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Flashcards in Health Service Management Deck (85):

Utilization review

The assessment of medical services for appropriateness and necessity of medical care
- manage health care cost by influencing pt care decision-making through case-by-case assessments of the appropriateness of care prior to its provision



- Health Plan Employer Data and Information Set (HEDIS) is a set of data that rates managed care plans.
- Developed and maintained by NCQA (National committee for Quality Assurance)
- HEDIS is often used by employers and other purchasers of managed care services.


What measures are included in HEDIS?

A variety of measures, such as quality, utilization, finances, and pt access and satisfaction



The Health Resources and Services Administration
- working through state and local agencies
- focuses on improving health care for disadvantaged and underserved populations, such as rural populations


Medicare part A

Covers inpatient hospital services


Medicare part B

Covers physicians services and outpatient services


Medicare part A is funded through?

A trust fund established from social security payroll taxes


Medicare part B is funded through?

Monthly insurance premiums paid by beneficiaries


Diagnosis-related group (DRG)

A system used by HCFA for Medicare and Medicaid and by some other payers to reimburse for certain treatment categories of inpatient hospital services bases on a fixed rate per admission
- DRGs is a prospective payment:
- a schedule for payments for services before they are delivered


The Resources-based relative value scale (RBRVS)

Is an attempt to reimburse physicians for time engaged in
- cognitive functions
- listening
- counseling
As part of its fee allowance, the RBRVS also takes into account such factors as:
1. the health care provider's malpractice insurance premium
2. office overhead cost related to delivery of the service
3. cost of medical specialty training related to delivery of services



A fixed fee per pt for specified health services required by a defined pt population


Business plan

Is a valuable management tool that can be used for a variety of purposes, including:
1. Setting goals and objectives for a company
2. Evaluate a company's performance
3. Determine financial and operating feasibility
4. Communicate the company's competence to potential investors



Joint commission on Accreditation of Health Care Organization - JCAHO
- accredits hospitals


Blake and Mouton feel that the most effective management style is?

an integrated team operation. This is best described as managerial grid.


The managerial grid implies?

That management can be measured according to two variables: (2Ps)
1. A concern for people
2. A concern for production
And the best management is team management


Key measurements of a quality program include?

1. Cost of quality
2. Departmental measurements
3. Conformance to requirements


Human performance measures usually include?

1. Frequency
2. Intensity
3. Latency
4. Duration
5. Reliability



Net present value

The discounted cash inflow minus the discounted cash outflow.
Often used to analyze and compare alternative methods of capital financing


Point of service plan?

- hybrid, with combined features of:
- managed care plans and
- fee- for-service plans



Part of HHS
SCHIP -State Children Health Insurance Program
CLIA - Clinic Laboratory Improvement Amendments



Federal program, federal pays all the cost



State & Federal funded



- part of CDC within HHS
- responsible for conducting research, providing education, information, occupational safety training, and providing recommendations for prevention of work- related injury and illness.
- provides funding for occupational safety and health research
- provides scientific input for OSHA regulations


Cost-benefit analysis - CBA

- A method to estimate the cost of a program necessary to produce a particular benefit (i.e., dollars of benefit per dollars expended)
- it is an economic analysis that converts all costs and benefits into dollar values.


Problems with CBA?

1. Difficulty measuring long-term health benefits
2. Difficulty measuring indirect costs and benefits
3. Difficulty in valuating human lives or health


Cost-effective analysis

- Estimate the cost of different or alternative programs to yield the same health outcome or end result (i.e., health outcomes per cost expended), e.g., the cost per individual who quits smoking.
- Cost is measured in monetary term
- Effectiveness is determined in terms of a clinical outcome such as:
- number of lives saved
- complications prevented
- diseases cured


Three core functions of public health agencies?

1. Assessment of public health needs
2. Policy development
3. Assurance


Which organization develops HEDIS measures?

National Committee for Quality Assurance (NCQA)


USPSTF is sponsored by?

