Practice Development Midterm

Question 1

Currently (2023), what percent of its GDP does the United States spend on healthcare?

Answer 1

17.6%

Question 2

What does GDP stand for and what does it mean?

Answer 2

Gross Domestic Product & it’s a measure of the value of all goods and services produced in a country during a specific period of time (1 year).

Question 3

What area accounted for approximately 32 % or 1/3 of healthcare spending?

Answer 3

Hospital Care

Question 4

Name the two key ideas underlying the concept of insurance

Answer 4

1. Risk transfer
2. Risk pooling

Question 5

What is the basis of insurance

Answer 5

a risk transfer mechanism that facilitates shifting the cost of risk away from the insured and goes to an external party in exchange for payment

Question 6

What is cost sharing?

Answer 6

when individuals purchase coverage and their resources are pooled together to protect against losses, and together they pool the potential risk for losses that they may experience

Question 7

What are some of the more significant factors that are driving up healthcare costs?

Answer 7

New Technology & Aging Population

Question 8

Distinguish between the effect of malpractice lawsuits and the impact of defensive medicine.

Answer 8

defensive medicine has a greater impact on healthcare costs, drives overutilization

malpractice contributes less than 1% overall whereas defensive medicine contributes 12% to overall cost
-due to the fact that providers do not want to be sued so they do more than they should

Question 9

How do the number of specialists and/or hospital beds in an area impact cost?

Answer 9

If you have more doctors/specialists in the community, they can do more healthcare (More OB Doctors = More OB appts).

The more beds/doctors the higher the cost and the higher the utilization. Greater access/availability per person makes doctors think the equipment needs to be used.

Question 10

Confronted with healthcare costs rising faster than GDP, officials trying to fund public programs like Medicare are left with what two economic alternatives?

Answer 10

1. decrease access
2. reducing reimbursement rates

raise taxes - tax more to pay for more. this is another alternative but everyone would much rather the first 2 options.

Question 11

Between 1960 and 2006, the gap between healthcare spending and GDP was 2.5 percentage points per year. How has this gap contributed to a large percentage of the long-term decline in coverage?

Answer 11

The gap increased over time which is how we ended up with 44 million people being uninsured. The cost of healthcare rose faster than the GDP, which meant people couldn’t afford it and stopped paying for health insurance (aka stopped being insured). Healthcare costs were rising but people’s salaries were not.

Question 12

What was done following the 2.5 gap?

Answer 12

affordable care act was created
-subsidized the healthcare and restricted discrimination from healthcare
-if they could not afford healthcare, they would be given tax dollars (tax credit or tax money would cover)
-this did not address cost, but did address access

Question 13

What are the three categories of payment sources for healthcare in the United States?

Answer 13

1. public - federal, state, & local gov programs like medicare, Medicaid, & tricare
2. private - made by individuals &/or employers
3. out of pocket

Question 14

Describe the continuum of managed care and how it is interpreted.

Answer 14

Left - Indemnity, higher premiums, no control over cost or quality of care. Increases risk for the insurer.

Middle - Preferred Provider Organization (PPO). Do not always fall in the middle of the continuum, depends on the individual plan. Can be free or restrictive.

Right - Traditional HMO (insurer was also the one delivering care), lower premiums, 100% control over cost and quality of care.

Question 15

What are the changes related to the demand for and use of health insurance over the past 100 years discussed in the text?

Answer 15

private and public sectors have expanded, most insurance included a comprehensive set of healthcare benefits, group health insurance began to be offered as a benefit, mechanisms for reimbursement have expanded and as a result cost of healthcare has increased meaning there is a higher demand for health insurance

Question 16

What does it mean to gain access to care?

Answer 16

gaining access to care = taking steps to receive healthcare services like finding a provider, getting insurance, & making an appointment

having access to care = availabilty of healthcare services within reach, whether or not you use them

-having access does not mean that you gain the access!

Question 17

What are the facets that determine real access?

Answer 17

service availability
utilization of services
barriers to access
relevance and effectiveness and equity

Question 18

Pertaining to the model discussed in class, what eventually happens to healthcare outcomes (quality) as healthcare costs increase and what does shifting this curve represent?

