U.S Healthcare terms & lecture--exam 1 Flashcards

Question

Deductibles

Answer 1

a specified amount of money that the insured must pay before an insurance company will pay a claim.

Answer 2

a contribution made by an insured person toward the cost of medical treatment or other services.

Answer 3

a type of insurance in which the insured pays a share of the payment made against a claim.

Answer 4

is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals.

Answer 5

a person or thing that provides something.

Answer 6

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.

Answer 7

a rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status, or other factors. so makes the cost of premiums the same regardless of age, gender, health status, or other factors!

Answer 8

the amount of loss that an insured party experiences compared to the amount of loss that similar insured parties have.

Answer 9

the state of having the right to do or obtain something through satisfaction of the appropriate conditions.

Answer 10

the action of enrolling or being enrolled.

Answer 11

Out-of-pocket Individual private insurance Employment-based group private insurance (which is a health policy selected and purchased by your employer and offered to eligible employees and their dependents. These are also called group plans) Government financing

Answer 12

Need versus luxury The unpredictability of need and cost: cannot predict illness or surgery Point of care physician recommendations

Answer 13

Individual Private Insurance Individual  Health Plan  Provider You have to get private insurance

Answer 14

Required healthcare Subsidies for costs help those with income between 100-400% federal poverty level Insurance purchased through marketplaces or health insurance exchanges have insurance thru job and entire family is covered so we meet the individual mandate

Answer 15

1929- Baylor University Hospital provided hospitalization for school teachers $6 per person per year WWII was unable to increase wages, instead increased benefits and began to offer health insurance (this is where benefits come from) After the war unions picked up on the healthcare option and negotiated benefits Employer premiums are tax deductible (employers can provide healthcare cause they get a tax break) expenses and the benefit is not considered taxable income for the employee, therefore the government “sponsors/subsidizes” employer-based health care, estimated to equal $250 billion yearly of “uncollected” “taxable” “income”. ACA mandated employers with 50 or more employees offer coverage or pay a fee in penalties for not providing insurance.

Answer 16

Community Rating- All have the same premium no matter their health status: everyone paid the same $, high-risk persons (someone working on ladders, coal miners) paid the same as low-risk (bankers) How insurances began Difficult to be competitive because everyone pays the same so basically, everyone in the community pays the same Experience Rating- The base premium is decided on the average “needs” of the group Higher premiums for coal workers, the elderly, sick Began due to competition to bring lower premiums for groups Appears to be discriminatory to some so basically, you pay based off of your experience

Answer 17

Insurers experience rates are limited to: Family size Geographic location Age within limits of younger versus older rates Smoking status: can be charged more because @ risk *If people do not need to pay much for health care then the use of services will increase and insurance companies will need to pay more, Having individuals responsible for part of the costs, which has been rising, causes less use of services* higher co-payments, people wait longer to be treated, if no co-payments, then they would be quick to go to the hospital

Answer 18

1950’s: Poor and Elderly were struggling for Health Care Poor: Either did not have a job or jobs without fringe benefits elderly: Could not afford the trend toward experience ratings Less than 15% of the elderly had health insurance: so lots of out-of-pocket purchases 1965: Medicare: For the Elderly Large deductibles, copayments, and gaps Covered approximately 58% of average medical costs in 2012 Medicaid: For the Poor Also need to meet other criteria: young child, pregnant, elderly, disabled Medicaid expansion in some states has taken away these stipulations

Answer 19

Medicare enacted for the elderly in 1965 People eligible for Social Security are automatically enrolled at age 65 Under 65, disabled for and receiving Social Security for 24 month Individuals with ALS, end-stage renal disease, or transplants-no waiting period required ( so they do not wait 2 years)

Answer 20

inpatient to your costs skilled nursing facility (SNF) Care to eligibility to your costs long-term in patient care (SNF) to your costs Financed through the Social Security System through income payments by employers, employees, and those self-employed.

Answer 21

Medically necessary services: lab work, x-rays, physicals... Preventative services Financed through income taxes, federal taxes, and premiums: some people get until 65

Answer 22

Medicare Part C: Includes more health coverage plus a full prescription drug coverage Private health plans also called Medicare Advantage Plans Medicare subsidizes the premium The majority of plans are health maintenance organizations (HMOs) Medicare Part D: Prescription Drug Benefit (drug covered only) Criticized for: major gaps in coverage, provided through private insurance versus a federal program, non-negotiable prices with pharmaceutical companies to lower drug prices

Answer 23

1965-2014: Low income plus needed to fit into categories of eligibility Children typically covered 100% Federal government pays 50-76% of total costs depending upon per capita incomes 2015: Medicaid expansion lifts eligibility criteria; income up to 138% federal poverty level The federal government pays 100% of newly eligible from 2014-2016 then decreased to 90% thereafter Undocumented immigrants are not eligible

Answer 24

Medicare: Eligible if you have paid a certain amount into the Social Security system Medicaid: Those who contribute may not be eligible Healthy employees tend to pay more into the system for health care than those disabled, lower income, who may be using more services

