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Health Services > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Are American automatically covered by insurance

A

no

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2
Q

Does a true system of healthcare exist?

A

no

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3
Q

Why do you need to understand the healthcare system?

A
  • be effective as possible in your role in the healthcare system
  • have knowledge about payment systems
  • learn about the diverse needs of patients
  • improve the health outcomes of patients and communities
  • identify strategies to reduce delays and lower costs
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4
Q

As a consumer, what are we paying for?

A

health insurance premium every month

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5
Q

Describe the healthcare spending growth in 2017

A

The healthcare spending growth in 2017 was similar to the average growth rom 2008-2013

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6
Q

How much is the US health care spending per person approximately?

A

10,739$ per person

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7
Q

How much did the federal government and households, private business, and state and local governments account for for shares of spending?

A
  1. federal government and households = 28% each
  2. private business = 20%
  3. state and local government = 17%
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8
Q

Describe the spending for hospital care in 2017 and how it compared to 2016.

A

Spending for hospital care increased 4.6% in 2017 which was slower than the 5.6% growth in 2016

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9
Q

List of stakeholders:

A
  1. providers
  2. inpatient and outpatient facilities
  3. payers, such as insurance companies
  4. government (federal insurance programs; regulations)
  5. patients (self-pay)
  6. suppliers (pharmaceutical companies, medical equipment companies, research and educational facilities)
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10
Q

Providers

A
  • The healthcare industry will continue to experience job growth (aging population and ACA with more individuals insured)
  • Multiple employment settings in public and private sectors
  • Rural areas continue to suffer physicians shortages
  • shortage of nurses nationwide - mostly in the south and west
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11
Q

Hospital systems

A
  1. Public hospitals
    a. receives money from the government; aka teaching hospitals
  2. Non-profit hospitals
    a. Provides services to the community - often charity (Mercy)
  3. Private hospitals
    a. owned by private investors
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12
Q

Outpatient services

A

The preferred method of receiving care.

  • in 2015, there was over 900 million visits to doctor’s offices
  • outpatient imaging centers, outpatient surgical centers, and outpatient therapy services
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13
Q

Payers (insurance companies)

A
  1. Private Payers (private insurance companies)
    a. Managed Care Organizations (MCO); Health Maintenance Organizations (HMO)
  2. Public Payers (federal insurance programs
    a. (medicare, medicaid, CHIP, VA (tri-care))
  3. Employee Sponsored Health Insurance
  4. Self-Pay
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14
Q

Access to Health Services

A
  1. Coverage
    a. health insurance, underinsured
  2. Services
    a. primary care provider, dentist, surgery, specialty clinics, therapy services)
  3. Timeliness
    a. onset of symptoms and seeing provider
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15
Q

Access to health services: barriers

A
  • cost
  • inadequate or no insurance coverage
  • lack of availability services
  • lack of culturally competent care
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16
Q

Access to health services: Consequences

A
  • unmet healthcare needs
  • delays in receiving appropriate care
  • inability to get preventative services
  • financial burdens
  • preventable hospitalizations
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17
Q

Health information Technology

A

Computerization of doc./charting

  • electronic patient record (EMR, EHR)
  • E-prescribing
  • E-health
  • Telemedicine
  • Remote patient monitoring
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18
Q

Describe the adoption of EHR

A

By year 2015, 80.5% of hospitals adopted at least a basic EHR system - Critical Access Hospitals (CAH) lagging behind

Reason: financial incentives from Medicare and Medicaid

Barriers: ongoing costs, obtaining physician cooperation, and up-front costs

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19
Q

Ethics

A
  • bioethics
  • patient right and responsibilities
  • advance directives
  • DNR orders
  • Licensure and Credentialing
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20
Q

Trends and Directions in the Health System

A

illness –> wellness
acute care –> primary care
inpatient –> outpatient
individual health –> community well-being
fragmented care –> managed care
independent institutions –> integrated systems
service duplication –> continuum of service

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21
Q

Prior to 1800, medicine in the US was referred to as a…?

A

“family affair”

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22
Q

When and where did the first medical college open?

A

1765 - University of Pennsylvania

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23
Q

When did private insurance emerge?

