Final Review Flashcards
(141 cards)
1
Q
Poorhouse
A
Almshouse: general welfare by providing food and shelter to poor
2
Q
Pesthouse
A
operated by local gov. to act as a place of quarantine for contagious diseases. Main function was to isolate people & contain the spread of diseases
3
Q
Dispensaries
A
1st one in 1786. Acted as outpatient clinics. Provided free care to those who couldn’t pay, medical care and dispensed drugs to ambulatory pts
4
Q
First Hospitals
A
Developed in 1850s. Poor sanitation & inadequate ventilation led to not great conditions. “Houses of death”.
5
Q
AMA
A
American Medical Association founded in 1847 and created a barrier between orthodox practitioners and “irregulars”.
6
Q
Medical Education
A
In 1756, one of the first colleges for medical school was established at the College of Philadelphia. Med education in the US was not as great as Europe
7
Q
Biggest cost of HC
A
Traveling to receive care and technology
8
Q
Blue Shield
A
Designated to pay for physician’s bills. Physicians dominated boards of directors not only because they underwrote plans, the plans were their response to the challenge of national health insurance. The plans met AMA’s stipulation of keeping med matters in the hands of physicians
9
Q
Harry Truman
A
In 1946, he made an appeal for a national health care program
10
Q
Union negotiations
A
In 1948, US Supreme Court ruled that health insurance is legitimate in union-management negotiations
11
Q
Deinstitutionalization
A
In 1963, Community Mental Health Centers act passed supporting “deinstitutionalization” of people with mental illnesses
12
Q
Amendment to the SSA and YEAR!
A
1965 - the Amendment to SSA to create programs to pay for HC for vulnerable populations was passed.
13
Q
Medicare Expands
A
1972 - expanded to cover disabled people w/ ESRD, dialysis/kidney transplant, people 65+ that select Medicare coverage
14
Q
Bill Clinton
A
Focused on economy in 92’ due to recession and ran on school choice, balanced budget amendment, opposition to illegal immigration and support for NAFTA
15
Q
Part D
A
Prescription Drug, Improvement, and Modernization Act of 03’. MMA created Part D drug benefit, which became available to Medicare beneficiaries on Jan 1, 06’. Voluntary outpatient prescription drug benefit provided through private plans approved by fed gov
16
Q
Quad Function Model
A
-Financing: having to finance for insurance
-Delivery: developed health service delivery models to contain costs and provides quality & accessible care
-Payment: philosophy of everyone contributing to the cost of HC according to their capacity to pay
-Insurance: pays the hospital/clinic
17
Q
Managed Care
A
Developed to contain HC costs & expenditures, seeks to achieve efficiency by integrating basic functions of HC delivery, employs mechanisms to control or manage utilization of med services, determines the price at which services are purchased & how much providers are paid, most dominant HC delivery system in US
18
Q
Military
A
Available free-of-charge to active-duty personnel, well-organized & highly integrated system, combines PH w/ med services, in general the military med care system provides high-quality HC
19
Q
Vulnerable populations
A
poor, uninsured, minority or immigrant status, live in geographically/economically disadvantaged communities, received care from “safety net” providers & pts have to forgo care or seek care in hospital ER, subsystem faces enormous pressure
20
Q
Integrated Delivery
A
the hallmark of US HC industry over past decade & becoming larger, organizational integration to form integrated delivery system or networks
21
Q
LTC
A
medical & nonmedical care that is provided to individuals who are chronically ill/who have a disability, HC & support services for daily living, not covered by Medicare, LTC insurance if offered separately
22
Q
Public Health
A
improve & protect community health: monitors health status, diagnose and investing, informing and educating health problems and hazards, developing policies, enforcing laws and regulations, assuring competent professional health workforce, research
23
Q
Third party payers
A
Patient is first party, provider is second party, intermediary is third party
24
Q
Technology
A
developments were instrumental in transforming the nature of healthcare delivery
25
Moral Hazard
once enrollees have purchased health insurance, they may use more health care services than if they were to pay for these services on an out of pocket basis
26
Imperfect Market
Factors limit patients’ decisions, item-based pricing, phantom providers, package pricing.