Answer 25

Progressive payments: Rising % of income taken as income increases Increased income Increased payments Income taxes are progressive The more I make, the more I pay make more, pay more Regressive payments: Falling % of income taken as income increases (considered “unhealthy”) Increased income  decreased payments Experience rated is a regressive method of financing Community-rated is also regressive but less so than experience-rated everyone pays 10% whether millionaire or poor make more, pay same--not cool Proportional payments: The ratio of payment to income is the same for all income classes The ratio of income to payment same for all classes

Answer 26

2017: 47% of health care expenditures were out-of-pocket payments and premiums= REGRESSIVE 43% funded through government revenues= PROPORTIONAL ____________________________________ Sum Total of health care financing= REGRESSIVE 2013: Medical expenses lowered the lowest income by 47.6% compared to the top decile by a mere 2.7%- so those who make the most, pay the least

Answer 27

Bronze: 60% coverage, premium is low, out-of-pocket is high Silver: 70% coverage, premium is higher, out-of-pocket is less gold: 80% coverage, premium is high, out-of-pocket is low platinum: 90% coverage, premium is very high, out-of-pocket is very low

Answer 28

- Identify reasons for being insured - Assess the difference health insurance may make versus those without health insurance including access and outcomes and the impact of Medicaid - Identifying underinsurance and knowing insured does not mean guaranteed access - Describe the impact that income and race have on health status

Answer 29

1980-2010: Number of uninsured grew from 25 million to 50 million 2010-2013: States began to enroll more individuals and families into Medicaid 2014: Implementation of ACA private insurance mandates and Medicaid expansion 2014: Decrease of uninsured from 41 million to 26 million 2018: Uninsured has increased again to 28.3 million (healthaffairs.org) 2023: Decreased to 25.3 million (per CDC)

Answer 30

Skyrocketing cost of health insurance -From 2000-2014 premiums rose 160% 2014: average individual plan cost=$6,025; average family plan cost=$16,834 -Shift of employers increasing cost burden to the employee paying 29%-44% in 2014 Economy and workforce of the United States -Decrease in manufacturing and unionized employees -Increase in service sector, part-time employment without health benefits Private insurance linked to employment leads to interruption of coverage -People laid-off or people who leave their job -Divorce or death of spouse that carries insurance -Consolidated Omnibus Budget Reconciliation Act (COBRA) allows those who leave job to continue coverage but are responsible for the full payment of the premium

Answer 31

Family work status family income race/ethnicity

Answer 32

Higher rates hypertension Higher rates cervical cancer Lower survival rates for breast cancer Less frequent blood pressure screenings Less frequent Pap Smears and Breast Exams Uncontrolled hypertension, diabetes, and cholesterol (= Metabolic Syndrome)

Answer 33

Better self-reported health Improved depression scores Increased use of preventative services Less financial stress Note: Having Medicaid did not increase the control of hypertension or diabetes

Answer 34

pharmacy copays for drugs covered by mass health, including both first time prescriptions and refills $1 for certain generic drugs $3.65 for each prescription and refills for the generic, brand name and OTC meds covered by masshealth a copay cap is the highest dollar amount that a person can be charged in copays for a given time period there is a cap for mass health-- no more than 2% of your monthly household income each month

Answer 35

problems paying medical bills

Answer 36

needed health care and meds

Answer 37

financial problems because of medicals bills or delaying care because of cost

Answer 38

Inability to Access: Shortage of Primary Care Providers; lack of after hours appointments Language barriers: Miscommunication, no understanding Health literacy: Forms that need to be filled out can be difficult Cultural barriers: Beliefs, values, and attitudes vary among patients and providers Gender: Women’s health services, scope of coverage/essential health benefits

Answer 39

Review who is uninsured and why there are still issues with uninsured. Recognize the impact of health insurance on health outcomes. Some with insurance are underinsured, be able to compare that with insured and uninsured. Describe the impact of income and race on health status.

Answer 40

Can be placed on a continuum ranging from simplest to the most complex methods Definitions of methods of payment important to know

Answer 41

A fee is paid for each service provided (office visit, diagnostic test, medication) The only form of payment based on each individual unit or component of health care provided No aggregation or grouping together of services into one unit of payment The fee may be paid by the patient or the private insurance company

Answer 42

Fee-for-service Episode of illness Capitation Payment for time (Salary)

Answer 43

Loose-knit organizations where insurers contract with a limited number of providers and hospitals forming a network Agreement is to care for patients on a discounted fee-for-service basis making use of utilization review The insurer authorizes or denies payment (prior authorization) deemed unnecessary or expensive Patients pay a higher share of the cost if they utilize providers or hospitals outside of the network

Answer 44

Physicians have an economic incentive to perform more services to bring in more payment Not seen often with physicians or hospitals

Answer 45

Risk – the potential to lose money, earn less money or spend more time without compensation for services

Answer 46

One sum is paid for all services delivered during one illness Uses bundling together of payments referred to as payment at the unit of the case or episode May lead to economic incentive for providers (surgeons, obstetricians) to limit the number of postop visits since they do not receive additional payment BUT may give incentive to perform more surgeries or see more patients The more services aggregated into one payment, the larger the share of financial risk shifted from the payer to the provider

