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US Healthcare System Midterm > Chapter 1-8 > Flashcards

Chapter 1-8 Flashcards

1
Q

Managed Care

A
  1. Seeks to achieve efficiency by integrating basic functions of health care delivery
  2. Installs mechanisms to control utilization of medical services
  3. Determines price at which services are purchased and how much providers get paid
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2
Q

Special Populations

A

Vulnerable populations; those with health needs but inadequate resources to address those needs
EX. poor and uninsured, minority or immigrants, economically disadvantaged communities

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3
Q

Medicare

A

Source of public health insurance in U.S.

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4
Q

Medicaid

A

Provides coverage for low income adults, children, elderly, and individuals with disabilities

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5
Q

CHIP

A

Provide insurance for children in uninsured families

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6
Q

Long Term Care

A

Care for individuals who are terminally ill or with disability
EX. nursing home; individualize the person

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7
Q

10 Characteristics of US Healthcare system

A
  1. No central governing agency; little integration and coordination
  2. Technology driven and focus on acute care
  3. High in cost, unequal in access, and average in outcome
  4. Imperfect market conditions (patients don’t have a choice in provider)
  5. Private sector main payer and government fills in gaps
  6. Fusion of market and social justice
  7. Multiple players and balance of power
  8. Quest for integration and accountability
  9. Access to health care based on insurance coverage
  10. Legal risks influence practice behaviors
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8
Q

U.S. Healthcare system is…

A

Fragmented, complex, and expensive

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9
Q

Defensive Medicine

A

Additional tests, check up appointments, and maintaining abundant documentation

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10
Q

Canada

A

Long waiting lists, controlling supply of technology, national healthcare system

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11
Q

Holistic Medicine

A

Treats individual as a whole person; non traditional

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12
Q

Illness

A

Persons own perceptions and evaluation of how he or she feels

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13
Q

Disease

A

Medical professionals evaluation of person

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14
Q

Acute condition

A

Severe and short in duration, often treatable

Ex. Heart attack

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15
Q

Subacute condition

A

Between acute and chronic, has acute features, may require extended stay in hospital
Ex. Head trauma

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16
Q

Chronic Condition

A

Less sever but long duration, can be kept under control with right treatment

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17
Q

Quality of Life

A

Overall satisfaction with life

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18
Q

4 Determinants of Health

A
  1. Environment
  2. Behavior and Lifestyle
  3. Heredity
  4. Medical Care
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19
Q

Market Justice

A

Healthcare as economic good; free market conditions for health services delivery; production and distribution market based demand; medical care based on people’s ability to pay; access to medical care viewed as personal effort and achievement

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20
Q

Social justice

A

Healthcare as social resource; active government involvement; medical resource allocation determined by central planning; equal access viewed as basic right

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21
Q

What type of justice system does the U.S. Have?

A

Fusion of both;
Market because private insurance and people pay out of pocket
Social because of government involvement with Medicare and Medicaid

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22
Q

Preindustrial era of medicine

A

No medical training; lot of competition because any tradesman could practice; people paid out of pocket; free market; hospitals had poor sanitation; barbers use to cut hair and do surgery; rural areas/farmers

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23
Q

Post industrial era of medicine

A

Development and growth of medical profession, hospitals; emergence of private insurance; creation of Medicare and Medicaid

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24
Q

Flexnor Report

A

Inspection of medical schools; found inconsistencies; work with AMA ; raised standards even more competitive

