Chapter 1 - Healthcare System In The United States

Question 1

Accountable Care Organizations (ACOs)

P. 22

Answer 1

Groups of Doctors, Hospitals, and other healthcare providers that come together voluntarily to give high-quality care using a fixed payment model: they work collaboratively and accept collective accountability for costs and the quality of care.

Question 2

Accreditation

P. 5

Answer 2

Voluntary assessment by an accrediting agency that approves a healthcare facility exceeds the minimum requirements set by licensing agencies.

Question 3

Affordable Care Act (ACA)

P. 9

Answer 3

Health Care reform with the goal of improving quality of care and Affordable Health Care coverage through health insurance exchanges provides Healthcare consumers with stability and flexibility of Health Care coverage.

• “Obamacare”; was signed into law on March 23, 2010.
• the following are the major goals of this law:
  1. Improve access to care and broaden insurance coverage
     2. Reduce costs by introducing new models of payment for services and improving care delivery and administrative processes
     3. Improve quality of care through expanded measurement and Reporting
     4. Increase health care Workforce
     5. Combat Fraud and Abuse
     6. Prevent chronic diseases
     7. Improve Public Health

• The ACA addresses both of these groups by expanding subsidized insurance as well as Medicaid for the uninsured and by supporting quality improvement initiatives combined with cost reduction goals for Medicare and Medicaid. Key provisions of the ACA include the following:

  * mandating that all individuals acquire health insurance or face Financial penalties enforced through the Internal Revenue Service (IRS)
  * requiring minimum standards for health insurance policies, including the cancellation of policies that do not meet the standards
  * requiring that the same insurance rates apply to all individuals regardless of medical pre-conditions (including chronic diseases, such as diabetes or hypertension) or gender
  * stipulating no cancellation of policies due to Chronic illnesses and no limits on care
  * mandating the individuals under 26 years of age can remain on their parents health insurance policy if they do not qualify for coverage on their own
  * establishing health insurance exchanges to encourage competition between insurance companies

Question 4

American College of Surgeons (ACS)

P. 4

Answer 4

A professional association of Physicians specializing in surgery, founded in 1913, with the purpose of improving quality of care by setting care and surgical education standards.

Question 5

American Hospital Association (AHA)

P. 4

Answer 5

A professional association of hospitals with the purpose of improving Medical Care through advocacy, education of healthcare leaders, and tracking of trending healthcare related issues.

Question 6

American Medical Association (AMA)

P. 3

Answer 6

A professional association of Physicians founded in 1847 with the purpose of developing standards for medical education, improving Public Health, establishing medical ethics, and advancing the study of science.

Question 7

American Recovery and Reinvestment Act of 2009 (ARRA)

P. 10

Answer 7

• its emphasis is on modernization of the healthcare system and included HITECH.
• Signed into law by President Obama on February 17, 2009

Question 8

Centers for Medicare and Medicaid Services (CMS)

P. 7

Answer 8

Formerly known as Health Care Financing Administration (HCFA), CMS manages Medicare and Medicaid claims and regulates Medicare and Medicaid programs.

• change occurred in 1977.

Question 9

Clinical decision support (CDS)

P. 13

Answer 9

Case specific computerized alerts, clinical guidelines, and current resources regarding diagnosis and treatment options, based on the data found in individual patient records.

Question 10

Conditions of Participation (CoP)

P. 6

Answer 10

Regulations that Healthcare facilities and providers must meet in order to receive reimbursement from Medicare and Medicaid.

Question 11

Deficit Reduction Act

P. 9

Answer 11

Legislation passed with the intent to reduce growth in Medicare and Medicaid spending and decrease the number of fraudulent Medicare and Medicaid claims.

Question 12

Department of Health and Human Services (HHS)

P. 17

Answer 12

The federal agency responsible for enduring the provision of vital Human Services and health protection to Americans.

Question 13

Diagnosis-related group (DRG)

P. 7

Answer 13

A system that classifies patients into groups based on a patient’s principal and secondary diagnoses, procedures performed, and other factors and determines the amount reimbursed to the hospital by Medicare, Medicaid, and other third-party payers.

Question 14

Evidence based medicine (EBM)

P. 21

Answer 14

Diagnostic and treatment protocols based on proven research and documented best practice.

Question 15

Fee-for-service

P. 7

Answer 15

Billing for health care services after the services have been provided (retrospectively) according to the facility’s or office’s actual fee for each service.

Question 16

Healthcare Facilities Accreditation Program (HFAP)

P. 6

Answer 16

A voluntary accreditation program used by the American Osteopathic Association, which, like The Joint Commission, holds deemed status for Medicare.

Question 17

Health Information Technology (HIT)

P. 10

Answer 17

The framework on which health information is collected, stored, exchanged, and reported.

Question 18

Health Information Technology for Economic and Clinical Health Act (HITECH)

(P. 10)

Answer 18

Legislation resulting from the ARRA that provides incentives to Providers and hospitals that adopt or upgrade existing electronic health record EHR system and associated technologies and use them in specified ways.