Answer 47

Payment per patient Monthly payments made to physician or group for each patient that receives care from them Explicitly defines in advance the amount of money available to care for each enrollee Shifts financial risk from insurers to providers Carve-outs: reintroducing fee-for-service payments for specific services not covered by the capitation coverage: --Specific diagnostic testing --Specific surgical procedures --Non-formulary medications based on a patient not illness if extra lab tests or services are required outside of what the insurance has paid the provider, then the provider will have to pay hospital bills insurance and insurance covers a set amount, anything above the set amount will be paid for by the provider

Answer 48

utilized for patients with serious illness that require more services than what is standard Provides higher monthly payments for elderly patients and those with chronic illnesses Often difficult to determine who (patient or insurance company) requires the higher monthly capitation payment

Answer 49

Patients required to register with a physician or group practice Allows more flexibility at the practice level in how to most effectively and efficiently organize and deliver services Provides framework for rational allocation of resources and development of better methods of service delivery Allows for continuity of care

Answer 50

Two-tiered structure-- Payments are paid directly to primary care physicians and referral services Three-tiered structure-- --An intermediary administrative structure is utilized for processing payments --Physicians join an independent practice association (IPA) and are paid on a fee-for-service basis from a pool of money (risk pool) --At the end of the year money left over in the risk pool is distributed as bonuses to the physicians --Provides incentive for judicious utilization of diagnostic and specialty services

Answer 51

Physicians in the public sector (municipal, VA, state facilities) are often paid an annual salary Also utilized in HMO’s (more to come) Physicians paid by salary bear little to no individual financial risk

Answer 52

Fee-for-service Per Diem Payment per episode of hospitalization (Diagnosis-related groups) Capitation Global budget

Answer 53

All services are itemized during a hospital stay The itemized bill containing reasonable costs is sent to private and public payers for reimbursement Allowed hospitals to have great influence in determining level of payment With increased concerns with cost containment for payers methods of payment have shifted away from fee-for-service Financial risk leans towards the payers

Answer 54

Insurers and Medicaid plans contract with hospitals for per diem payments rather than fee-for-service The hospital receives a lump sum for each day the patient is in the hospital Per diem payments represent a bundling of all services provided Insurers may perform utilization reviews of charts to verify that patients need to be in the hospital Length of stay is monitored closely Where does the risk lie?- with insurer

Answer 55

The insurer is at risk for the number of days a patient stays in the hospital because they pay by the day The services delivered in a day is a fiscal concern (risk) to the hospital More days in the hospital equals more money the insurer is billed for Risk is shared between the insurance and provider insurance pays per diem (pays per day to day basis) hospital using their services paying for however long the patient is in hospital

Answer 56

DRG payments lump together all services performed during one hospital episode The episode under the DRG system refers only to the portion of the illness spent in the acute care hospital The amount of the payment is dependent on the patient's diagnosis The insurer or Medicare program is at risk for the number of hospital admissions The hospital is at risk for the length of stay and the resources used during the hospital stay risk on hospital, lump sum payment for illness. just like per episode of illness insurance pays set amount and if hospital wants the patient to stay for extra tests and services then the hospital will have to pay

Answer 57

Hospitals conduct internal utilization reviews to reduce the costs incurred Hospitals closely monitor the length of stay Risk?- hospital depends on payments or services if the diagnosis is more than what the insurance is set to over then the hospital/provider will have to pay for the services that will be used for the progressing diagnosis

Answer 58

Admissions Length of stay Resources used Hospitals bear all of the risk and the insurer bears no risk Capitation payment to hospitals is uncommon in the United States

Answer 59

Used in large integrated health delivery systems What is an integrated heath delivery system? What are some examples of integrated health delivery systems? The hospital is entirely at risk no matter how many patients are admitted and how many services are provided Hospital needs to stay within its fixed budget This is the most extensive bundling of services Every service given to every patient during 1 year is aggregated into one payment

Answer 60

Used by Veterans’ Health Administration, Department of Defense hospitals Standard payment method in more socialized healthcare systems

Answer 61

The National Commission on Physician Payment Reform (2013) called for reform of physician payment and elimination of fee-for-service payment Favors payment that rewards value rather than volume of services and patient care

Answer 62

Pay-for-performance Bundled payments Care coordination payments Accountable care organizations

Answer 63

Involves paying not only for units of service but for quality in the delivery of those services (measures outcomes) Public and private insurers supplement basic payment methods with bonus payments based on their achievement of a specified high level of performance on certain measures --Preventive care --Diabetes care --Patient satisfaction --Cost reduction

Answer 64

Seen under Medicare payment reform Bundling of units using episode-based rather than fee-for-service reimbursement Physician and hospital payments are all bundled together into one single payment Provides incentive for the staff to collaborate to eliminate unnecessary costs Places the hospital and physician at financial risk for post-op care expenses (shared risk)

Answer 65

Medicare and some private insurers pay primary care practices through a blended model Adds a small capitation payment to the fee-for-service payment May provide resources and incentives for better management of patients with chronic conditions

Answer 66

While retaining other payment methods, ACOs create an overall budget target Puts physicians and hospitals at financial risk for overall expenditures ACOs create an overall budget target Allows physicians and hospitals to retain a larger share of the upside risk if they are willing to assume some of the downside risk and pay money back if total costs exceed a target threshold (shared risk) Provides incentive for all providers to collaborate in elimination of wasteful healthcare spending

Answer 67

Community Rated premiums are calculated based on everyone's medical claims within a community (or risk pool) Experience Rated premiums are calculated based on each individual's claims history.