A

Private insurance emerged prior to WW1, but Blue Cross was est. toward the end of the 1920s

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24
Q

American Hospital Association (AHA) began supporting…

A

group hospitalization plans

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25
Q

Explain the medical plan that started during WW2

A

started by Henry J. Kaiser which featured a pre-paid program that paved the way for HMOs 40 years later

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26
Q

Timeline of major events: 1934-1939

A

NHI and the New Deal

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27
Q

Timeline of major events: 1945-1950

A

NHI and the Fair Deal

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28
Q

Timeline of major events: 1960-1965

A

Medicare and Medicaid

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29
Q

Timeline of major events: 1976-1979

A

Cost-containment

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30
Q

Timeline of major events: 1992-1994

A

The Health Security Act

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31
Q

Timeline of major events: 2010 - Present

A

Patient protection and affordable care act

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32
Q

1934-1939: NHI and the New Deal

A

The Great Depression (1929-1939)

  • Calling for government relief
  • Elements of reform – state-run system with compulsory health insurance for state residents; expanding hospitals, public health, and maternal and child services
  • Strong opposition from AMA citing that physicians would lose autonomy
  • Social Security Act passed in 1935 – only provided matching funds but no national health insurance
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33
Q

1945-1950: NHI and the Fair Deal

A
  • During WW II, the War Labor Board ruled in 1943 that health insurance coverage should be excluded from the period’s wage and price controls
  • After WW II ended, President Truman called upon Congress to pass a national program to ensure the right to medical care
  • Proposed national health insurance but was defeated
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34
Q

1960-1965: Medicare and Medicaid

A
  • Productivity expanded, as well as the middle class, with a well-educated workforce as a result of the G.I. Bill post WW II
  • Increasing use of private insurance plans, but the elderly and the poor became of the focus of health care reform
  • Medicare and Medicaid were incorporated into the Social Security Act, signed by President Lyndon Johnson, in 1965
  • Health care costs increased the federal budget substantially
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35
Q

Medicare and Medicaid Milestones: 1972

A

Medicare eligibility was extended to individuals with long-term disabilities and to individuals with end-stage renal disease (ESRD)

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36
Q

Medicare and Medicaid Milestones: 1986

A

The Emergency Medical Treatment and Labor Act (EMTALA) required hospitals participating in Medicare that offer emergency services to provide stabilizing treatments

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37
Q

Medicare and Medicaid Milestones: 1997

A

The Balanced Budget Act of 1997 created the Children’s Health Insurance Program (CHIP)

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38
Q

Medicare and Medicaid Milestones: 2003

A

Medicare Prescription Drug, Improvement and Modernization Act: Created Part D prescription drug program

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39
Q

1976-1979: Cost-Containment Trumps NHI

A
  • President Ford withdrew NHI for fear of worsening inflation
  • Carter pledged as presidential candidate to support a comprehensive NHI plan
  • National health insurance was not a priority so defeated once again in the face of economic recession, inflation, and uncontrollable health care costs
  • Priority was on cost-containment
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40
Q

1992-1994: The Health Security Act

A
  • Federal debt reached record levels – the Federal Reserve Board succeeded in acting to control inflation, unemployment decreased, but health care costs continued to escalate rapidly
  • Fundamental health care reform needed
  • President Clinton proposed universal coverage, employer and individual mandates, competition between private insurers, and regulated by government to keep costs down
  • Once again, proposal defeated but bipartisan support for the Children’s Health Insurance Program (CHIP) in 1997
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41
Q

Affordable Care Act

A

Signed into law on March 23, 2010.

  • On June 28, 2012, the Supreme Court rendered the final decision to uphold the law.
  • put in place comprehensive health insurance plans
  • working to make healthcare more affordable, accessible, and of higher quality
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42
Q

Who was the Affordable Care Act available to

A

Available to previously insured Americans, and Americans who had insurance which didn’t provide them adequate coverage and security

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43
Q

medicaid work requirements

A

January 2018, CMS issued new guidance for state Medicaid waiver proposals
- As of January 9, 2019, seven states have approved the waivers; 9 others pending

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44
Q

Purpose of medicaid work requirements

A

Meant to help enrollees find jobs

ex. in Arkansas, everyone enrolled in Medicaid has to document work hours through state online portal

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45
Q

medicaid work requirement findings:

A
  • Low-income may lose their health coverage
  • Most people currently on Medicaid already work, go to school, have a disability, or are the primary caregiver for relatives
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46
Q

Why was the ACA again under assault by 20 republican states in 2018?

A

by asking the courts to rule the entire ACA unconstitutional

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47
Q

Describe the enrollment in health care exchanges in 2018

A

Enrollment in the health care exchanges just 4% lower than 2017

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48
Q

What was the proposed rule by HHS in 2018?

