Exam 2 Review Flashcards
public hospitals
oldest type of hospital
owned by federal, state, or local government
American Medical Association (AMA)
protected the interests of providers
caused their rep to become more prestigious
federal hospitals
don’t serve the general public, they serve beneficiaries like veterans, military members, and native americans
voluntary hospitals
not government owned and non-profit
financed through community efforts
proprietary hospitals
investor owned hospitals
for profit, owned by corporations, individuals, or partnerships
primary goal is to make money
acute care hospitals
focuses on patients that stay 30 days or less
Medicare Rural Hospital Flexibility Program (MRHFP)
created because rural hospitals see more poor and elderly, resulting in financial issues
it allows some rural hospitals to be classified as critical access hospitals if they have <25 acute care beds–they can get extra Medicare reimbursement
chief of medical staff
in charge of the medical staff/physicians that provide clinical services to the hospital
certification of hospitals
allows them to get Medicare and Medicaid reimbursement
mandated by DHHS
must adhere to conditions of participation
accreditation of hospitals
private standard developed by accepted organizations to meet certain standards
-The Joint Commission accreditation means they met Medicare and Medicaid standards and don’t need certification
Patient Self-Determination Act of 1990
requires hospitals that are in Medicare and Medicaid programs to provide patients with information on their rights upon admission
-Patient Bill of Rights
3 cost containment approaches for facilities
- Lean-staff identify patient care processes that are inefficient and revise them
- Six Sigma-uses statistics to identify and eliminate defects in patient care
- Plan Do Study Act-4 step cycle that focuses on improving workflow
why were urgent/emergent care centers established?
for consumers that needed medical care but not life threatening. they take the place of the ER for those that really don’t need it
Health Centers
provide culturally competent primary healthcare services to the uninsured or indigent population
respite care
temporary care program, established to provide relief to the caregivers of chronically ill patients that needed a mental break
hospice care
provides care for patients with life threatening illness and comfort for the patient’s family
hospice care teams
work together to care for chronically ill patients
nurses, doctors, social workers, therapists, clergy, etc
why is primary care the essential component of the us healthcare system?
it is often the point of entry of most people since it focuses on preventative and routine care
secondary care
focuses on short term interventions that may require a specialist’s intervention
-hospitalization, routine surgery, specialty consultation
difference between a doctor of medicine and a doctor of osteopathic medicine
a doctor of osteopathic medicine uses more holistic approach focusing on the entire person, and a doctor of medicine uses an allopathic approach
allopathic approach
actively intervening in attacking and eradicating the disease
hospitalist
physician that provides care to hospitalized patients, usually a general practitioner and can provide more efficient care. they monitor the patient from admittance to discharge
nonphysician practitioner (NPP)
general term including physician assistants, nurse practitioners, and certified nurse practitioners
physician extenders
NPP are often called this because they are often used as a substitute for physicians but not involved in total care
physician assistants (PA)
category of NPP, provide range of diagnostic and therapeutic services, can prescribe medicines in all but 3 states, and must be supervised by a physician but can be indirect
how are nurses represented in the workforce
largest group of healthcare professionals and provide majority of care, they are the advocates though there is always a shortage
certified nursing assistants (CNA)
unlicensed attendants that work under supervision of physicians and nurses
-answer call bells, help patients with personal hygiene, ordering meals, changing beds
dentists
pregvent, diagnose, and treat teeth, gum, and mouth disease
-bachelors degree then 4 years of dental school with DDS or DDM degree, and 2-4 years after for a specialty such as orthodontics
sonographer
provides patient services using medical ultrasound, which photographs internal structures
exercise physiologists
assess, design, and manage individual exercise programs for both healthy and unhealthy individuals
prosthetist
designs “prostheses” or devices for patients who have limb amputations to replace the limb
perfusionist
operates equipment to support or replace a patient’s circulatory or respiratory function
-responsible for administering blood byproducts or anesthetic products during surgical procedure
recreational therapists
provide individualized and group recreational therapy for individuals experiencing limitations in lift activities as a result of a disabling condition, illness or disease, aging, and/or developmental factors
transfusion medicine specialists
specialists in blood bank technology (SSB)
provide routine and specialized tests for blood donor centers, transfusion centers, labs, and research centers
general tasks of pharmacy technicians
- take info needed to fill prescriptions
- count pills and measure other meds
- compound or mix medications
- pack and label meds
- process insurance claims
- do routine tasks
health services administrators
responsible for strategic planning and overall success of organization
- responsible for financial, clinical, and operational outcomes of an organization
- focus on efficiency and effectiveness at all levels
why was health insurance developed?
provide protection should a covered individual experience an event
copayments
costs that patients must pay at the point of service, and is designated
coinsurance
type of copayment that is part of a fee-for-service policy
-patient pays a % of the total cost of service, typically 20%
deductible
payments that must be met prior to insurance paying for services
-ex) if deductible is $250, the consumer must pay up to $250 before the insurance begins to cover services
flexible spending accounts (FSA)
allow employees to set aside pretax income to pay for out-of-pocket expenses
-must submit claims for the expenses and are reimbursed, but must be spent within 1 year
Medicare Part B
supplemental health plan to cover 2 types: medically necessary services and preventive services
-financed 24% from enrollee payments
Community First Choice
optional Medicaid benefit from ACA, that allows consumers to receive care at home or community health centers rather than a hospital or facility
balance billing
would allow the physician to bill the patient the difference between Medicare payments and their own charges, even if they accepted Medicare reimbursement as full payment
resource utilization groups
type of diagnostic related group designed to differentiate patients based on how much they use the resources of the facility
Home Health Resource Group
prospective payment used by Medicare that pays a fixed predetermined amount for each 60-day episode of care
Bundled payments initiative
4 models of care that link payments that multiple service beneficiaries receive during an episode of care
retrospective bundled payment
models 2 and 3 of a bundled payment initiative
-actual expenditures are reconciled against a target price for an episode of care
accountable care organizations (ACO)
groups of providers and hospitals that volunteer to give coordinated care to Medicare patients
-goal: ensure patients receive timely care while avoiding duplication of services and errors
auditing
ensuring accounting procedures are performed in accordance with regulations
claims processing
disbursement of funds
-most insurance companies and MCOs have a claims department to handle these
managed care
cost management of healthcare services by controlling who consumer sees and how much service costs
health maintenance organizations (HMO)
oldest type of managed care
- must see PCP first in order to see a specialist
- there are 4 types
independent practice associations (IPA)
type of health maintenance organization
-contract with a group of physicians who are in private practice to see MCO members at a prepaid rate per visit
preferred provider organizations (PPO)
providers agree to value-based fee schedule or a discounted fee
- no gatekeeper=no referrals needed
- no copay but there is a deductible
physician hospital organizations (PHO)
physician hospitals, surgical centers, and other medical providers that contract with managed care plan to provide services
point of service plans (POS)
blend of HMO and PPO
- encourage but don’t require PCP, but there is a lower fee if they do
- can see out of network provider but will be charged more
capitation policy
“per member per month (PMPM) policy”
provider is paid a fixed monthly amount per member regardless of how often the members use the service
prospective utilization review
implemented before the service is performed by having the procedure authorized by the MCO, having the PCP refer member for service, or assessing service based on guidelines
carve-outs
services that Medicaid is not obligated to pay for under MCO contract
-mental health services and substance abuse treatment often fall under this category
Accreditation Association for Ambulatory Health Care (AAAHC)
reviews and accredits MCOs, and can survey Medicare Advantage HMOs and PPOs