Answer 68

the amount you pay for health care services before your health insurance begins to pay. How it works: If your plan's deductible is $1,500, you'll pay 100 percent of eligible healthcare expenses until the bills total $1,500. health insurance will be paid if the bill exceeds $1,500 so if your deductible was $1,000 you would pay $1,000 and the insurance will pay $500

Answer 69

On LTC delivery

Answer 70

Health, social, housing, transportation, and other supportive services needed by persons with physical, mental or cognitive limitations

Answer 71

activities of daily living (ADL) Instrumental activities of daily living (IADL)

Answer 72

they are basic human functions such as - feeding -dressing -bathing or showering -getting to and from the toilet and caring for incontinence -Getting in and out of a bed or chair

Answer 73

activities necessary to remain independent -Doing housework and laundry -Preparing meals -Shopping for groceries -Using transportation -Managing finances -Making and keeping appointments -Taking medications

Answer 74

52% long term services and support

Answer 75

no, it does not Medicaid only helps if one meets specific requirements

Answer 76

Direct out-of-pocket payments by patients finance 15% of the $236.15 billion on LTC in the US

Answer 77

about 21% of the time

Answer 78

Skilled care: services required by registered nurses (nursing facility, hospital, home care service), physical therapists, occupational therapists, and speech therapists

Answer 79

Custodial care: assist with ADL/IADL rather than treat a condition or provide rehabilitation

Answer 80

Only pay for a short duration: -100% for 20 days -Any cost exceeding $167.50 from days 21 to 100

Answer 81

Part A will pay for skilled nursing care in certain situations -prior hospital stay of at least 3 days -Admitted to nursing facility within 30 days of hospital stay -Require physical therapy or skilled nursing

Answer 82

-Medicaid finances 40% of long-term care -Must first spend down savings and assets -Will assess available funds up to five years prior to application -Will cover complete care in a nursing home -May NOT for home 24-hour care

Answer 83

MassHealth Standard (Individual) -Monthly income at or below $1,133* -Assets at or below $2,000 Before Medicaid assists with coverage, will require patients and family spend down their assets until they qualify for Medicaid “5-year lookback” -State will review any gift within 5 years preceding the date of Medicaid application -Gifts added together result in a penalty disqualification period basically, be poor to have access

Answer 84

patient needs LTC but because they do not have enough money, they cannot afford the care that they need so they die due to inadequate care

Answer 85

Minor role in LTC The largest market is the elderly --Experience-rated --Pay more because are at high risk of needing LTC Premiums have increased up to 90% since 2010 --Generally considered a poor investment

Answer 86

Informal caregivers - Over 66 million people serve as unpaid caregivers -The majority are women over the age of 60 (wives, daughters) Struggle with job loss (40%) cause they can't keep a job due to caring for family members and depression (70%) because they see their loved one suffering

Answer 87

Home care Adult daycare Hospice Mental health care Assisted Living Nursing homes - wide variation in quality -Nurse aids provide much care to keep costs down

Answer 88

- simplify/consolidate med -deprescribe - pill packs and calendar: helps manage complexities

Answer 89

Medication packaging and delivery services Work with assisted living facilities to provide pharmacy services for patients --Medication management --May be contracted with / required for a long-term care facility Examples in MA: --Eaton Apothecary --Greater Boston Long-Term Care Pharmacy --Prescott Pharmacy LTC

Answer 90

Role of social security and taxes --Fund Medicaid programs Social insurance to finance LTC Shift care from nursing home to community by improving funding (want patients to stay home) Train and support family Expand the number of comprehensive acute and LTC organizations

Answer 91

into primary secondary tertiary care

Answer 92

The right patient receives The right health care services At the right time In the right place By the right caregiver

Answer 93

-Dawson model of regionalized heath care -A free-flowing model US health care as a whole follows the more dispersed for format

Answer 94

care that addresses common health problems and preventive measures (acute minor illnesses, well visits, and preventive care) – account for 80 – 90% of visits to a physician or caregiver ooohhhh PCP: primary care provider

Answer 95

addresses health issues that require more specialized clinical expertise such as hospital care for acute renal failure, routine surgeries go to see a specialist

Answer 96

at the apex of the organizational pyramid involves the management of rare disorders: congenital malformations, and complex chronic diseases

Answer 97

yes It is a highly structured system Based on a regionalization concept: The organization and coordination of all health resources and services within a defined area

Answer 98

need to understand the British National Health Service in order to compare it to the United States