27
Lobbyists
provide information to policy makers
28
Defensive Medicine
a way to avoid litigation
29
Market Justice
leaves the fair distribution of health care up to the market forces in a free economy
30
Social Justice
the equitable distribution of health care is a societal responsibility
31
Indicators of Health
Things you can measure (life expectancy, morbidity, mortality, mental well-being, social functioning, functional limitation, spiritual well being)
32
Determinants fo Health
environment, behavior and lifestyle, hereditary, medical care
33
3 phases of disease
Normal state, pre-disease state, disease state
34
primary prevention
activities undertaken to reduce the probability that a disease will develop in the future (hand washing)
35
Secondary prevention
the early detection and treatment of disease (screening)
36
Tertiary prevention
interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability
37
Incidence**
the number of new cases occurring in the population at risk within a certain period of time (ex: month/year)
38
Prevalence**
the total number of cases at a specific point in time, in a defined population
39
Information systems
Clinical information systems
Administrative information systems
Decision support systems
Internet and e-health
40
Class I medical devices
Pose the lowest risk.
Require general controls regarding fraudulent claims
Ex) Box of band-aids
41
Class II medical devices
Subject to labeling and performance standards, and post-market surveillance
Ex) Wheelchair
42
Class III medical devices
Devices that support life, or present a potential risk of illness or injury
Require premarket approval regarding safety and effective
Most regulated
Ex) Pacemaker or breast implant
43
Inpatient
Overnight stay in the hospital
Hospital: Has to have at least 6 beds
44
Hill-Burton Act
Federal grant to the states to construct hospitals
Growth of hospitals in the 50s and 60s
45
Medicare Reimbursement change 80'
In 2018: 2.4 beds per 1000 people
Since the mid 1980s due to:
-Changes in reimbursement (Medicare
switches to PPS)
-Managed care: cost containment
-Hospital closures
46
Physician-owned hospitals Pros and Cons
Pro - one stop shopping
Con - limited expansion
Controversy - self referred
47
Reimbursement to critical access hospitals
Total payment to the hospital is fixed at 101% of reasonable costs
48
Critical Access Hospital
Medicare designation for small rural hospitals with 25 or fewer beds that provide emergency medical services in addition to short-term hospitalization for patients with noncomplex health care needs
49
Outpatient care
-"ambulatory care"
-initially meant diagnostic and therapeutic services & treatments provided to the "walking" ambulatory pts
50
Outpatient services
any HC services that don't require an overnight stay
51
Primary reason for growth in outpatient services
The payers like it because it costs less, technology, patients want to be at home
52
Types of outpatient care
Physician offices, hospital out-pt departments, hospital emergency departments, home health agencies, surgery centers, chiropractors, mobile diagnostic, & screening services, community health centers & free clinics, alternative medicine clinics, hospice.
53
Primary Care
-Basic & routine HC provided in an office/clinic by a provider who takes responsibility for coordinating all aspects of a patient’s health care needs, an approach to health care delivery that is the patients first contact with the health care delivery system and the first element of a continuing health care process
54
Secondary Care
routine hospitalization, routine surgery, and specialized outpatient care, such as consultation with specialists and rehabilitation. Compared to primary care these services are normally brief and more complex, involving advanced diagnostic and therapeutic procedures
55
Tertiary Care
the most complex level of care, which is typically institution based, highly specialized and highly technological. Examples include burn treatment, transplantation, and coronary artery bypass surgery
56
Primary Prevention
the prevention of disease, for examples, health education, immunization, and environmental control measures
57
Secondary prevention
efforts to detect disease in early stages to provide a more effective treatment for example, screening
58
Tertiary prevention
Interventions to prevent complications from chronic conditions and avoid further illness, injury, or disability
59
Coordination of care
PCP coordinated the delivery of care from many sources
60
What is LTC?
