes advanced practice nursing (APN) occupations - Answer>>Nurse Practitioner (n = 179,650) *growing rapidly •Nurse Anesthetist, CRNA (n = 43,520) •Nurse Midwife, CNM (n = 6,250) The importance and influence of nursing and nurses on the delivery of health care cannot be overestimated. Advanced practice degree (Master's Degree usually) - Answer>>Nurse Practitioner (NP) •Clinical Nurse Specialist •Certified Registered Nurse Anesthetist (CRNA) •Certified Nurse Midwife (CNM) •Women's Health Nurse Practitioner (WHNP) •Family Nurse Practitioner (FNP) State nursing board establishes licensing; - Answer>>scope of practice set by state medical board (some states don't require physician supervision) 184 DNP programs in 2011 - Answer>>In 2018 = 354 programs There are more than 840 baccalaureate programs in the United States - Answer>>Total enrollment in 2014 in all nursing programs leading to the BSN was 320,074, an increase from 299,118 in 2013 In 2014, graduate nursing programs enrolled - Answer>>•113,788 students in master's programs •5,290 students in research-focused doctoral programs •18,352 students in practice-focused doctoral programs The landmark Institute of Medicine (IOM) 2010 report, The Future of Nursing, recommended - Answer>>At least 80% of nurses hold baccalaureate degree or higher by 2020, compared to 50% in 2010. •Doubling number of nurses with a doctorate ANA 2003 - Answer>>"Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" ANA definition emphasizes and makes explicit the importance of - Answer>>•Understanding the patient's social context •Promoting social justice •Advancing scholarship for the practice of nursing RNs typically do the following: - Answer>>•Assess patients' conditions Answer>>•Returning Vietnam-veteran medical corpsmen were among the first PAs •Although there is an overlap between PAs and NPs (and scope of practice debates), the PA profession has become an established health services profession in the United States. In 2019, there were more than 250 accredited PA programs - Answer>>•Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) has accredited PA programs since 2001. •Most programs offered through medical schools, teaching hospitals, or schools of the allied health professions in 4-year colleges PAs role involves - Answer>>•Approaching •Analyzing health status data •Formulating, implementing, and monitoring an individualized treatment or management plan •Instructing and counseling patients regarding compliance •Performing routine procedures By the mid-1990s, it was estimated that PAs could perform - Answer>>80% of the primary functions of a primary-care physician practice and would be widely accepted by patients. From its beginnings, the PA profession was conceived as an extension of the profession of medicine - Answer>>•Unlike nursing, it was not meant to be another separate profession •In each state, PA licensure is provided for under the Medical Practice Act rather than under a separate law •Although about 72% of PAs are women, in the beginning it was predominantly male. This status is reflected in the AAPA definition of a PA - Answer>>Physician assistants are health care professionals licensed to practice medicine with physician supervision PA practice - Answer>>Practice settings for physician assistants, 2018 Offices of physicians- 55% Hospitals; state, local, and private- 26 Outpatient care centers- 8 Educational services; state, local, and private- 3 Employment services- 2 Pharmaceuticals - Answer>>Products that work on a biochemical or cellular/tissue level Medical supplies - Answer>>products typically used once Medical Equipment - Answer>>products designed to be used repeatedly or for a long-time National health Expenditures - Answer>>20%/ $760B in 2019 FDA Definition - Answer>>Products intended to cure, treat, mitigate, diagnose, or prevent disease in humans or otherwise affect the structure or function of the human body through chemical action in and/or metabolized by the human body are considered human drugs or biological products. What are the two major classes of drugs - Answer>>Conventional and small molecule -drugs typically contain an "active pharmaceutical ingredient" (or sometimes several) that generally have well-defined chemical structures Biological Products (biologics) - Answer>>are complex mixtures big molecule drugs produced through biotechnology in a living system, such as a microorganism, plant cell or animal cell that are not easily identified or characterized. Drug approvals - Answer>>Grew from 8% in 2005, and 17% in 2017 Biologics (specialty drug) - Answer>>Due to their complex nature, it is challenging to ensure the product remains consistent, and so the production process