Answer 99

yes it is a regionalized model yes it is organized health care

Answer 100

: general practitioners (GP) practicing in small to medium sized groups, main responsibility is ambulatory care, accounts for about 50% of all physicians specialists in internal medicine, pediatrics, neuro, psych, OB/GYN, general surgery. Located at hospital-based clinics, consult on referrals from GP. Physicians also provide care to hospitalized patients in their specialty subspecialists (cardiac surgeons, immunologists, pediatric hematologists) located at a few tertiary care medical centers

Answer 101

yes Hospital model the same as physician model Patient care moves in a stepwise process across the different tiers GPs work closely with practice nurses, home health visitors, public health nurses and midwives utilizes teamwork, accountability, a defined population of enrolled patients, universal health care coverage

Answer 102

The dispersed model A far less structured approach to levels of care Insured patients traditionally able to refer themselves and enter the system directly at any level Many take their symptoms directly to a specialist of their choice Approach to primary care has been to broaden the role of internists and pediatricians, family medicine

Answer 103

PCPs, both adult and pediatric --are in secondary care positions both outpatient and inpatient --they are about 33% of all physicians hospitalists (physicians who exclusively practice within the hospital) mostly use hospital Some physicians at the secondary and tertiary level act as PCP’s also Nurse practitioners and physician assistants more likely to work in primary care settings as providers

Answer 104

Hospitals not constrained by rigid secondary and tertiary care boundaries All hospitals aspire to offer specialized care Rural hospitals lack specialized units Top-heavy specialist and tertiary care orientation (leads to shortage of primary care physicians) Lacks organizational structure

Answer 105

-Describe models of organizing care Primary, Secondary and Tertiary Care -Compare the regionalized model to the dispersed model Understand the value of primary care in the U.S. Health Care System -Describe the Patient-Centered Medical Home: a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal of obtaining maximal health outcomes. -Identify forces driving the organization of health care in the U.S. The Biomedical Model Financial incentives Professionalism

Answer 106

that we do not have to go over primary care (PCP (NP, PA etc) to see a secondary or tertiary provider that patient would not need anything beyond primary care you can think of a PCP as a gatekeeper who manages chronic problems such as dyslipidemia, HTN, and diabetes--these can be easily managed with meds and easily solved

Answer 107

public health nurses, midwives etc as a team to ensure quality patient care

Answer 108

sees pediatrics, adults, and seniors within the scope of family ---mom, dad, and baby may have the same provider The pediatrician is a primary care provider in U.S healthcare

Answer 109

can provide secondary care PCP makes less money than specialists so not a lot of people do it--because the U.S. HealthSystem is top-heavy in where the money goes (more money goes to the secondary and tertiary systems) Rural hos. Has not a lot of beds do not have as much specialized care and take care of acute care to discharge quickly

Answer 110

Most illnesses or common disorders can be managed by primary care physicians/providers –they need to know when to refer you to someone else! The minority of patients with severe conditions require secondary or tertiary care What percentage of resources should be spent on primary, secondary, and tertiary care?

Answer 111

The first contact is PCP Longitudinally: sustaining a patient-caregiver relationship over; care over a period of time Comprehensiveness: ability to manage a wide range of health care needs Coordination: integrates services delivered by other caregivers through referral and follow-up; they should be aware of other care and coordinate all of that!

Answer 112

Family physicians General internists General pediatricians Nurse practitioners Physician assistants This should lead to a high level of preventive services should want all patients to get physical and high meds compliance

Answer 113

Continuity of care associated with greater patient satisfaction Higher use of preventive services Higher medication compliance Reductions in hospitalizations and emergency room visits Overall lower costs to the healthcare system Better outcomes for those that utilize it appropriately People go to the emergency room and urgent care for ear aches sore throat etc

Answer 114

they are gatekeepers! Help patients navigate the complexities of the healthcare system Advocate on behalf of their patients--The PCP should act as a conduit for ESL and advocate for them Work in partnership with patients to integrate services from secondary and tertiary care providers to avoid duplication of services, enhance patient safety and care for the whole person

Answer 115

Developed to address a perceived crisis The PCP’s ability to meet patient demands for accessible, comprehensive, well-coordinated medical care Gaps in quality in primary care An ever-widening gap between the salaries of PCPs and specialists

Answer 116

The American Academy of Family Physicians American College of Physicians American Academy of Pediatrics American Osteopathic Association

Answer 117

New model primary care Patients are those registered in PCP’s medical home Care is proactive to meet health needs, with or without a visit Care is standardized based on evidence-based guidelines Quality is continuously measured and improved at all times A team of professionals works with patients to coordinate care Tests, consultations, and ED visits are tracked and followed up Interdisciplinary team

Answer 118

The Biomedical Model Focuses on the physical and biological aspects of disease and illness Associated with the diagnosis and treatment of disease The science behind the practice of medicine Evidence-based (been Studied, compared to other treatments, and determined to diagnose and treat)

Answer 119

biomedical model, financial incentives, professionalism Financial Incentives: --The growing differential in payment/salaries between PCPs and specialist physicians --Federal involvement: Changes in Medicare Shifts in the insured Professionalism --Autonomy and authority of health care providers—be a hospitalist who does not have as much autonomy as a PCP practicing in a group

Answer 120

a fence or other obstacle that prevents movement or access.