A variety of individuals, well-coordinated services that are designed to promote the maximum possible independence for people with functional limitations. These services are provided over an extended period to meet the patient’s physical, mental, social, and spiritual needs, while maximizing quality of life
61
Reimbursement of LTC
-Medicare doesn't cover most LTC services & requires spending down most of one’s assets to poverty levels to quality for LTC coverage
-Most people are likely to have few options for paying for such care
-Unprepared to cope with the high risk of needing LTC in their retirement years, a period when incomes from most people also dwindle
-Public policy created few incentives to spur LTC insurance growth
-ACA did little to address the LTC dilemma
-Medicaid & Medicare expenditures for LTC will be unsustainable in the long term
62
ADL
eating, bathing, dressing, toileting, and getting into/out of bed/chair
63
IADLs
home maintenance, cooking, shopping, and managing money
64
Palliation
Serving to relieve/alleviate, such as pharmacologic pain management and nausea relief
65
Home Health Services
Bring certain types of services to pts in their homes
66
Adult Daycare
daytime program designed to meet the needs of cognitively impaired adults & to provide partial respite to family caregivers so they can work during the day.
-Designed for ppl who live w/ their families but can't remain alone during the day because of physical/mental conditions
67
Adult foster care
-a small, family-ran homes providing room, board, & varying levels of supervision & personal care to non-related adults who are unable to care for themselves.
-The caregiving family resides in part of the home. To maintain the family environment, most states license fewer than 10 beds per family unit
68
MOW
A home-delivered meal system for homebound persons who can't prepare a nutritionally balanced noon meal for themselves
69
Emergency Responses
Personal emergency response systems provide at-risk elderly pts w/ an effective and convenient means to summon help if an emergency occurs
70
Specialty care
refers to a higher level of medical services that typically require a request from your primary care provider
71
Hospitalists
physicians who specialize in the care of hospitalized patients
72
Medicare Part A
Hospital insurance - covers inpatient hospital stays, care in skilled nursing facilities, hospice care, some home health care
73
Medicare Part B
Medical insurance - covers certain doctors’ services, outpatient care, medical supplies, preventative services, rural health clinic services, annual physicals, ER services
74
Medicare Part C
Medicare Advantage - covers routine dental care, vision care, hearing care, and wellness programs
75
Medicare Part D
Prescription Drug Coverage - helps cover the cost of prescription
76
ACA impact on physician owned hospitals
prohibits them from expanding their facilities capacity
77
ACA impact on primary care
Improves the quality of care and lowers the cost
78
HMO
A type of managed care organization that provides comprehensive medical care for a predetermined annual fee per enrollee
79
PPO
A type of managed care organization that has a panel of preferred providers who are paid according to a discounted fee schedule. The enrollees have the option to go to out-of-network providers, but incur a higher level of cost sharing for doing so
80
Risk
the possibility of a substantial financial loss from some event
81
Insured/enrollee
an individual who is protected by insurance against the possible risk of financial loss is called the insured
82
Underwriting
systematic technique for evaluating, selecting (or rejecting) classifying and rating risks
83
Cost-sharing
sharing costs of health care so that the insurer assumes at least part of the risk
84
Deductible
the amount the insured must first pay before any benefits by the plan are payable
85
Coinsurance
Cost sharing in the from of a percent amount
86
Stop-loss provisions
called reinsurance for to decrease the high losses so they wont go broke
87
Means-tested
government programs available only to individuals below the poverty line
88
Medicare is administered by
federal agency - Centers for Medicare & Medicaid Services (CMS)
89
Medicare is financed by
payroll taxes
90
Medicare covered
in-pt services, short-term convalescence and rehabilitation in a SNF, home health (must be homebound), and hospice
91
Medicare's benefit period
begins on the day the patient is hospitalized. Ends when the patient has not been in a hospital or SNF for 60 consecutive days. After- new benefit period begins
92
Medicare hospital understand the graphs
deductible paid for in the first 60 days, copay is required from 61-90 days, after 90 days the copayment increases, after 150 days the patient pays. Starts back at 0 after 60 days out of hospital
93
Medicare SNF understand the graphs
starts after 3 nights in the hospital, first 20 days free, after 20 days pay a coypay, after 100 days patient pays. Starts over at 60 days out
94
Medicare - hospice
patient must be terminally ill, only a small copayment required
95
Medicare - home health
patients must be homebound and require nursing care or rehabilitation care
96
Medicare Part C (Medicare Advantage) covers...