Answer 18

as cost goes up, there is only so much that quality can continue to increase until it plateaus out
-this level off is the point where we can say that yes we may be spending more but the quality is not continuing to improve
-our job is to “shift this curve up” so that there is better quality at the same cost
-done by continuing education

Question 19

What were some of the key characteristics of the uninsured population in the US in 2008?

Answer 19

• % of people w/o health insurance coverage varies across states (more in south & west)
• they use healthcare systems differently, they don’t usually have a PCP and they delay seeking care until they get sicker which results in serious financial consequences (unable to pay bills & medical debt)
• the cost of insurance & being jobless are also major contributers to being uninsured

Question 20

How do the majority of Americans get their healthcare insurance?

Answer 20

Through their employer

Question 21

What impact did the affordable care act have on employer-based insurance?

Answer 21

there may be something known as a Cadillac tax, which is taxing high-cost employer-sponsored health plans

The Affordable Care Act more people got insurance, we went from 44 million people uninsured to 15 million.

Question 22

What type of access was addressed by the affordable care act?

Answer 22

financial accessibility

Question 23

When was the “great divide” in healthcare reached, and what was it?

Answer 23

1910-1912
this was when any random patient with any random disease had a 50-50 chance of an encounter with any doctor being successful

Question 24

What two issues related to health policy have been central issues concerning healthcare since the early 1900s?

Answer 24

Financial Accessibility & The Cost of Healthcare

Question 25

What is adverse selection?

Answer 25

those who were sick would seek coverage and those who were healthy would not

Question 26

How far back in US history does concern about the cost of care go and have attempts been made to address it?

Answer 26

about 100 years invented insurance, employer-based coverage, risk pooling, risk transfer

Question 27

What factors contributed to the rapid increase in healthcare spending in the early 1970’s?

Answer 27

- High Medicare expenditures - rapid inflation of the economy - expanses of hospital expenses and profits - changes in medical care: new technology, medications, and conservative approaches to treatment all the pieces were in place but there was not any control

Question 28

What act was passed in response to this increase in 1973?

Answer 28

Health Maintenance Act (HMO) promoted prepaid health plans as a more cost-effective way to provide health care services

Question 29

Name the most significant piece of healthcare legislation in the last century.

Answer 29

Social Security Act of 1965 - Created Medicare

Question 30

How successful was managed care at controlling cost?

Answer 30

- They were controlling costs by denying medically necessary services to PTs even in life-threatening situations or providing low-quality care - Control care however, it still received backlash regarding the restricted care and poor outcomes that occurred * big issue = restrictions that were placed * what happened as a result from this backlash to managed care? ◦ resulted in insurance becoming closer to PPOs from HMOs, ultimately leading to healthcare cost increase ◦ moving from the far right to the center caused the premiums to increase as there is no control over the cost

Question 31

What happened as a result from the backlash of managed care?

Answer 31

resulted in insurance becoming closer to PPOs from HMOs, ultimately leading to healthcare cost increase -moving from the far right to the center caused the premiums to increase as there is no control over the cost

Question 32

What happened in the mid-1990s that affected MCOs significantly and what has happened to healthcare costs (and premiums) as a result?

Answer 32

- cost did not rise as much as we were expecting in the 1980's due to HMO's (HMO=type of MCO) - premiums went up when we switched from HMO to PPO - they are bearing greater risk so they are charging more

Question 33

What did the IOM report “To Err is Human” reveal about the US healthcare system?

Answer 33

44,000-98,000 people die each year from medical errors

Question 34

What is the meaning of the component phrases in the IOM definition of quality?

Answer 34

- a wide array of services (mental & physical health) - good quality = increases likelihood for good outcomes - highlights the link b/w care that is provided & its effect on health - healthcare professionals need to be prepared to revise the way they practice as new knowledge is generated

Question 35

What are the 4 problems in quality of healthcare?

Answer 35

underuse (too little care) overuse (too much care) variation in use (variations within practice protocols) misuse (mistakes within care)

Question 36

What are Donabedian's measures of quality and how are they defined?

Answer 36

Structure - the capacity of health systems to deliver care. the number of board-certified staff, equipment, and facilities. Process - interactions b/w patients and clinicians. Immunization rates & best practice standards. Outcomes - changes in the patient's health status as the result of health care interventions. Recovery rates, mortality, & health status.