Answer 121

a public service providing medical care.

Answer 122

those events occurring as a result of an intervention.

Answer 123

you were uninsured for a period of less than three consecutive months during the year.

Answer 124

category that includes health issues that are unique to women, such as menstruation and pregnancy

Answer 125

a measure of how people perceive their health

Answer 126

law in the U.S. that mandates an insurance program gives some employees the ability to continue health insurance coverage after leaving employment.

Answer 127

the application of healthcare measures to prevent diseases

Answer 128

being able to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Answer 129

MassHealth pays providers directly for each covered service received by an eligible MassHealth member

Answer 130

the total allowable remittance for a patient's sequence of care related to a single episode or medical event is predetermined, instead of separate compensation for each service and provider along the way.

Answer 131

is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care

Answer 132

defined based on the principal diagnosis, secondary diagnoses, surgical procedures, age, sex and discharge status of the patients treated. Through DRGs, hospitals can gain an understanding of the patients being treated, the costs incurred and within reasonable limits, the services expected to be required.

Answer 133

providers are paid a fixed amount for treating a patient population over a defined period, instead of being paid for each service piecemea

Answer 134

A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians.

Answer 135

the chance to lose money

Answer 136

programs reward health care providers with incentive payments for the quality of care they give to people with Medicare

Answer 137

groups of clinicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care a designated group of patients.

Answer 138

Primary care is when you consult with your primary care provider. Secondary care is when you see a specialist such as an oncologist or endocrinologist. Tertiary care refers to specialized care in a hospital setting such as dialysis or heart surgery.

Answer 139

the integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region.

Answer 140

people can go to a specialist of their choice without seeing their provider first

Answer 141

an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system.

Answer 142

complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system. PGPs' ability to manage their physician staffing efficiently must be placed in context with the cost and quality of their care.

Answer 143

is a medical insurance group that provides health services for a fixed annual fee.

Answer 144

when physicians work directly for hospitals, rather than in independent practices there should be greater efficiencies through economies of scale, and better quality of care for patients through coordination and information sharing.

Answer 145

to link different parts of the healthcare ecosystem so that patients receive better care. virtual integration doesn't achieve this through acquisition. virtual integration focuses on patient management agreements, provider incentives and information systems.

Answer 146

groups of clinicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care a designated group of patients.

Answer 147

Define prepaid group practice: complex organizations that directly combine prepayment for health care with a comprehensive health care delivery system Describe the evolution of Health Maintenance Organizations Compare vertically and virtually integrated HMO models Understand the role of Accountable Care Organizations Discuss medical homes and medical neighborhoods: are groups of health care providers that work as a team to coordinate care for a group of patients, with the goals of providing high-quality, patient-centered care and reducing costs.

Answer 148

Example: Kaiser Health Plan Attempt to meld the financing and delivery of health care into a single organizational structure Premiums serve to directly purchase in advance (prepaid) health services from a particular system of care Care is delivered by a large group of practitioners working under a common administrative structure or group Currently called health maintenance organizations (HMO)

Answer 149

Kaiser Foundation Health Plan – performs functions of the health insurer Kaiser Foundation Hospitals Corporation – own and administer Kaiser hospitals Shared Board of Directors for Health Plan and Hospital Corporation Permanente medical groups – physician organization providing medical services to Kaiser plan members under a capitated contract

Answer 150

Vertical integration Consolidating under one organizational roof Common ownership of all levels of care from primary to tertiary care Common ownership of the facilities and staff necessary to provide the full spectrum of care Kaiser-Permanente Physicians paid salary Hospitals utilize global budget Regionalized tertiary care services

Answer 151

Often owns and requires members to utilize --Their pharmacies --Their group physician practices --Their hospital(s) --Their home health agencies Often everything is available under one roof (physician, lab, x-ray, pharmacy, specialists)

Answer 152

Easier to organize than prepaid group practices A hospital or insurance company could recruit office-based, fee-for-service physicians practicing in the community into a network Physicians can continue to see their non-HMO patients Physicians can establish contractual relationships with numerous HMO’s and IPA’s

Answer 153

Many groups of physicians and specialists Multiple hospitals Multiple pharmacies Multiple home health agencies

Answer 154

patients did not want to see a limited amount of providers Allows patients to see physicians outside of the network but requires patients to pay a higher share of the cost out of pocket Physicians joining a PPO agree to accept discounted fees hoping that by being listed as a preferred provider they will attract more patients to their practice

Answer 155

Serves as broker/middleman on behalf of physicians Negotiates and administers contracts with HMO’s and other types of health plans

Answer 156

Tighter organizational structure Physicians are employees, do not own their practices Can have contractual agreements with multiple managed care plans and HMO’s Physicians can care for out of network patients