-Additional benefits such as dental and vision
-Still includes Part A and B Includes additional benefits such as dental and vision
-Still includes Part A and B
97
Medicaid
-Covers people under the poverty line
-Jointly financed by the state & fed gov
-Each state administers its own Medicaid program
98
CHIP
-Covers those w/ income up to 200% below the FPL, just for children
-financed by fed and state funds
-each state administers their own programs
99
IHS
-Covers American Indians and Native Americans
-To serve the HC needs of native peoples, & to provide fund for tribal & urban Indian health programs
-Lack clarity & understanding regarding the IHS's formal structure, policy, & roles
100
Prospective Payment System
DRGs for in-pt hospital services
101
Retrospective payment systems
amount paid is determined by what the provider charged or said it cost to provide the service after tests or services had been rendered to beneficiaries
102
Regulatory Tools
uses of health policy in which the government prescribes and controls the behavior of a particular target group by monitoring the group and posing sanctions if it fails to comply
EX - federally funded quality improvement organizations, state insurance departments, Department of Health and Human Services (DHHS), the U.S. Department of the Treasury
103
Allocative Tools
use of health policy in which there is a direct provision of income, services, or goods to groups of individuals who usually reap benefits from receiving them
104
Distributive
Policies spread benefits throughout society, typically include funding of medical research through the NIH, the development of medical personnel, the construction of facilities, and the initiation of new institutions under the health maintenance organization act
EX - Hill-Burton Act 46'
105
Redistributive
tax payer funded healthcare programs that help the poor or disabled
EX - mediare and medicaid
106
Subsidiary
any corporation that is controlled directly/indirectly by a health corporation. Coverage for healthcare is at little or no cost for people whose income falls below a certain level
107
Fragmented
Federal, state, and local governments pursue their own policies, with little coordination of purpose or programs occurring.
1)the employed are covered voluntary with insurance by employers
2) the elderly are insured through private-public Medicare
3) the poor are covered by Medicaid through a combination of federal and state tax revenues
4) special population groups have coverage directly from the federal government
108
Incremental
refers to the small changes that can generate large results. The focus is to change small things at a time to hopefully make health a habit and prevent and treat conditions. Incremental reforms divide groups, and focus on fixing the problems of specific groups
109
Interest Groups
refers to a group of people who have a common view on a health policy and work together to see it through, (AMA, AARP, AHA) or employers, consumer groups, manufacturers of technology.
110
Decentralized
refers to a system in which most decisions in health care are handled by lower levels in the government, means local governments will make healthcare decisions for the people in their immediate area
111
Steps in a Policy Cycle
1. Issue Raising
2. Policy Design
3. Public Support Building
4. Legislative Decision Making and Policy Support Building
5. Legislative Decision Making and Policy Implementation
112
Groups interested in Health policy
AARP, ACA, Medicare, Medicaid, U.S. Department of Health and Human Services (DHHS), U.S. Department of Treasury, CHIP, WIC, NIH, Certificate-of-need (CON) programs
113
GDP 2020
18% spent on HC
114
GDP - less money to spend on...
other goods, moral hazards, businesses won't stay globally competitive, small businesses suffer, takes tolls on individual, & gov can only raise taxes so much
115
GDP: waste
Many high HC costs are due to unnecessary items.