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25
Why has national health insurance not developed in the U.S. ?
AMA opposes; values of Americans; unwilling to pay higher taxes for it
26
Part A of Medicare
Hospital insurance; covers hospital care, skilled nursing facility, nursing home, hospice, home health services; through social security taxes
27
Part B of Medicare
Covers physicians bills through government subsidized insurance (general taxes); preventative services also included such as mammograms
28
Part C of Medicare
Coverage; receives a b d of Medicare through MCO
29
Part D of Medicare
Drugs
30
Osteopathic Medicine
Practiced by DOs emphasizing musculoskeletal system; stress preventative medicine such as diet and and environment factors
31
Allopathic Medicine
MDs; medical treatment as as active intervention to produce a counteracting reaction to neutralize effects of disease
32
What is wrong with our primary care versus specialty care?
Maldistribution of primary care
33
Primary care physicians are also known as...
Gatekeepers; protects patients from unnecessary procedures by specialists, care for common illnesses less expensive when done by primary
34
HIPAA
Patients rights to privacy; strict control on transfer of health data between two entities
35
Why is there a delay in telemedicine?
Delay in reimbursement
36
Impact of medical technology
1. Quality of Care 2. Quality of Life 3. Health Care Costs (costs high with some technologies) 4. Access 5. Structure and Processes of Delivery 6. Global Medical Practice 7. Bioethics (stem cells cause ethical issues)
37
Assessment of technology
1. Efficacy- benefit from technology 2. Safety 3. Cost-Effectiveness- weighing benefits against costs
38
Benefits of Technology
Delivering value, cost-containment, standardized practice protocols
39
Moral Hazard
Consumer behavior that leads to a higher utilization of health care services when services are covered by insurance; cost sharing promotes more responsible use: co payments, deductibles, and premiums
40
A country like Canada will promote...
Supply side rationing; restricts availability of expensive medical technology and specialty care; how national health care systems control costs
41
Risk
Financial loss from some event
42
Underwriting
Systematic technique for evaluating, selecting, classifying and rating risks; determines premium rate for insured/enrollee
43
4 Principles of Insurance
1. Risk is unpredictable for individual 2. Risk can be predicted with some accuracy for large population 3. Insurance can shift risk from individual to group by pooling resources 4. Losses shared by all members
44
Premium
Amount charged for insurance coverage ; monthly; shared with employer
45
Deductible
Amount insured must pay first before any benefits by plan are payable; paid annually
46
Copayment
Amount the insured has to pay out of pocket each time health services are received after the deductible has been paid
47
Group Insurance
Obtained through an organization such as employer, union, or professional organization; large number of people will participate; type of private
48
Self insurance
Large corporations fund bills on their own by budgeting
49
Individual private insurance
Determines premium price based off of individuals health status; family farmer, early retiree, employee of business that does not offer insurance and self employed
50
Managed care plans
Offered by HMOs and PPOs; assume risk in exchange for an insurance premium ; monitor utilization
51
High-Deductible Health Plans
Low premium costs; consumers have great control over their funds
52
Who does Medicare care for?
1. 65 years and older 2. Disabled individuals entitled to social security 3. People who have permanent kidney failure
53
Affordable Care Act
1. Must have health insurance; tax penalties for not having it 2. 50 or more employees must offer health insurance 3. Medicaid expanded 4. Mandates states to establish health insurance exchanges 5. Tax credit allowed for businesses with fewer than 25 6. Illegal to deny health insurance to people with preexisting medical conditions
54
Fee for service
Charges set by providers; services billed separately; drawback is provider induced demand
55
Package pricing
Bundled charges; number of related services included in one price
56
Resource Based Relative Value Scale
Method to reimburse physicians according to relative value to each physician service; values based on time, skill, and intensity
57
Reimbursement under Managed Care
PPOs use variation of fee for service, fee schedules based on discounts negotiated with providers HMOs have physicians paid salary, capitation also used (monthly fee per enrollee and removes incentive for provider induced demand)
58
Retrospective Reimbursement
Rates set after evaluating costs; providers had no incentives to control costs; cost dependent upon length of stay and cost of services
59
Prospective Reimbusrement
Pre-established criteria to determine in advance the amount of reimbursement; incentives cost management; DRG based prospective reimbursement force hospitals to control costs
60
DRGs
Diagnosis related groups; approx 500 for most prevalent diagnoses; sets bundled price according to ad,it ting diagnosis; forces hospitals to control costs
61
Mental health
Not covered under health insurance due to stigma related
62
Ambulatory Care
Consists of diagnostic and therapeutic services and treatments provided to the walking patient
63
Outpatient
Refers to any health care services that do not require an overnight stay in an institution
64
Why has their been such a shift between inpatient and outpatient services?
Reimbursement, technology, utilization factors, and social factors
65
Secondary Care
Short term; sporadic consults from specialist | Ex. Rehab, mammograms, dermatologist
66
Tertiary Care
Highly specialized; usually uncommon; surgery ,trauma care
67
Domains of Primary Care
1. Point of entry 2. Coordination of care 3. Essential care 4. Integrated care 5. Accountability
68
Community-oriented primary Care
- included people with little control over their own health care and health should be attained from response from community - incorporates good primary care delivery and adds a population based approach to identifying and addressing community health problems
69
What is the problem with the ACA?
Cost 150 billion dollars with 21 million left uninsured
70
What increased hospital beds in the 40s
Hill Burton Act

US Healthcare System Midterm (1 decks)

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