Answer 157

Developed as an alternative to the IPA model Physicians partner with a hospital to jointly contract with health plans for both physician and hospital payment rates Physicians are independent practitioners on the hospital’s medical staff and physicians directly employed by the hospital

Answer 158

Vertical – first generation – staff model HMO (and group model HMO) Virtual – second generation – network HMO – Utilizes IPA, IMG’s, PHO’s

Answer 159

Virtual = contractual links, no brick and mortar, no common ownership Virtual – physicians can see IPA and non-IPA patients

Answer 160

Often use web-based “patient portals” to facilitate communication between physicians and patients Can improve patient satisfaction (patients feel that their physician knows them well) Can be an obstacle to patient satisfaction (fewer choices in where care and services will be covered)

Answer 161

ACO – A provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population The Affordable Care Act authorized Medicare to initiate an ACO program beginning in 2012 The number of ACO’s in the US has risen dramatically since 2010 and is projected to cover 70 million lives by 2020 Span a spectrum of organizational structures

Answer 162

Describes the grouping or bundling of Services Providers Organizations in a health system Contributes to the care of a population of patients

Answer 163

Includes primary, secondary and tertiary care Related services needed by different patients at different times to meet their comprehensive health care needs Provides care that is functionally integrated but not necessarily structurally integrated

Answer 164

Primary care groups Multispecialty groups A unified electronic medical record Interdisciplinary health care teams A quality improvement infrastructure

Answer 165

Explain briefly, an overview of US Health Care and answer, “Why do we need to study U.S Healthcare?: a lot of money is wasted annually, it is a right, it is sometimes unaffordable and because of that people do not have access to it, there are lots of barriers to it Identify the features of health care and all the players: the features are: accessible, affordable, appropriate and high quality (who are the players) Define terminology of key components of health care--terms Begin to formulate an answer as to why insurance is important, or is it?- protects you from unexpected, high medical costs

Answer 166

Identify various models of health care payment/insurance: --out-of-pocket --individual private --employment based private --government financed Discern the variations of health care cost options provided through private insurance -bronze: 60% coverage, low premiums, high out of pocket -silver: 70% coverage, higher premium, low out of pocket -gold: 80% coverage, high premium, low out of pocket -platinum: 90% coverage, very high premium, very low out of pocket the arguments of ratings-Community rating: everyone has the same premium no matter health status, this is how health insurance began, it is difficult to be competitive Experience rating: premium decided on average needs, coal miners, elderly and the sick have higher premiums, began due to competition to bring lower premiums to groups, appears to be discriminatory to some people Build the foundational knowledge of Medicare and Medicaid options, how they are financed and basic eligibility medicare eligibility: -people eligible for social security are enrolled at 65 -under 65, disabled and receiving social security for 24 months -mostly financed by the government medicare part A: covers inpatient services financed by SS Medicare Part B: covers medically necessary preventive services. financed by income taxes, federal taxes, and premiums medicare part C: more health coverage + full prescription coverage, subsidizes premiums medicare part D: prescription drugs medicaid: -poor -mostly financed by the government -young child, pregnant, elderly, disabled Progressive: make more, pay more Regressive: make more, pay less Proportional: make more, pay accordingly; The ratio of payment to income is the same for all income classes

Answer 167

Health insurance premiums are what you pay to have coverage, while out-of-pocket costs like deductibles are what you pay when you need care. Lower premiums are generally tied to a higher deductible. Higher premiums usually mean you have a lower deductible.

Answer 168

Part A provides inpatient/hospital coverage: Skilled nursing facility care. Nursing home care Part B provides outpatient/medical coverage: Part C offers an alternate way to receive your Medicare benefits Part D provides prescription drug coverage.

Answer 169

Identify reasons for being uninsured: -healthcare is expensive: premiums rose 160% -economy and workforce of U.S: more part time employees, less manufacturing and unionized employees -private insurance linked to employment lead to interruption of coverage: laid off or leave job, divorce or death of spouse with insurance, -COBRA: can leave job and be covered but pay more for premiums Assess the difference health insurance may make versus those without health insurance including access and outcomes and the impact of Medicaid -insured: better self reported health, improved depression scores, increased use of preventative services, less stress -uninsured: higher rates of HTN, DM2, TC/HLD, cervical and breast cancer, little to no blood pressure screening, no pap smears and breast exams Identify underinsurance and know insured does not mean guaranteed access - underinsurance: does not have adequate insurance to meet health services needs - insured does not always mean access Describe the impact that income and race have on health status - wealth linked to longevity - lower socioeconomic status people eat worse, smoke and do not exercise - women with care get check ups more - minorities die sooner than white, get diseases less likely to be treated