A

To test a new payment model to substantially lower the cost of prescription drugs

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49
Q

What did private companies such as Amazon, Berkshire Hathaway and J.P. Morgan Chase announce in 2018

A

announced the intent to form independent nonprofit health care company

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50
Q

What was the trend in 2018 of the growth in health care spending?

A

growth in healthcare spending slows.

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51
Q

PPACA stands for

A

Patient protection and affordable care act

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52
Q

When was the PPACA signed into law

A

March 23, 2010. Put in place comprehensive health insurance reforms - the first time since 1965

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53
Q

What happened following the 2010 mid-term elections?

A

The republicans gained control of the House of Representatives and voted 245-189 to repeal the ACA but on January of 2011, the repeal failed in the Democratic-controlled senate in a party-line vote. On June 28, 2012, the Supreme court rendered the final decision to uphold the law

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54
Q

By 2014, most American’s would be required to what?

A

Most Americans would be required to carry a minimum level of health insurance or pay a penalty (individual mandate)

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55
Q

State had until what year to create health insurance exchanges?

A

2014

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56
Q

In 2014, eligibility requirements for Medicaid would be revised to cover what?

A

to cover anyone earning less than 133 percent of the poverty level (Medicaid expansion)
- 133% = minimum threshold for adults but children is much higher because they want to make sure children are covered

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57
Q

Businesses with how many workers would be assessed a penalty starting in 2014 if they did not offer benefits?

A

50 or more

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58
Q

Federal funds could not be used for abortions except in what cases?

A

rape, incest or when the mother’s life was endangered

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59
Q

Illegal immigrants would not be able to buy what?

A

insurance from subsidized exchanges – even if they paid the full cost themselves

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60
Q

Based on predictions by the Congressional Budget Office (CBO), the legislation would extend coverage to…?

A

32 million Americans by 2019

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61
Q

Coverage of the Federal Health Insurance Exchange

A

October 1, 2013 - first exchanged opened

8 million people enrolled during the first open enrollment period

Subsidies provided to allow low-income individuals to purchase health insurance

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62
Q

After the establishment of the ACA, how many people gained health coverage?

A

more then 20 million people; about half of the increase reflects gains in private coverage due to subsidies.

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63
Q

As the ACA took effect, Uninsured rates fell dramatically for

A

low income, all age groups, all race, ethnicity, all levels of education (almost all demographic groups)

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64
Q

Texas v. U.S. Decision

A

On December 14, 2018, a federal judge rules that the ACA’s individual mandate is unconstitutional and that the entire law should be struck down as a result.

On July 2019, Texas will ask a federal appeals court in New Orleans to end the law in its entirety, without offering a replacement plan

Currently, waiting on decision from the U.S. 5th Circuit Court of Appeals on whether the law should stand

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65
Q

Steps in Accessing Health Services

A
  1. Gaining entry into the health care system (usually through insurance coverage)
  2. Accessing a location where needed health care services are provided (geographic availability)
  3. Finding a health care provider whom the patient trusts and can communicate with (personal relationship)
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66
Q

Barriers in Accessing Health Services

A
  1. High cost of care
    a. premium, copay, deductibles
  2. Inadequate or no insurance coverage
    a. situational changes, eligibility issues, 5-year waiting period for immigrants
  3. Lack of availability services
  4. Lack of culturally competent care
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67
Q

What is the percent of adults who reported delaying or going without care due to costs (2016)

A

27%; those who delayed care or did not get care resulted in worse health

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68
Q

Trends over time of the insured vs. the uninsured

A

The insured – not a lot of fluctuation

Insured – more fluctuation

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69
Q

Uninsured Population – Key Facts (4)

A
  1. 20 million gained insurance coverage through the ACA – but in 2017, the number of uninsured increased by more than .5 million
  2. Many people remain uninsured due to high cost of insurance, not having insurance through employer, and not knowing how to navigate exchanges
  3. The uninsured are mostly low-income families and have at least one worker in the family (higher risk: adults and people of color)
  4. Lack of access and medical debt
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70
Q

Insurance coverage gains particularly large among what groups?

A

Coverage gains particularly large among adults and poor

and low-income individuals, Hispanics

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71
Q

Considering people living in the US, most of the uninsured are what percentages?

A 
US citizens (75%)
Non-citizens (25%)
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72
Q

Individuals living in non-expansion
states most likely to
be _____.