becomes critical ("the product is the process") Specialty drugs are those that meet one or more of these criteria - Answer>>•Available in very limited supply •Require special handling (e.g., constant temperature regulation or biohazard or similar toxicity) •Have a very high price tag •Includes Orphan Drugs and Biologics Specialty Drugs and Cost in 2017 - Answer>>4 of the top 5 medicines by nondiscounted spending were specialty drugs and specialty share of net spending on drugs rose from 24.7% in 2008 to 46.5% in 2017. Orphan diseases - Answer>>occur in less than 200K in the US/1:2K people. Drugs for these disease not econ. feasible to develope unless subsidized. Orphan Drug ACT 1983 - Answer>>grants special tax treatment and sometimes offers federal grant money to fund research. Orphan drugs for cancer generate the largest profits DEA Drug Schedule I - Answer>>no accepted medical use and a high potentional for abuse and therefore may not be prescribed or dispensed Generics and Biosimilars - Answer>>Once the patent and other exclusivity has expired, competitors may develop and sell generic versions of FDA-approved drugs after completing an Abbreviated New Drug Application (ANDA) The requirements for ANDA are? - Answer>>much lower than the original NDA which allows competitors to enter the market with equivalent drugs (80 - 120% of original), without which the original inventor of the drug would retain monopoly control until an entirely new cure is found. How much was spent on OTC drugs in 2017? - Answer>>about 34.6 billion Net payments to pharmaceutical companies for prescription drugs - Answer>>sold in the United States were about $325 billion in 2017-About 77% of this for patented drugs and 23% for generic prescription drugs, though the latter accounted for about 90% of prescriptions filled Generics accounted for the vast majority of - Answer>>•the volume of prescription drugs dispensed, patented drugs accounted for a significant majority of the expenditures on drugs due to their typically orders of magnitude greater price per-unit Generic drugs in the U.S. cost more than in other countries HC providers decide (drugs) - Answer>>which drug to prescribe, how much, and how frequently based on their medical judgment in the context of the patient and their needs. Pharmacy Benefit Managers (PBM) - Answer>>often pick and choose which drugs to include in covered formulary of insurance companies Group Purchasing Organization (GPO) - Answer>>•- seeks discounts from drug companies and suppliers, often through formulary restrictions; most hospitals be long to >1 GPO; 75% of supplies bought through GPOs Medical devices are items used in - Answer>>the diagnosis, cure, mitigation, treatment, or prevention of disease but are not absorbed or metabolized by the body Medical supplies versus equipment - Answer>>Medical supplies are intended to be used once (e.g., like latex gloves or disposable syringes). Medical equipment (e.g., an MRI system) is expected to be used multiple times over its life Conventional medical devices - Answer>>are products that are easy to manufacture with relatively few barriers for entry for new companies and relatively little product differentiation (e.g., an IV pole) High tech medical devices - Answer>>typically require significant investment in research and development to design, often resulting in patents, and greater regulatory scrutiny from the FDA (e.g., a pacemaker, surgical instruments and implants) FDA approved - Class I - Answer>>includes elastic bandages, handheld surgical instruments, etc. -Manufacturers simply need to register the device before bringing to market (pre-approval is not required) FDA Approval- Class II - Answer>>includes surgical drapes, infusion pumps, etc. -Pre-approval is required but manufactures only need to demonstrate that the medical device is substantially equivalent to a device already on the market FDA Approval- Class III - Answer>>includes heart valves, implanted pacemakers, etc. -Devices are generally required to demonstrate that they are safe and effective before they may be marketed though evaluations typically not as rigorous as drug studies Most medical devices are purchased by? - Answer>>health care providers—hospitals in particular—and represent an input to the health care delivery system rather than a product purchased directly. Sales cycles to large organizations like hospitals are typically long with multiple gating steps. - Answer>>Providers typically look for coverage by third-party payers like Medicare or managed care organizations (which often look to Medicare) for new products. Who do Hospitals often look to for negotiate prices and set terms? - Answer>>GPO-especially for