Agency for Healthcare Research and Quality (AHRQ)


Four elements of a malpractice action are?

1. Duty
2. Breach of duty
3. Causation
4. Damages


The testimony of an expert witness should generally meet the standard of?

" To a reasonable degree of medical certainty"


Case management?

A system to direct medical care, contain cost, improve quality of care, and return employees to work as early as feasible


Risk management is?

Is a broader concept which connotes all clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury or loss to employees or to the company itself


Demand management

Is the provision of support systems for decision making and self-management by health care consumers to enable them to make the best use of medical care.
It takes into account that health care consumers will often be influenced by other factors besides information, such as personal experiences, societal pressure, and ethnic or cultural norms



Is the process of reviewing a health care professional's licenses, hospital privileges, history of malpractice activity, etc., to determine if that health care professional is acceptable for hospital privileges, for a contract with a managed care organization, or for some other privileges or duties


Electronic data interchange (EDI)

Is the electronic exchange via computers of information between different organizations.
EDI is being developed to transmit claims information in a more expeditious manner


Fee schedule

Delineate reimbursements for clinicians providing services on a fee-for-service basis.
Many workers compensation jurisdictions use a mandatory fee schedule in determining the reimbursement for services provided to injured workers


Loss ratio

Describes total claims liability and expenses divided by premiums.
A lower loss ratio is considered more desirable (and more profitable) by the insurer.


Centers for Medicare and Medicaid Services (CMS) is formally known as?

The Health Care Financing Administration (HCFA)



Health Insurance Portability and Accountability Act


DRG refers to

Diagnosis-Related Group
- a system to classify hospital cases into one of approximately 500 groups, also referred to as DRGs, expected to have similar hospital resource use.
- used since 1983
- under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of actual cost of care for the individual investors



- Reflect relative resource use of hospital pts
eg, a pt receiving a heart transplant has a more resource intensive DRG than a pt hospitalized for pneumonia
In 1972, the Congress gave Medicare the authority to do demonstration to control the rate of growth in hospital spending.



Is an organization that provides or arranges for member coverage of designated health services for a fixed prospective premium


HMO classification

HMO can be classified as:
1. A staff model
2. Group model
3. Network model
4. Independent practice association


Integrated Delivery System

Is a formal or informal union group of providers who typically represent different levels of care in order to market and sell the combined level of care


PPO (Preferred Provider Organization)

A plan that providers offer heath care services to group members at substantial discount from their usual rate.

Members receive lesser coverage when they seek care from providers outside the plan.



Exclusive Provider Organization (EPO)
A type of PPO
Members must see providers within the network for designated services
They must generally bear the entire cost of those services received from providers outside the network


Gatekeeper model

A gatekeeper is primary care physician whom pts must generally see for the initial visit.
The gatekeeper controls referral and consultations with specialist


Group model HMO

The group model HMO contracts with independent physicians to provide medical services exclusively to HMO members at a negotiated rate.
Members pay HMO a fixed prospective payment.


Staff model HMO

The HMO employs its own clinicians to furnish medical services to members, frequently in its own clinics and offices

Members pay the HMO a fixed prospective payment


Independent Practice Association model HMO

An IPA model of HMO contracts with individual practitioners and group practices or with an entity (the IPA) representing these practitioners and group practices to provide medical services to HMO members for a negotiated rate.

IPA providers generally also provide medical care outside the HMO


The National Practitioner Data Bank is administered by which agency?

- NPDB was established by the Health Care Quality Improvement Act of 1986 - to facilitate a comprehensive review of professional credentials
- Administered by the Bureau of HRSA, HHS


The 3 categories for measuring health care quality proposed by Donavedian including?

1. Structure
2. Process
3. Outcome


Network model HMO

HMO contracts with more than 1 multi specialty group to provide all covered services for the enrolled population of HMO


Group-model HMO

When only 1 group is contracted, it is called a Group-model HMO.