A

uninsured

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73
Q

Consequences of Being Uninsured

A
  1. Less likely to receive preventive care and services for major health conditions
  2. Do not obtain the treatments that their health care providers recommended; end up paying a fortune or not doing it at all
  3. More likely to be hospitalized for avoidable health problems because they didn’t get their preventative care
  4. Safety net providers have limited resources and service capacity
    a. public hospitals
    b. Community health centers
    c. free clinics
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74
Q

net providers

A

where people don’t have insurance/under insured go when they need care

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75
Q

Both farm and rural populations experience lower access to health care along what dimensions?

A

Along the dimensions of affordability, proximity, and quality, compared with their non-farm and urban counterparts.

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76
Q

Rural residents: to have quality health care access

A
  • Financial means to pay for services
  • Health literacy
  • Confidence in quality of care
  • Means to reach and use services
  • Privacy
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77
Q

What is considered urbanized, urbanized cluster, and rural

A

Urbanized = 50,000 or more

Urbanized Cluster = at least 25 hundred up to 50,000

Rural = below 25,000

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78
Q

Barriers to Access in Rural populations

A
  1. Structural
    a. The number, type, concentration, location, and original configuration of providers (often predicted by the health care financing system)
    - health care plan or provider refuses care
    - inadequate supply of providers
    - prolonged waiting times
  2. Financial
    a. The cost of care to individuals and families, including the presence and type of health insurance coverage (includes consideration of the underinsured)
    - uninsured cannot afford care
    - underinsured cannot afford co-pay or deductible
    - absent coverage for certain conditions
  3. Personal and Cultural
    a. A set of either explicit or implicit rules that determine the behavior of social subjects in relations to their health
    - unable to travel to care
    - unable to communicate to providers
    - disrespectful provider behavior
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79
Q

Causes and consequences to barriers to access to care in the rural populations

A
  1. Rural hospitals close at a higher rate than urban hospitals
  2. Losing hospitals creates a “domino effect”
  3. For those underinsured, usually delinquent in paying providers
  4. Small businesses are at a disadvantage
  5. Health is affected
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80
Q

Estimated in 2017, almost what percentage of veterans are aged 65+

A

50%

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81
Q

Large cohort of younger veterans have registered for VA healthcare over the past 10 years come from what organizations?

A

Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND)

82
Q

Compared to age-matched Americans, veterans enrolled in VA what?

A

poorer and have more complex medical conditions

83
Q

Veteran population projections

A

overall veteran population will decline, increase in female veteran population, increase in minority veteran population

84
Q

How many of the recent enrollees in VA had a mental health diagnosis?

A

more than half

85
Q

What injury is more prevalent in the younger cohorts of the VA?

A

traumatic brain injury (TBI)

86
Q

approaches to rehabilitation of combat-related injuries include:

A
  • Systematic screening for TBI
  • Incorporation of features of the patient-centered medical home model to include mental health services
  • Integrated electronic medical record system
  • Encourage family support in the form of informal caregiving
87
Q

Where are many veterans treated?

A

in the community as well as military health facilities

88
Q

Moral injury

A

“the lasting psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”

89
Q

VA Program to Address Homelessness (2009)

A

Systemic screening for homelessness, creation of multiple portals through which veterans can access services, housing first policies, and community partnerships

90
Q

Youtube video: VA Pathways from Homelessness this video will have a short answer on the exam –> what were the different types of programs and services for veterans

A

veterans outreach program, emergency shelters, GI bill, home loans (to get ppl housed), working with community people to help get people jobs (Eddie got job at coffee shop)

91
Q

What are some innovations that could be integrated to better improve the healthcare to veterans

A
  1. Patient Centered Medical Home (PCMH) model
  2. Integrated primary and mental health
  3. Telehealth programs
  4. Integrating chaplains into the healthcare team
  5. Enhancing the delivery of programs designed to prevent chronic illness
  6. Legislation (Choice Act; VA MISSION Act of 2018)
92
Q

highest number of homeless are in what states

A

California, New York, Oregon, Hawaii

93
Q

What factors might contribute to homelessness

A

Disability, simply not enough money, living in poverty, substance abuse, mental health issues, divorce, breakup, domestic abuse, losing a job,

94
Q

3 different categories of homeless

A
  1. Chronically homeless (older indiv, the ones sleeping under the bridge, ped mall, etc.)
  2. Transitional homeless (more younger people, lost job, domestic abuse)
  3. Episodic (younger generation, teenagers, early 20s, trouble with delinquency, substance use issues, couch surfers, overstay welcome, parents kick them out, can be a pattern)
95
Q

point in time count

A

where you count the homeless

96
Q

Total number of people experiencing homelessness per year: trends

A
  1. Veterans homelessness has dropped by 38%
  2. People in families has decreased by 23%
  3. chronic homeless decreased by 19%
97
Q

Health disparities exist among the homeless population

A
  • severe and persistent mental illness
  • substance abuse
  • depression
  • communicable disease
  • temperature related illness
  • chronic disease
98
Q

There is an increased risk of suicide among homeless population by how much?