conventional medical products. This true of medications (via formularies) as well Who must be convinced to select or switch to a new product? - Answer>>Providers or committees Provides an incentive to keep costs down - Answer>>The cost of a drug or medical device may be included in the global payment that a hospital receives, particularly common with Medicare/Medicaid (CMS) Physician preference items (PPI) are devices for which - Answer>>physicians express strong preferences but don't generally bear the cost of their choice Implantable medical devices (IMD) - Answer>>such as pacemakers, artificial hip joints, etc. are an important category of Three branches of government - Answer>>executive, legislative, and judicial Under separation of powers - Answer>>each branch of the federal government has its own authority and responsibility (spelled out in the constitution). System of checks and balances - Answer>>the Constitution spells out "checks" on the powers of each branch, exercised by the other two Judicial review - Answer>>•Not found in the Constitution •Established early in the 19th century by the third Chief Justice of the Supreme Court, John Marshall, and his colleagues on the bench •Has become an accepted part of the U.S. constitutional system only because the other two branches have granted the Court that authority At the tertiary level of government - Answer>>(local) the boundaries between the branches at times become blurred Legislatures create the laws that establish the means to safeguard the public's health - Answer>>•For example, assurance of pure water supply and protecting health of workers in their places of employment Legislatures also enact - Answer>>the legal framework within which the health care delivery system functions Although a state legislature creates the licensing law for physicians - Answer>>the executive branch administers it, the judicial system determines the guilt or innocence of a person charged with "practicing medicine without a license Judicial system also plays a vital role in safeguarding the public's health - Answer>>enforces sanitary protection and pollution control legislation, with criminal sanctions if necessary Judicial system handles disputes arising from the provision of health services - Answer>>(civil law) through the process of malpractice litigation Judicial system adjudicates contract cases arising from health care system disputes - Answer>>disputes between providers or patients, on one side, and a third-party payer on the other Judicial system protects the rights of? - Answer>>individuals under the due process and equal protection clauses of the Fifth and Fourteenth Amendments to the Constitution. Government in HC (executive branch) - Answer>>•Oversees the delivery of health care services •Drafts and enforces provider/payer regulations •Administers health care financing programs Government in HC (legislature) - Answer>>•creates the programs or regulatory authority •The courts that settle disputes arising under the laws and adjudicates violations of them Provision of Personal Health Services- At the federal level? - Answer>>personal health services are provided, for the most part, to categories of persons, for example: (i.e. Members of the uniformed services, their families and Native Americans) State Government provides personal health services to? - Answer>>Persons who have specific diseases (i.e. people with mental illness and TB) Generally for the poor? - Answer>>Local governments' personal health services are stratified by class Governments at all levels provide health services for - Answer>>prisoners and those in poverty (ex: FQHCs, State vaccination programs, local public health centers) Government participates in financing in three ways - Answer>>1. pays directly and indirectly for the operation of its own programs 2. supports other types of health-related programs (grants and contract) 3. pays providers for the delivery of HC services to patients Many federal agencies are involved in the health care system in ways big and small including - Answer>>-provision of patient care -biomedical and health policy research -HC workforce training -financing HC Two other federal agencies have major health services responsibilities - Answer>>Department of Veterans Affairs (VA) and Department of Defense (DOD) The U.S. Department of Health and Human Services (DHHS) - Answer>>is the most important federal actor in health and health care. Other federal agencies with significant health-related responsibilities include - Answer>>USDA, EPA, DOL, and OSHA DHHS is the third largest department in the federal government - Answer>>•11 operating divisions •115 health-related programs •Over 80,000 FTE employees