Week 1

Question 1

Triple Aim

Answer 1

optimize health system performance by
1. improve pt experience of care
2. improve health of populations
3. reduce cost of health care
Simplified as: Cost, Access, Quality

Question 2

Two different arrangements for birth of modern American insurance

Answer 2

baylor hospital partnership-blue cross

kaiser permanente

Question 3

employer sponsored insurance- fully insured:

Answer 3

employer buys ins from private company, ins company assumes financial risk. profit goes to ins company

Question 4

employer sponsored insurance- self insured

Answer 4

employer contracts w/ private company and acts as payer and assumes risk. profit goes to employer

Question 5

COBRA

Answer 5

allows ppl to retain employer ins for up to 18-36 months following loss of coverage

Question 6

types of public insurance

Answer 6

medicare
medicaid
state children's health insurance program (S-CHIP & CHIP)
indian health services
veterans health administration
tricare

Question 7

non-hospital inpatient facilities

Answer 7

skilled nursing facilities (nursing homes)
long term acute care hospitals (LTACHS)
inpatient rehab facilities

Question 8

what are nursing homes used for

Answer 8

pts who need 24 hour care

Question 9

what are LTACHS used for

Answer 9

pts who need intensive, hospital-level care for weeks or months

Question 10

what are inpatient rehab facilities used for

Answer 10

pts who require rehabilitation, but may not be medically complex

Question 11

define certificate of need (CON)

Answer 11

requires that new facilities need to show there is a need for services before approval

Question 12

three major accreditation agencies in US

Answer 12

1. national committee for quality assurance (NCQA)
2. the joint commission for the accreditation of healthcare organizations (Joint Commission)
3. Utilization review accreditation commission (URAC)

Question 13

what year did medicare and medicaid pass?

Answer 13

1965

Question 14

what was the health maintenance organization act?

Answer 14

req employers with over 25 employees and offering health insurance to include at least one HMO-type plan

Question 15

what did the mental health parity act do?

Answer 15

expanded psychiatric benefits

Question 16

what was the Health Insurance Portability and Accountability Act

Answer 16

protection of health info

Question 17

what was the Medicare Prescription Drug, Improvement, and Modernization Act

Answer 17

created prescription drug coverage through Medicare Part D

Question 18

what was the State Children’s Health Insurance Program

Answer 18

Expansion of Medicaid to low-income children

Question 19

what year was the affordable care act implemented?

Answer 19

2010

Question 20

define a policy

Answer 20

specifies what risks are covered

Question 21

define coverage

Answer 21

risks covered and money paid for losses

Question 22

what is the term used to describe the person who purchases the insurance policy?

Answer 22

subscriber

Question 23

term for other individuals on insurance policy?

Answer 23

dependents

Question 24

what are the two ways that premiums are set?

Answer 24

community rating: all subscribers pay the same monthly premium
underwriting: subscribers charged differently depending on medical care required and personal factors

Question 25

what is cost sharing?

Answer 25

remaining amount the member pays after insurance pays health care provider/facility

Question 26

what factors make-up cost sharing? | the sum of these factors determines what?

Answer 26

deductible copayment coinsurance out of pocket max

Question 27

which source of insurance is the most common type?

Answer 27

employer sponsored insurance

Question 28

COBRA allows someone to stay on insurance for up to 18 months if:

Answer 28

coverage lost due to termination or reduced hours

Question 29

COBRA allows someone to stay on insurance for up to 36 months if:

Answer 29

spouses or dependents who lose coverage due to separation or employee's death