Answer 170

Physicians: Fee for service- pay for each service provided Episode of Illness- 1 sum payment for 1 illness, the more services aggregated into 1 payment the $ risk for provider Capitation- payment per patient, monthly payment made to physician for each patient, risk on provider Payment per time- Salary; physicians are paid an annual salary, bear little to no $ risk, used in HMOs Hospital: Fee for service- itemized bill from hospital sent to private an public payers for reimbursement, risk on payers Per diem- hospital get slump sum for each day the patient is in hospital, length of stay is monitored closely, risk is with insurer because they pay by day, the more day spent then the risk becomes shared Diagnosis-related groups- lump together all services performed during one hospital episode, insurer at risk for number of hospital visit of patient, hospital also at risk for the services used so risk is shared Capitation- hospital at risk for services used and length of stay, risk all on hospital Global budget- hospital given a budget and need to stay in budget Understand value-based payment and payment reform - Pay-for-performance - Bundled payments - Care coordination payments - Accountable care organizations

Answer 171

Identify the different activities of daily living IADL: Housework, laundry, meals, groceries, transportation, finances, appointments, medications ADL: feeding, dressing, bathing, toilet, bed Understand and describe long term care - consequences of illness, accident and old age - projected increase soon - IADL & ADL needed by a person who cannot provide for themselves - Recognize limitations and pitfalls of the long term care system --Costs: health insurance does not cover and medicaid only covers a little bit, medicare does not cover LTC or custodial services like ADL &I ADL only 21% if needed for skilled care like RN visits, PT visits, OT, ST visits, costs are paid out of pocket most times, medicare part A will cover a short period of LTC --Medicaid: medicaid only covers a little bit if you have no more money and after looking at 5 years preceding date of medicaid application --Impact on family and quality of life: wives an daughter suffer by leaving jobs and having depression Describe the mechanisms to improve long term care - fund medicaid (role of SS and taxes) - shift care from nursing home to community by improving funding - train and support family - expand number of comprehensive acute and LTC organizations

Answer 172

Describe models of organizing care Primary: for common health problems for preventative measures, accounts for most visits to a physician or caregiver Secondary: specialized care like renal failure and routine surgeries Tertiary Care: rare disorders, congenital malformation ties, chronic diseases regionalized model: care provided regionally Dawson model, vertical model, define population receiving care from same group, primary: GP, secondary: ob/gyns, general surgery, etc, can lead to good (builds relationship with caregivers and gets to know them more) or bad patient satisfaction (limited in who they can get care from) the dispersed mode/U.S system: patient refer themselves to caregivers, specialist can act as PCPs, NPs and PAs work in primary care setting Understand the value of primary care in the U.S. Health Care System: preventive measures so good that patient would not need secondary or tertiary care--have a comprehensive knowledge of health to provide, gate keepers to care, able to give referrals and follow ups to connect patient to secondary or tertiary professionals - first contact - Longitudinality - comprehensiveness - coordination Describe the Patient-Centered Medical Home --Developed to address a perceived crisis --The PCP’s ability to meet patient demands for accessible, comprehensive, well-coordinated medical care --Gaps in quality in primary care --An ever-widening gap between salaries of PCP’s and specialists --Patients are those registered in PCP’s medical home --Care is proactive to meet health needs, with or without a visit --Care is standardized based on evidence-based guidelines --Quality is continuously measured and improved Identify forces driving the organization of health care in the U.S. --The Biomedical Model: Focuses on the physical and biological aspects of disease and illness --Financial incentives: specialists make more $ than PCPs, changes in medicare, shifts in the insured --Professionalism: autonomy and authority of heal care providers

Answer 173

IPA (negotiate for doctors to be part of insurance provider) IMG (physicians work for hospital, contracts with HMOs) HMO (prepaid to physicians to provide care) ACO (if we pay for healthcare, it should be high quality) vertical (tightly organized, brick and mortar, less expensive, can have high or low patient satisfaction) virtual (patient can pick whoever they want to see, more expensive, not brick and mortar medical homes (individualistic to patient, tries to limit if patient needs to go to secondary or tertiary care) medical neighborhoods (focused on population health)

Answer 174

Define prepaid group practice: essentially HMOs: Premiums serve to directly purchase in advance (prepaid) health services from a particular system of care Describe the evolution of Health Maintenance Organizations Vertical Integration: - all care under 1 roof - Common ownership of all levels of care from primary to tertiary care under one common ownership - Physicians paid salary - Hospitals utilize global budget - Regionalized tertiary care services - Limits where patients are able to get their health services –can lead to patient dissatisfaction - patients have same care givers which can make them happy Virtual Integration - Easier to organize than prepaid group practices - A hospital or insurance company could recruit office-based, fee-for-service physicians practicing in the community into a network - Physicians can continue to see their non-HMO patients while. In vertical the physicians are prepaid and only see patients that are in the plan - Physicians can establish contractual relationships with numerous HMO’s and IPA’s - Many groups of physicians and specialists, Multiple hospitals, Multiple pharmacies, Multiple home health agencies - patients get a wide variety of options of care - more expensive for patients cause they get more Compare vertically and virtually integrated HMO models--look above Understand the role of Accountable Care Organizations: they ensure that the care that you get is what you pay for; are ppl getting good healthcare and it correctly priced Discuss medical homes and medical neighborhoods - medical homes using interconnected team to follow patients with illness -medical neighborhoods looks at overall patient population

U.S Healthcare terms & lecture--exam 1 Flashcards

here are the terms and lecture info for U.S Healthcare (198 cards)