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US Healthcare System Midterm > Chapter 1-8 > Flashcards

Chapter 1-8 Flashcards

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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
Q

Why has national health insurance not developed in the U.S. ?

A

AMA opposes; values of Americans; unwilling to pay higher taxes for it

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26
Q

Part A of Medicare

A

Hospital insurance; covers hospital care, skilled nursing facility, nursing home, hospice, home health services; through social security taxes

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27
Q

Part B of Medicare

A

Covers physicians bills through government subsidized insurance (general taxes); preventative services also included such as mammograms

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28
Q

Part C of Medicare

A

Coverage; receives a b d of Medicare through MCO

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29
Q

Part D of Medicare

A

Drugs

30
Q

Osteopathic Medicine

A

Practiced by DOs emphasizing musculoskeletal system; stress preventative medicine such as diet and and environment factors

31
Q

Allopathic Medicine

A

MDs; medical treatment as as active intervention to produce a counteracting reaction to neutralize effects of disease

32
Q

What is wrong with our primary care versus specialty care?

A

Maldistribution of primary care

33
Q

Primary care physicians are also known as…

A

Gatekeepers; protects patients from unnecessary procedures by specialists, care for common illnesses less expensive when done by primary

34
Q

HIPAA

A

Patients rights to privacy; strict control on transfer of health data between two entities

35
Q

Why is there a delay in telemedicine?

A

Delay in reimbursement

36
Q

Impact of medical technology

A
  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
Q

Assessment of technology

A
  1. Efficacy- benefit from technology
  2. Safety
  3. Cost-Effectiveness- weighing benefits against costs
38
Q

Benefits of Technology

A

Delivering value, cost-containment, standardized practice protocols

39
Q

Moral Hazard

A

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
Q

A country like Canada will promote…

A

Supply side rationing; restricts availability of expensive medical technology and specialty care; how national health care systems control costs

41
Q

Risk

A

Financial loss from some event

42
Q

Underwriting

A

Systematic technique for evaluating, selecting, classifying and rating risks; determines premium rate for insured/enrollee

43
Q

4 Principles of Insurance

A
  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
Q

Premium

A

Amount charged for insurance coverage ; monthly; shared with employer

45
Q

Deductible

A

Amount insured must pay first before any benefits by plan are payable; paid annually

46
Q

Copayment

A

Amount the insured has to pay out of pocket each time health services are received after the deductible has been paid

47
Q

Group Insurance

A

Obtained through an organization such as employer, union, or professional organization; large number of people will participate; type of private

48
Q

Self insurance

A

Large corporations fund bills on their own by budgeting

49
Q

Individual private insurance

A

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
Q

Managed care plans

A

Offered by HMOs and PPOs; assume risk in exchange for an insurance premium ; monitor utilization

51
Q

High-Deductible Health Plans

A

Low premium costs; consumers have great control over their funds

52
Q

Who does Medicare care for?

A
  1. 65 years and older
  2. Disabled individuals entitled to social security
  3. People who have permanent kidney failure
53
Q

Affordable Care Act

A
  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
Q

Fee for service

A

Charges set by providers; services billed separately; drawback is provider induced demand

55
Q

Package pricing

A

Bundled charges; number of related services included in one price

56
Q

Resource Based Relative Value Scale

A

Method to reimburse physicians according to relative value to each physician service; values based on time, skill, and intensity

57
Q

Reimbursement under Managed Care

A

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
Q

Retrospective Reimbursement

A

Rates set after evaluating costs; providers had no incentives to control costs; cost dependent upon length of stay and cost of services

59
Q

Prospective Reimbusrement

A

Pre-established criteria to determine in advance the amount of reimbursement; incentives cost management; DRG based prospective reimbursement force hospitals to control costs

60
Q

DRGs

A

Diagnosis related groups; approx 500 for most prevalent diagnoses; sets bundled price according to ad,it ting diagnosis; forces hospitals to control costs

61
Q

Mental health

A

Not covered under health insurance due to stigma related

62
Q

Ambulatory Care

A

Consists of diagnostic and therapeutic services and treatments provided to the walking patient

63
Q

Outpatient

A

Refers to any health care services that do not require an overnight stay in an institution

64
Q

Why has their been such a shift between inpatient and outpatient services?

A

Reimbursement, technology, utilization factors, and social factors

65
Q

Secondary Care

A

Short term; sporadic consults from specialist

Ex. Rehab, mammograms, dermatologist

66
Q

Tertiary Care

A

Highly specialized; usually uncommon; surgery ,trauma care

67
Q

Domains of Primary Care

A
  1. Point of entry
  2. Coordination of care
  3. Essential care
  4. Integrated care
  5. Accountability
68
Q

Community-oriented primary Care

A
  • 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
Q

What is the problem with the ACA?

A

Cost 150 billion dollars with 21 million left uninsured

70
Q

What increased hospital beds in the 40s

A

Hill Burton Act

US Healthcare System Midterm (1 decks)

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