A

10x higher

99
Q

What is the percentage of homeless teens that struggle with depression?

A

40%; 12 percent higher than housed peers

100
Q

LGBTQ youth experiencing homelessness are how much as likely to commit suicide than heterosexual youth who are homeless?

A

twice as likely to commit suicide

101
Q

Case study - Suitcase Clinics

A

Uses the principles of community-based participatory research (CBPR)

  • Direct service, advocacy, and community engagement
  • Formation of a “healthcare for the homeless” coalition
  • Targeted needs assessment (windshield tours and direct observation)
  • Suitcase clinics held at five local shelters staffed by volunteer providers, nursing case manager, and numerous volunteers
102
Q

Most prevalent diseases found during the suitcase clinics

A

hypertension, diabetes, COPD or asthma

103
Q

Refugee

A

someone who is in fear of being persecuted, is outside the country of his/her nationality, and is unwilling to avail him/herself to the protection of that country

104
Q

How do refugees poses a challenge to the countries they go to?

A

Poses a challenge to host countries to provide access to health services

105
Q

What is the worldwide displacement level of refugees

A

Worldwide displacement is at the highest level ever recorded (59.5 million)

106
Q

Health concerns for refugees

A
  • mental health
  • chronic disease
  • physical problems and disabilities
  • malnutrition and anemia
  • complicates the delivery of maternal obstetric care
107
Q

Ethical concerns for refugees

A
  • medical screening only
  • Asylum seekers have restricted access to health care (emergency medical care, pregnancy and childbirth care, immunizations)
  • Many host countries often impose waiting periods
  • According to the Organization for Economic Cooperation and Development (OECD), access to health care services is conditional on confinement in detention facilities
108
Q

Improving Access to Health Services for refugees

A
  • should be a fundamental human right
  • donor countries should support efforts to improve access to secure essential health-care services
  • Greater efforts needed to strengthen the resilience of health systems to foster equity and efficiency in refugee health
109
Q

A high overall ranking indicates _____ prevalence

of mental illness and _____ rates of access to care. What is Iowa ranked

A

lower; higher
Iowa ranked 6th
Massachusetts ranked #1
Nevada ranked #51

110
Q

How can we ENSURE access to quality healthcare

A
  1. Addressing the social determinants of health
  2. Adopting new and innovative virtual care strategies
  3. Designing global budgets
  4. Using inpatient/outpatient transformation strategy
111
Q

Nurses

A

The largest group of healthcare professionals

  • Registered nurses (RN)
  • Licensed Practical Nurses (LPN)
  • Certified nursing assistant (CNA)
112
Q

Projections indicate there will be a deficit of how many nurses by 2030?

A

918,232

113
Q

What comprise the largest group in nursing occupations?

A

registered nurses

114
Q

Trends in the nursing workforce of the US

A
  • older RNs over 50 comprised 44.7% pf the total population up from 33% (2000)
  • increasing percentage of internationally educated nurses
  • Racial/ethnic minority representation increased
115
Q

Employment settings of registered nurses

A 
#1: hospital (62.2% )
#2: ambulatory care (10.5%)
#3: public and community health (7.8%)
116
Q

Physicians

A

Generalists and specialists

- work settings and practice patterns

117
Q

Physicians: expanding the role of hospitalists

A
  • grew out of increasing complexity of patients requiring hospital care; dedicated physicians
  • do not have a relationship with patient prior to hospitalization
  • increasing use to reduce inpatient costs, increase efficacy without compromising quality or patient satisfaction
118
Q

Issues in medical practice, training, and supply: Medical training

A

Graduate Medical Education (GME) – Medicare primary funding source to offset a portion of direct costs associated with training physicians

119
Q

Issues in medical practice, training, and supply: Supply of medical professionals

A

Labor force increasing but still not meeting demand

120
Q

Labor force increasing but still not meeting demand: unequal distribution

A
  • geography

- Specialty (general practice, internal medicine, pediatrics, mental health)

121
Q

mortality rate

A

number of deaths per 100,000 population

122
Q

Physician Supply and Demand through 2025

A

Study commissioned by the Association of American Medical Colleges

Categories: primary care, medical specialties, surgical specialties; other

By 2025, demand for physicians will exceed supply by a range of 61,700 to 94,700
Primary care physicians (14,900-35,600)
Medical specialists (3,600-10,200)
Surgical specialists (25,200-33,200
123
Q

What is affecting the supply of physicians?