Question 37

What are some examples of models of oversight?

Answer 37

Peer Review: certification of specialty based on professional training, clinical practices, and/or organizations Accreditation: Independent organization that uses published criteria such as assess quality in and accredit provider settings/organizations (i.e. acute care, long term care, primary care, networks) Inspection : National or regional statutes prescribing levels of competence and/or safety

Question 38

Which part of Donabedian’s quality conception does CQI focus on?

Answer 38

Process

Question 39

Why is control of variation at the heart of CQI?

Answer 39

when understanding and addressing variation, we can go to those areas to improve it and address those problems to get better outcomes 2 types of variation - common (small) and special cause (large)

Question 40

What role do measurement and metrics (statistics) play in CQI? Why is the role so critical?

Answer 40

foundational and central to the process. can not control quality without measuring the data consistently and accurately.

Question 41

What is CQI?

Answer 41

continuous quality improvement focuses on the process part of Donabedian’s quality conception -should not be a one time process and should be continuous -identifying factors that create variation, aiding in improvement of quality

Question 42

What is PDCA?

Answer 42

Plan, Do, Check, Act The improvement cycle

Question 43

What are the common elements of quality improvement programs?

Answer 43

- empowering the people doing the work - use of metrics/measurement

Question 44

What is the difference between quality assurance and quality improvement?

Answer 44

quality assurance - retrospective, at the end. not changing anything just saying what the outcome is. quality improvement - prospective, how do we produce better outcomes and have fewer bad outcomes? wants to change the system so we have less bad outcomes

Question 45

What is the definition of a risk?

Answer 45

exposure to the chance of injury or financial loss (adverse possibility)

Question 46

Tell me about the risk management process

Answer 46

identification of risks, development of alternative risk control/risk financing techniques, implementation of the chosen technique and monitoring the programs effectiveness and modifying it as risks change over time

Question 47

How does the cost of risk management for any given risk play into the equation in determining if the effort is worth it?

Answer 47

If it costs more to manage than it costs to endure. As the cost/risk of liability goes up we want to decide what is worth spending more money on.

Question 48

James Reason’s explanation of the cause of errors – the basis for the “Swiss Cheese Model” and “Blame” culture.

Answer 48

-revolved around the idea that there are barriers that protect workers from errors however if these barriers all break down at the same time it can lead to an adverse outcome occurring -errors occur from these holes in the system that align opening up for those error opportunities to occur

Question 49

What is ALARP and why is it used?

Answer 49

"As Low as Reasonably Practicable" we want the chance of risk to be as low as possible but we need to consider cost and time that would be needed to control it to decide if it is worth it

Question 50

What is the “Duty of Reasonable care” and how does such a ‘duty” come about?

Answer 50

Anytime a healthcare professional treats a patient they have a duty to reasonable care. The duty comes into being when you accept someone as a patient by seeing them as a patient.

Question 51

Is any form of payment necessary for the duty of reasonable care to come about?

Answer 51

They do NOT have to pay you for this to come into existence.

Question 52

How do ongoing training and continuing education support patient care risk management?

Answer 52

maintaining and keeping knowledge current supports patient care and risk management, as it allows to practice the latest and greatest standards of care

Question 53

The two most important factors influencing a practitioner’s ability to reduce exposure to liability

Answer 53

Awareness & Education

Question 54

What elements must be present for a tort of negligence to be viable/pursued?

Answer 54

duty of reasonable care, a breach of legal duty must exist, a proximate cause must exist between breach of duty & injury, an actual loss or damage must result from the injury

Question 55

What is a tort?

Answer 55

civil wrong committed by one person against another person -unintentional tort is the most common civil litigation to be brought against us

Question 56

What is the definition of Malpractice?

Answer 56

negligence or carelessness of a professional person, can either be civil (tort) or a criminal concern

Question 57

How to avoid a malpractice suit?

Answer 57

understand state law, understand hospital and institution policies, communicate with the patient, ongoing risk management and document!!

Question 58

What is Root Cause Analysis?

Answer 58

a step-by-step method that leads to the discovery of a fault's first or root cause. the process should be "thorough and credible."

Question 59

What is an Adverse Event?