Question 19

Health Insurance Portability and Accountability Act (HIPPA)

P. 8

Answer 19

A law consisting of five rules - privacy, security, data sets and electronic transaction standards, administrative simplification, and enforcement and compliance it impacted Health Care in general and the health information professionals particular more so than any piece of legislation since Medicare and Medicaid.

Question 20

Hill-Burton Act

P. 6

Answer 20

Legislation that supplied funding for the modernization of existing hospital and the building of new ones, in exchange for which hospitals providing care at a reduced rate or for free to people who did not have the ability to pay.

Question 21

Independent Practice Association (IPA)

P. 16

Answer 21

A group of Physicians that contract with a managed care organization to provide care at a pre-determined, pre-negotiated (often reduced) rate.

Question 22

Informed consent

P. 8

Answer 22

Patient consent required for invasive surgical procedures and any treatment or procedure that carries a risk to the patient; informed consent provides explanation of the procedure/treatment to be performed and the reason for it; in other words, the risks and benefits of the procedure/treatments, alternatives to the procedure/treatment and their risks and benefits, and the name(s) of the healthcare provider(s) performing the procedure/treatment.

Question 23

Licensure

P. 4

Answer 23

Regulations regarding the minimum requirements to practice medicine or provide medical services; they vary from state-to-state.

Question 24

Managed care insurance plans

P. 9

Answer 24

Insurance plans that promote Quality, cost-effective Health Care through the monitoring of patients, preventive care, and performance measures.

Question 25

Meaningful Use

P. 11

Answer 25

The section of HITECH meant to increase the effective use of electronic health records through monetary incentives to adopt and used certified technology.

Question 26

Medicaid

P. 6

Answer 26

Title XIX of the Social Security Act of 1935; Medicaid provides financial assistance for healthcare coverage to poor and indigent populations.

Question 27

Medicare

P. 6

Answer 27

Title XVIII of the Social Security Act of 1935 Medicare provides financial assistance for healthcare coverage to persons 65 years of age and over, to persons who are disabled, and to those with end-stage renal disease.

Question 28

Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA)

(P. 9)

Answer 28

This act provides Medicare beneficiaries with financial assistance in paying for prescription medications.

Question 29

mHealth

P. 25

Answer 29

The sending and receiving of health information using a mobile phone, mobile device, or other wireless device.

Question 30

Office of the National Coordinator for Health Information Technology (ONC)

(P. 11)

Answer 30

Located within the office of the secretary of Health and Human Services, the ONC is the federal agency promoting a national health information technology infrastructure and overseeing is development.

Question 31

Omnibus Budget Reconciliation Act of 1968

P. 7

Answer 31

The act focused on substandard care and resulted in the requirement that PROs report substandard care to licensing agencies.

Question 32

Patient-centered medical home (PCMH)

P. 23

Answer 32

A healthcare model that involves the patient and family in the care of the patient; care is rendered in a team approach.

Question 33

Patient-centric

P. 13

Answer 33

Communications, information sharing, and decision making that includes the patient and is managed by both the patient and the provider.

Question 34

Patients’ rights

P. 8

Answer 34

Patients have the right to know who their healthcare team consists of, the right to privacy and confidentiality and the right to be informed about their diagnosis and treatment, the right to refuse treatment, the right to actively participate in their care plan, and their right to be cared for in a safe environment, free from abuse. Patients also have the right to read or have a copy (paper or electronic) of their health record, the right to know who has access their health record, and the right to request an amendment to their health record.

Question 35

Physician Quality Reporting Initiatives (PQRI)

P. 9

Answer 35

A voluntary pay-for-performance incentive program.

Question 36

Population health management (PHM)

P. 21

Answer 36

Providing quality healthcare to a specific group of patients in a more cost-effective manner through the use of digitized patient records and analytics.

Question 37

Primary care physician (PCP)

P. 9

Answer 37

A family practitioner, an internist, or a pediatrician who manages a patient’s basic healthccare needs and coordinates care with a specialists under a managed care insurance plan.

Question 38

Prospective payment system (PPS)

P. 7

Answer 38

A fixed reimbursement system based on the diagnosis related group (DRG) assigned to each inpatient stay; used by Medicare and Medicaid reimbursement and some third-party payers.

Question 39

Quality Improvement Organizations (QIOs)

P. 7

Answer 39

Entities with which CMS contracts to review medical care, based on health record documentation, and to assist Medicare and Medicaid beneficiaries with complaints about quality of care issues and to implement improvements in the quality of care available throughout healthcare facilities.

Question 40

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)

P. 7

Answer 40

Legislation that resulted in a shift from fee-for-service reimbursement to a prospective payment system.

Question 41

The Joint Commission (TJC)

P. 6

Answer 41

Formerly known as The Joint Commission on Accreditation of Hospitals, a voluntary accrediting agency holding deemed status by Medicare.