A

retiring, supply for GME growth, millennial hours, and people retiring earlier

124
Q

Affordable Care Act - Physicians

A

In 2013, $12 million in ACA funding was awarded to train more than 300 new primary residents during the 2013-2014 academic year

  • Loan repayment for pediatric medical, mental health, and surgical sub-specialties in exchange for providing care in medically-underserved areas
  • Authorizes grants to increase training in geriatrics
125
Q

Affordable Care Act - Physicians

A

Advanced Nursing Education Expansion Program

  • Allocated $30 million to support academic
    training programs for nurse practitioners and
    certified nurse-midwives
  • Funds pay for instructor and for students’
    housing and living expenses
126
Q

National health services corps

A

Federal program established in 1972 to strengthen and grow the primary care workforce.

127
Q

National health services corps Awards scholarships and loan repayment to?

A

primary care providers in eligible disciplines

128
Q

National health services corps: Since 1972, more than _____ primary care medical, dental, and mental and behavioral health professionals have served

A

50,000

129
Q

Becoming a member of the National Health Service Corps requires

A

commitment of at least two years at an NSHC-approved site located in a Health Professional Shortage Area (HPSA)

130
Q

Health Professional Shortage Areas (HPSAs): geographic area

A

shortage of providers for the entire population

131
Q

Health Professional Shortage Areas (HPSAs): population groups

A

shortage of providers for a specific population group

132
Q

Health Professional Shortage Areas (HPSAs): facilities

A
  • Public or non-profit medical facility serving a population or geographic area designated as a HPSA
  • Correctional facility
  • State mental hospitals
  • Federally qualified health centers; Indian health facilities, IHS and Tribal hospitals; CMS-Certified Rural Health Clinics
133
Q

National Health Service Corps eligibility

A
  • US citizen or US national
  • enrolled as a full-time student
  • Attending - or accepting to attend - an accredited school or program in one of the 50 states, D.C., or a US territory
134
Q

National Health Service Corps disciplines

A

Physician, dentist, nurse practitioner, nurse midwife, physician assistant

135
Q

Mid-level providers

A

Do not have a MD or a DO degree

  • receive less training than physicians but more than RNs
  • can often substitute for physicians (NP, PA, certified nurse midwifes)
136
Q

Allied Health Professionals

A

Therapists, OTs, dietician, EMTs etc.

137
Q

The Resident Physician Shortage Reduction Act of 2019

A

Increase the number of residency positions eligible for Medicare DGME and IME support by 15,000 slots above the current caps
- 3,000 each fiscal year from 2021-2025

  • A hospital may not receive more than 75 slots in any fiscal year unless the HHS Secretary determines there are eligible slots for distribution
  • One-third of the new residency slots available only to hospitals that are already training at least 10 residents in excess of their cap
  • Slots would be fill slots based on priority
138
Q

To determine which hospitals receive slots, the HHS Secretary would have to consider the likelihood of a hospital filing the positions and would be required to prioritize hospitals in the following order:

A
  1. hospitals in states with new medical schools
  2. hospitals in training partnerships with Veterans Affairs medical centers
  3. Hospitals that emphasize training in community-based settings or hospital outpatient departments
  4. non-rural hospitals that operate a training program in a rural area or a program with an integrated rural track
  5. all other hospitals
139
Q

Bodenheimer and Smith conducted a literature review on the primary care shortage (50 articles). Most of the articles proposed…?

A

An increase in the number of clinicians. Others suggested adding capacity through different professionals

140
Q

Reform proposals giving attention to the non-clinician components can move primary care toward a…?

A

a balance of demand and capacity

141
Q

What are the components of balance and capacity

A
  • non-clinician licensed practitioners
  • non-licensed personnel
  • patient self-care
  • technology
142
Q

Non-clinician Licensed Practitioners are who?

A

Nurses, pharmacists, psychologists, licensed clinical social workers, physical and occupational therapists, and health educators

  • Extremely underused in their capacity to fill roles generally performed by clinicians
143
Q

Non-Licensed Personnel are who?

