Exam 1 Flashcards
(42 cards)
Insurance company pays provider set amount of money each month to provide a defined set of Healthcare Services
Capitation
Reimbursement for healthcare services based on predetermined fixed Price–per–case/ diagnosis
DRGs
Providers reimbursement based on the patient’s diagnosis; most common method of payment in today’s healthcare system
Perspective payment system
Method of reimbursing healthcare providers based on each individual service provided; a.k.a. Fee-for-service.
Retrospective payment system
What is the impact of rising healthcare costs on families?
–rely on home remedies/ OTC’s
–skipped dental care
–postponed needed healthcare
–skip medication doses
–did not get prescriptions filled
–skipped recommended treatments/tests
Possible reasons for rising healthcare costs in US:
– aging population
–better technology= increased cost
–wasteful spending
–more chronic illnesses
–Pt’s A lower share of expenses
Method of reimbursing providers based on quality of care provided w/an emphasis on disease prevention and reduction of complications. Better patient outcomes= increased payment.
Pay-for-performance
Disadvantage: noncompliant patients= decreased reimbursement for provider
Medicare provides coverage for:
Persons over 65
Certain disabilities
end-stage renal disease
Joint Federal/State program to provide health insurance for impoverished families and people with certain disabilities.
Primary payer of LTC nationwide.
Fastest-growing component in most state budgets.
Medicaid
Federal entitlement program funded by wages from employees:
Medicare
Provider agrees to or is required by law to accept the Medicare approved amount as full payment for services.
Assignment
Neither Medicare A or B cover:
LTC (unless receiving dialysis)
Dental care/ dentures
cosmetic Sx
acupuncture
hearing aids/exams
Medicare A covers:
Hospitalization:
Inpatient in hospital/SNF
hospice care
Home healthcare
Medicare B covers:
Outpatient/MD services:
Ambulance services
preventative services
mental health inpatient/ outpatient
Pt pays premiums/ deductibles
Medicare D covers:
Prescription drugs:
Voluntary
Pt pays premium/ deductible
Medicare C/ medigap covers:
What Medicare A/B/D do not
Pricing discounts given to a Pt by the hospital they’re typically determined by income, Family size, and debt level:
Charity care:
Required for nonprofit hospitals
Five major reasons people over 65 experience medication related problems:
Physiologic changes: altered Pharmokinetics
Polypharmacy: Often by Multi-provider
incorrect dosage/ med errors
self-medication/ nonadherence
Any injury/Harm occurring during a patient’s therapy as a result of medications:
Adverse drug event
And unforeseen/Unintended/Undesired effect of a drug that occurs during therapy:
Adverse drug reaction
Any undesirable condition in a patient occurring as a result of treatment by a healthcare professional; pertaining to an illness or injury result from medication
Iatrogenic event
Causes for polypharmacy:
Increased number of doctors
Increased number of pharmacists
increase number of chronic conditions
OTC not considered
Pt equate going to the doctor with getting pills
decreased knowledge about meds by Pt
sharing meds
inappropriate scripts/ underused Meds
Reasons for adverse drug events in elderly:
Physiological change/ pharmokinetics
Drug absorption changes
drug distribution changes: reduced proteins/Albumin
slower drug metabolism
decrease drug elimination/GFR
Creatinine levels decrease in the elderly d/t loss of lean body mass could appear normal d/t:
Decreased GFR:
Allows buildup of creatinine which could mask the reduced creatinine levels; normal indicator of renal dysfunction
