Healthcare Systems: DRG, PCMH, ER Visits, and More
Diagnosis-Related Group (DRG) Payment System
The Diagnosis-Related Group (DRG) payment system provides financial incentives to decrease the duration of inpatient stays and to increase service delivery efficiency. It provides more incentive for hospitals to spend just what is needed to achieve optimal patient outcomes. If hospitals spend more, they absorb the excess cost.
Patient-Centered Medical Homes (PCMH)
Patient-Centered Medical Homes (PCMH) provide continuous and coordinated care throughout a patient’s lifetime to maximize health outcomes. PCMH is responsible for providing all of a patient’s needs, including preventive services, treatment of acute and chronic illnesses, and assistance with end-of-life issues.
Principles of PCMH
- Every patient has an ongoing relationship and continuous care with a personal physician.
- The physician leads a team of individuals to help with patients.
- The physician takes responsibility for all healthcare needs of the patient.
- Care is coordinated.
- Quality and safety are hallmarks.
- Enhanced patient access, including more hours of operation and email.
- Payment for services.
Reasons for Emergency Room (ER) Visits
Reasons for Emergency Room (ER) visits are due to life-threatening conditions or those treatable in primary care settings. There is an increasing number of visits due to population growth, an aging population, and overcrowding at other facilities.
Free-Standing Services
Free-Standing Services are operated by hospitals, hospital systems, physician groups, or by independent, for-profit, or not-for-profit single entities or chains.
People who use emergency care may have a life-threatening illness or injury or may be uninsured.
Ambulatory Surgery Centers
Ambulatory Surgery Centers provide outpatient surgeries. They were established in the 1970s, and the rate of use has increased approximately 300%. Anesthesia advances are the primary driver.
Public Health
Public Health programs are prevention-oriented. There has been a renewed focus on federal, state, and local public health agencies in providing public protection and supporting national security after 9/11.
Physician Specialties (Average Annual Compensation)
- Primary Care Physician (PCP): $526 million
- Medical Specialist: $198 million
- Surgical Specialist: $178 million
- General and Family Medicine: 23.1%
- Internal Medicine: 13.9%
- Pediatrics: 13.6%
- Obstetrics and Gynecology: 7.7%
- Ophthalmology: 6.4%
- Orthopedic Surgery: 5.3%
- Oncology: 1.6%
- Other: 28.4%
Solo Practice Drivers (1960s)
- Convenient staffing and scheduling
- Less competition for facilities
- Medical specialization
- After-hours and vacation coverage
- Informal collegial consultation
- Informal system of peer review
Low-Income ER Use
Low-income individuals may be unaware of other sources of care, and Medicaid covers ER visits.
Community Health Centers
Community Health Centers were established in the mid-1960s during Lyndon Johnson’s presidency under the Office of Economic Opportunity. Responsibility was transferred to the Public Health Service in the mid-1970s. Centers were established in cities and rural communities.
American Medical Association (AMA)
The goal of the American Medical Association (AMA) in the late 1800s and early 1900s was to improve medical education.
Flexner Report (1910)
The Flexner Report, issued in 1910, was an indictment of most medical schools. Some schools closed, while others received praise. It resulted from a comprehensive review of the quality of education in U.S. and Canadian medical schools. Funded by the Carnegie Foundation, it gave leverage to medical education reformers and stimulated financial support from foundations and wealthy individuals, enabling university-affiliated medical schools to gain significant influence over the direction of medical education.
American Board of Medical Specialties (ABMS)
The American Board of Medical Specialties (ABMS) was established as an independent, not-for-profit organization to maintain and improve the quality of medical care by assisting member boards in their efforts to develop and utilize professional and educational standards for the certification of physician specialists in the U.S. and internationally.