A

Medical assistants, front desk staff, health coaches, patient navigators, and lay educators (community health workers)

  • also underused
144
Q

health coaches and health educators can provide care for patients with

A

chronic illnesses

- non-licensed personnel

145
Q

Medical assistants can recognize and coach patients with

A

depression resulting in significant improvement compared to those receiving physician-only care
- non-licensed personnel

146
Q

How do patients feel about reallocation?

A

The patient-provider relationship is already in a fragile state
—> 78% of physicians believe they are providing compassionate care compared to 54% based on patient perspective

147
Q

Participating in self-care

A

self-care helps balance primary care demand and capacity by reducing demand instead of increasing capacity

148
Q

Examples of participating in self-care

A
  • Home pregnancy tests, HIV testing, Cologuard
  • Monitoring glucose and insulin doses
  • Blood pressure monitoring, self-treatment with OTC medications
  • Serve as peer coaches for patients with the same condition
149
Q

insurance is the mechanism for …?

A

protection against risk

150
Q

Risk

A

the possibility of a substantial financial loss from an event of which the occurrence is relatively small

151
Q

4 fundamental principles of insurance

A
  1. Risk is unpredictable for the insured
  2. Risk can be predicted with a reasonable accuracy for a large group or population
  3. Insurance mechanism transfers risk from the individual to the group through the pooling of resources
  4. Members of insured group share actual losses on some equitable basis
152
Q

In 2017, private health insurance

coverage continues to be more prevalent than…

A

than government coverage

153
Q

Percentage of people by type of health insurance coverage and change from 2013 to 2017: Between 2016 and 2017,
Medicare coverage increased by how many percentage points

A

0.6 percentage points

154
Q

Percentage of people by type of health insurance coverage and change from 2013 to 2017: Military coverage rate increased by how many percentage points?

A

0.2 percentage points

155
Q

Percentage of people by type of health insurance coverage and change from 2013 to 2017: Employment-based, direct-purchase coverage, and Medicaid

A

did not

statistically change

156
Q

Types of Private Insurance: Group Insurance

A

Gained through employer (pre-taxed), a union, or professional organization

157
Q

Types of Private Insurance: Individual private insurance

A

Directly with insurance company, marketplace exchanges

158
Q

Types of Private Insurance: Self-insurance

A

The employer acts as its own insurer instead of obtaining insurance through an insurance company

159
Q

Types of Private Insurance: Managed care plans

A

HMOs, PPOs

160
Q

Types of Private Insurance: Short-term stop-gap coverage

A

Consolidated Omnibus Budget Reconciliation Act (COBRA)

161
Q

Types of Private Insurance: Medigap (Medicare Supplemental Insurance)

A
  • Eligible only to those enrolled in the original Medicare program
  • Does not cover extended long-term care, vision, dental, hearing aids, or private nursing
162
Q

Open enrollment for health insurance runs from…?

A

November 1 – December 15, 2019

163
Q

The health insurance marketplace is for people who don’t have health coverage. What you pay if you have job-based insurance or medicare

A

If you have job-based insurance, you will pay full price

If you have Medicare, you can’t switch to marketplace insurance

164
Q

Types of Public Insurance

A

Public financing supports programs benefiting certain categories of people:

a. Medicare for elderly and disabled individuals
b. Medicaid for the indigent
c. Department of Defense programs for active service members and their families
d. Department of Veterans Affairs (VA) health care for military veterans

165
Q

When was Medicare first implemented

A

1966 - covering more persons 65+

166
Q

In 1973, Medicare benefits expanded to include those entitled to…

A

…Social Security or Railroad Retirement disability cash benefits for at least 24 months and most persons with end-stage renal disease

167
Q

Medicare Traditionally consisted of two parts:

A

Hospital Insurance (HI), aka Part A (inpatient care, SNF, hospice, some home health)

Supplementary Medical Insurance (SMI), aka Part B (doctors’ services, outpatient care, PT, OT, some home health)

168
Q

Prescription Drug Coverage (Part D) –>

A

Goal to lower prescription drug costs and help protect higher costs in the future

169
Q

Prescription Drug Coverage (Part D) –> describe the monthly premium

A

Monthly premium for this coverage – began in January 1, 2006

170
Q

Prescription Drug Coverage (Part D) –> estimated national average

A

Estimated national average, 2017, was $42.17

171
Q

Stand-alone prescription drug plans provide what coverage

A

Prescription Drug Coverage (Part D)

172
Q

If a beneficiary does not enroll in a drug plan when they are first eligible, what happens?