Answer 59

untoward incident, therapeutic misadventure, iatrogenic injuries or other occurrence directly associated with care or service provided -may result from acts of commission or omission

Question 60

What is a Sentinel Event?

Answer 60

an unexpected occurrence that involved death or serious physical or psychological injury or risk

Question 61

What is Reliability?

Answer 61

performing as intended in common and uncommon circumstances -wanting to to work well every time -three level design that includes prevent, identify and mitigate IMPORTANT ***

Question 62

What is a co-payment?

Answer 62

a set amount of money you pay out of pocket when you get a medical service and the insurance covers the remaining amount of the allowed. it is a way to share costs between you and your insurance

Question 63

What is coinsurance?

Answer 63

set % amount you pay out of pocket and the insurance covers the remaining % cost-sharing arrangement in health insurance where the PT pays a % of the cost of healthcare service and the insurance company covers the remaining % to the allowed amount typically applies after PT meets their deductible a percentage of the allowed amount

Question 64

What is a deductible?

Answer 64

amount you pay before insurance will pay anything set amount of money you must pay out of pocket for covered healthcare services before your health insurance starts to share the costs

Question 65

What is a prospective payment?

Answer 65

A method of reimbursement in which healthcare providers are paid a predetermined, fixed amount for each case or patient, regardless of the actual cost of care.

Question 66

What are captivated costs?

Answer 66

set amount to care for a set number of people for a set period of time Set amount of $, for a set amount of patients, for a set amount of time. A capitated contract is a payment arrangement in healthcare where a provider is paid a fixed amount per patient for a specific period (usually monthly), regardless of the actual number or cost of services provided to the patient. (likely intended to be Capitated Costs): A payment arrangement where a healthcare provider is paid a set amount per patient per period (e.g., per month) regardless of the number or type of services provided. This is often used in managed care systems to control healthcare costs.

Question 67

What is moral hazard?

Answer 67

The concept is that individuals may take more risks or use more healthcare services when they are protected from the full cost of those services, such as when they have insurance coverage. It highlights the potential for increased utilization due to reduced personal financial responsibility. if you have the coverage you do not care what it costs, you just go and go as much as you want and the doctor treats you without concern for cost because of the guaranteed source of payment Moral hazard refers to a situation in which an individual or organization is more likely to take risks because they do not bear the full consequences of their actions. This typically occurs when one party in a transaction is shielded from risk, leading to potentially careless or irresponsible behavior.

Question 68

What are the 3 pillars of healthcare?

Answer 68

access quality cost

Question 69

What is the hill-burtons act?

Answer 69

passed in 1946 by Congress and made direct government grants for communities to build hospitals, leading to an increase in access to care and hospital beds

Question 70

What is the concept of insurance?

Answer 70

Risk Pulling - multiple members put into towards their health insurance Those with greater health have less risk and are paying into the insurance We want to have more healthy people = more money This leads to being more likely to cover everyone who is sick If everyone is sick it won’t work as well

Question 71

What is a contracted rate?

Answer 71

allowed amount what the insurance will pay the physician for the service

Question 72

Coinsurance & Copayments are similar in that?

Answer 72

they are a portion of the allowed amount owed by the patient not both set amounts bc coinsurance is a % so it's not a set amount, it varies

Question 73

Which government program helps older Americans over 65 pay their healthcare costs?

Answer 73

Medicare

Question 74

A very generous PPO plan that makes provision for patients to see any provider out of network and only pay 15% of the providers bill.

Answer 74

appears close to traditional indenmity plans on the continuum of managed care

Question 75

Prior to the backlash against managed care in the 1990's it can be said that?

Answer 75

managed care beat the predicted rise in cost by controlling cost and utilization

Question 76

The inclusion in the IOM definition of quality in the terms populations and individuals draws attention to

Answer 76

the need of all populations for have access to necessary and appropriate services

Question 77

What are the 3 pillars of healthcare?

Answer 77

cost, quality, & accessibility

Question 78

What occurred following the end of world war 2?

Answer 78

people were coming back from the war to spread the word about the new types of medicine, resulting in the hill burton act being passed which produced government grants for communities to build hospitals

Question 79

How can quality oversight occur?

Answer 79

peer review, accreditation and inspection