Ex - expensive wound care equipment that isn't needed, defects in equipment, overproduction, duplication of services
116
GDP - Global competition
high cost of HC has been shown to hinder US industry competitiveness in the global marketplace
-providers of HC attract pts who can choose several different providers
-price competition but can also be based on technical quality, amenities, access, or other factors
-fall into 4 categories: demand-side incentives, supply-side regulation, payer-driven price competition, & utilization controls
117
Imperfect Market
The U.S. healthcare delivery system is largely in private hands, this system is only partially governed by free-market forces. The delivery and consumption of healthcare in the United States does not quite pass the basic test of a free market, so the system is best described as a quasi-market or an imperfect market
118
Medical Model
Set of procedures in which all doctors are trained. Includes complaint, history, physical examination, tests if needed, diagnosis, treatment, and prognosis
119
Administrative costs
Associated with the management of the financing, insurance, delivery, and payment functions. Include management of the enrollment process, setting up contracts with providers, claims processing, utilization monitoring, denials and appeals of claims, and marketing and promotional expenses.
120
Practice variations
Economic consequences of practice variations can be demonstrated as an increase in resource utilization, the length of stay in the hospital, out-of-pocket costs, and welfare loss that varies between each clinician
121
Cost containment
control the cost now and keep it low for the future. This is done by reducing unnecessary expenses and finding other ways to use cheaper equipment but for better care.
122
Shopping
Each hospital operating in the United States will be required to provide clear pricing information. This makes it easier for consumers to shop and compare prices before going to the hospital.
123
Micro view
focuses on services at the point of delivery and their subsequent effects. It also looks at the performance of individual caregivers and health care organizations. One example of lack of clinical quality is medical errors.
124
Macro view
looks at quality from the standpoint of populations. It reflects the performance of the entire healthcare delivery system by evaluating indicators such as life expectancy, mortality rates, incidence and prevalence of certain health conditions
125
Quality Assurance
Involves the development, sustenance, improvement, and evaluation of standard training of medical professionals. Guaranteeing and maintaining a high standard of services provided. Help hospitals improve clinical outcomes but also increases staff engagement. The more money a hospital receives the better the quality of healthcare, but that increases the healthcare service costs.
126
Improving quality
collect data for patient outcomes, improve access to healthcare, really focus on the patient
127
Overutilization
Some people go to the doctor at any inconvenience, which then takes away from the medical services that people may actually need. This also causes hospitals to buy more than they really should, and could also raise prices
128
Underutilization
On the other hand, some people are too afraid to reach out and get health care, causing their issues to worsen. If not many people are using healthcare services, the cost may rise
129
Clinical practice guidelines
are recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options
130
ACA
requires plans and issuers that offer dependent child coverage to make the coverage available until a child reaches the age of 26. Both married and unmarried children qualify for this coverage
131
Market place
The Health Insurance Marketplace is a platform that offers insurance plans to individuals, families, and small businesses. The Affordable Care Act (ACA) established the Marketplace as a means to extend health insurance coverage to millions of uninsured Americans.
132
Medicaid
expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($17,774 for an individual in 2021) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations
133
Federally Qualified Health Centers
ACA's coverage expansion provided the opportunity for uninsured low-income FQHC patients to gain coverage
134
HRRP improves...
Americans’ health care by linking payment to the quality of hospital care. CMS incentivizes hospitals to improve communication and care coordination efforts to better engage patients and caregivers on post-discharge planning.
135
The individual mandates...
is a provision within the Affordable Care Act that required individuals to purchase minimum essential coverage – or face a tax penalty – unless they were eligible for an exemption
136
Scholarships
Include Maxine Williams Scholarships, Graduate Student Scholarships, and many more. They’re a lot of scholarships provided when entering the medical field
137
Loan Repayments
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and, in turn, reduce avoidable readmissions
138
Largest barrier to HC will be
expenses and insufficient insurance coverage, not enough workers, transportation, language barriers
139
ACAs impact on economy
The ACA impacted the economy by subtracting $250 billion from GDP and will reduce the deficit by an average of 0.5 each year
140
Individual responsibility
-prioritizing a healthy lifestyle
-going to annual doctor visits
-having an effective health insurance plan
141
Medical home model
for the person who has high medical demands