A

they may pay a penalty if they choose to join later.

- certain low-income beneficiaries are automatically enrolled without having to pay a premium.

173
Q

Medicare has established two main trust funds

A
  1. Hospital Insurance (HI) trust fund provides the money pool for Part A services
  2. Supplemental Medical Insurance (SMI) trust fund provides the money pool for Parts B and D

Taxes, premiums, and other revenues are credited to the respective trust funds but benefit payments and administrative costs are the only purposes for which disbursements from the funds can be made
Area of concern: Trustees predict depletion of the HI funds by 2027

174
Q

Medicaid became law when?

A

1965 as a cooperative venture jointly funded by the Federal and State governments

175
Q

For medicaid, each state…

A
  • Establishes its own eligibility standards
  • Determines the type, amount, duration, and scope of services
  • Sets the rate of payment for services
  • Administers its own program
176
Q

Eligibility of Medicaid

A

Federal law requires states to cover certain groups of individuals:

  • low income families
  • qualified pregnant women and children
  • ind. receiving Supplemental Security Income (SSI)
  • disabled adult children
  • Ind. with TB
  • many others listed on the “List of Medicaid Eligibility Groups”
177
Q

Children’s Health Insurance Program

A

Created in response to the 10 million children whose families’ incomes exceeded the Medicaid threshold levels
- eligibility varies by state

178
Q

Children’s Health Insurance Program provides coverage through

A

both medicaid and separate CHIP programs

179
Q

Children’s Health Insurance Program (CHIP) medicaid expansion:

A
  • Provides the standard Medicaid benefit package
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services
  • Mental health services
  • Dental services
180
Q

Military Health System - TRICARE is a health insurance program for…?

A
  • Uniformed service members and their families
  • National Guard/Reserve members and their families
  • Survivors
  • Former spouses
  • Medal of Honor recipients and their families
  • Others registered in the Defense Enrollment Eligibility Reporting System (DEERS)
181
Q

Military Health System - VHA

A

Operates the largest integrated health services system in the United States

182
Q

Congress requires VHA to…?

A

provide services on a priority basis to veterans with service-connected illnesses and disabilities, low incomes, or special health needs

183
Q

VHA is funded through

A

the annual appropriations process (discretionary budget)

184
Q

VHA suffers from

A

capacity and financing constraints

185
Q

TRICARE Benefits

A
  • your services may vary depending on you health plan

- your TRICARE health plan’s rules and costs will apply

186
Q

VA benefits

A

Your eligibility and copayment depend on:

  • discharge
  • service-connection
  • income
187
Q

VA and TRICARE Benefits and plans will vary depending on your…

A
  • Prime plans or traditional TRICARE plans

- Choosing between TRICARE or VHA Benefits

188
Q

GO LOOK AT TRICARE AND VA BENEFITS IN PPT

A

kk

189
Q

Indian Health Services

A

Federal program that provides comprehensive health care services directly to members of federally-recognized American Indian and Alaska Native tribes and their descendants

190
Q

Indian Health Services are eligible to participate in what

A

all public, private, and state health programs available to the general population – but challenging due to geographic barriers

191
Q

Indian Health Services serve how many people and where?

A

IHS serve almost 2.6 million AIANs residing on or near reservations – and in rural communities

192
Q

What was established in 1935?

A

Social security

193
Q

What was established in 1965

A

medicare and medicaid

194
Q

How did the Balanced Budget Act impact hospitals?

A

They put a cap on residency slots in teaching hospitals

195
Q

Marketplace plan category: bronze

a. the insurance company pays how much?
b. you pay how much?

A

a. 60%

b. 40%

196
Q

Marketplace plan category: silver

a. the insurance company pays how much?
b. you pay how much?

A

a. 70%

b. 30%

197
Q

Marketplace plan category: gold

a. the insurance company pays how much?
b. you pay how much?

A

a. 80%

b. 20%

198
Q

Marketplace plan category: platinum

a. the insurance company pays how much?
b. you pay how much?

A

a. 90%

b. 10%

199
Q

Where does the funding come from for public insurance

A

mandatory budget

200
Q

How are TRICARE and VA related?

A

TRICARE is the insurance arm of the VA system, the VA is the entire system

201
Q

Marketplace plan category: catastrophic

age and reason

A

people under 30

- people of any age with hardship exemption or affordability exemption

Health Services (2 decks)

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