Sensitivity analysis

- Is used to determine how results would change if the assumptions or parameters used in the primary analysis were varied.
- To determine whether an economic evaluation changes when the value of one variable is changed while other variables are held constant.
- It helps determine how "robust" the result is in the face of changes in these inputs.


Decision analysis

Uses the probability and costs of outcome events to projects the average cost per pt for alternatives being compared.


Cost-minimization analysis

Determines the least costly intervention to accomplish a given result.
Eg. to compare the least costly drug that shown equivalent therapeutic effect.


FDA is in charge of

1. Safety of human and animal drugs
2. Biologics
3. Food safety
4. Cosmetics
5. Devices used for medical purposes


Meat and poultry products are regulated by?




1. Care is prepared
2. Includes a specified set of services
3. The organization controls the cost through various approaches.



A supplement nutrition program for women, infant and children
A grant program to states for qualifying adults and children in need
Administered by Dept of Agriculture


Managed Health Care

- A health care system with administrative control over health care services
- it Aimed at managing the cost of health care, access to health care, and quality of health care in defined populations


The objectives of Managed Health Care

1. Reduce health care cost (through a primary care physician)
2. Improve health care quality
3. Increase access to health care


Who does the government provides health care directly?

1. Veterans
2. Military personnel and their families
3. Native Americans


Title III grant to States

Unemployment compensation


Title V

Maternal and child health services block grants


Healthy people 2010 tow overall goals?

1. Increase quality and years of healthy life for the U.S. Population
2. Eliminate health disparities amongst the U.S. Population


Cost-utility analysis

Is used to determine cost in terms of utilities, esp. quantity and quality of life.
QALY - quality-adjusted life -year is often used.


Marginal cost

In cost analysis, marginal cost is calculated as cost to produce one additional unit.


What congressional act created the State Children's Health Insurance Programs (SCHIP)?

Balanced Budget Act of 1997


3 core functions of public health agencies?

1. Assess (of public health needs)
2. Policy development
3. Assurance (to constituents that services necessary to achieve agreed upon goals are provided )


(Utilization Review Accreditation Commission)

Is a nonprofit organization promoting healthcare quality by accrediting healthcare organizations.


The financing of health care by the government in America is handled through?

The Dept of Health and Human Services


The two primary payers for government sponsored health care in the US are?

1. HCFA (the Health Care Financing Administration
2. HRSA (Health Resources and Services Administration)


The Institution of Medicine definition of quality?

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.


Of the three component of health quality measure,
- Structure measures is?

- Assess the availability and quality of resources, management systems, and policy guidelines
- Structure measures are often critical for sustaining processes over time


Of the three component of health quality measure,
- Process measures ?

- use the actual process of health care delivery as the indicator of quality through analysis of activities of physicians or other healthcare providers, to determine whether medicine is practiced in accordance with clinical practice guidelines.


Of the three component of health quality measure,
- Outcome measures ?

- Measure the end results of healthcare
- are often dependent not only on medical care but also on genetic, environmental, and behavioral factors.


Public health has we codified academic base with five core areas in ?

1. Biostatistics
2. Epidemiology
3. Social science and health behavior science
4. Health management and policy
5. Environmental health


Prospective payment

DRGs - hospital
RBRVS - physician


(National Committee for Quality Assurance)

1. Non-profit, private organization (1991)
2. For MCO Accreditation
3. Evaluate how well a health plan manages all parry of its delivery system
4. Provide information that enable purchasers and consumers of managed health care to distinguish among plans based on quality
5. Introduced HEDIS


The four principles that medical ethic theories are based on?

1. Autonomy - respect for person
2. Beneficence
3. Nonmaleficence - do no harm
4. Justice


Certificate of Need (C.O.N)

- " Health Planning Resources Development Act" of 1974
- seek to reduce overall health and medical costs


(Drug Enforcement Administration)

- provide oversight and licensure for the appropriate and safe use of medications
- including narcotics
- other types of medications
- regulates:
- pharmacist
- nurses
- physicians
- physician's assistants