Final Exam Flash cards

Question

modes of paying for health care in the US. from most used to least used

Answer 1

government financing employment based private insurance out of pocket payment

Answer 2

more avoidable hospitalizations later diagnosis of life threatening conditions more seriously ill when hospitalized fewer preventative services higher mortality less care and worse health outcomes

Answer 3

62% of bankruptcies in US due to inability to pay medical bills caused by medicare coverage gaps an long term coverage gaps cost sharing (The share of costs covered by your insurance that you pay out of your own pocket. )reduces ambulatory care utilization

Answer 4

fee for service per diem per episode per patient modes unique to HCP group

Answer 5

billed for services offered

Answer 6

according to diagnosis, you get paid a certain amount. paid based on what they are treating.

Answer 7

you get paid a fixed amount per patient

Answer 8

traditionally was ffs, but moved to other models such as per diem per episode per pt global budget

Answer 9

traditionally was ffs, but moved to other models such as per episode per patient global budget

Answer 10

physicians and hospitals bill separately

Answer 11

initially nurse was responsible for managing meds. small hospitals have central pharmacy only 1. central specialist model: central pharmacists that manage distribution and specialist manage clinical activities 2. decentral model: small# of rph in the pharmacy, more on the floor doing clinical an distributive activities on the floor

Answer 12

am care pharmacy: work in prescriber offices. see pts separately from prescriber general vs specialist: specialist liks warfarin dosing community pharmacy

Answer 13

health care expenditures outpaced inflation by 2.9% pharmaceutical expenditures increased more rapidly

Answer 14

painful or painless (to the patient) financed-focus or reimbursement focused

Answer 15

control reimbursement reduce price of supplies reduce administrative wastes eliminate interventions of no benefit substitute less costly options that are equally effective increase preventative care

Answer 16

1. regulatory: a. limits on taxes or premiums. b. regulatory supply limits. 2. competition

Answer 17

regulatory competitive utilization aggregate units of payment increase pt. cost sharing utilization managements supply limits by the DEA mixed controls

Answer 18

refusal of coverage increased cost sharing: tiered formlary prior authorizations step therapy generic substitution requirement

Answer 19

``` equitable timely effective safe efficient patient centered ```

Answer 20

access to care adequate scientific knowledge competent health care providers separation of financial and clinical decisions organization of health care institutions

Answer 21

licensing and accreditation peer review malpractice

Answer 22

clinical practice guidelines measuring practice patterns continuous quality improvement computerized information cystems public reporting pay for performance financially neutral clinical decision making

Answer 23

structure: process outcomes:

Answer 24

characteristic of setting/ providers ex: use of EHR. ratio of providers to patients

Answer 25

services provided | prescribed drug X, received testing

Answer 26

results of care i.e mortality, quality of life

Answer 27

HEDIS: hmo rating medicare hospital compare medicare physician compare medicare nursing compare

Answer 28

AKA medical model doing something to one person counseling therapeutic intervention

Answer 29

AKA public health model public health initiatives clean water, air and public sanitation, public schools

Answer 30

for non infectious disease, individual plays major role in causing own illness INTERVENTIONS stains/dietary counseling for high cholesterol pts exercise counseling for obese smoking cessation

Answer 31

ban smoking in areas tax on cigarrettes food pyramid health plans pay for gym membership

Answer 32

``` feeding dressing bathing or showering getting to and from the toilet getting in and out of bed or chair dealing with incontinence ```

Answer 33

(activities necessary to remain independent) ``` doing housework and laundry preparing meals shopping for groceries using transportation managing finances making and keeping appointments taking medications telephoning ```

Answer 34

medicaid pays for custodial care such as.. nursing home care(NHC) home health care (not 24 hour custodial care tho) medicare pays for skilled, non custodial care

Answer 35

the obligation of health care providers to help people in need

Answer 36

the duty of a health care provider to do no harm

Answer 37

the right of the patient to make choices regarding their health care.

Answer 38

the concept of treating everyone in a fair manner

Answer 39

fiscal commodity

Answer 40

limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients; and distribution of these limited resources in a fair manner

Answer 41

specific items are in limited supplies i.e number of organs needed

Answer 42

money available in the health sector is restricted. ex:

Answer 43

``` inpatient care outpatient care emergency care pre/post natal care prevention services laboratory services peds care prescription drugs mental health services medical devices/equipment ```

Answer 44

place-based, multi sector, equity orientated initiatives advocating for policy reform training future health professionals

Answer 45

high risk insurance pools for individuals with no insurance expansion of dependent converge for young adults up to age 26 elminiation of provisions that allow health insurers to cap lifetime benefits or deny coverage to children based on preexisting conditions reductio of medicare coverage gap expansion of medicaid to all individuals below 133% of the federal poverty level individual health insurance mandate subsidized health insurance exchanges for the uninsured to purchase insurance elimination to deny coverage based on preexisting conditions employers with 50 or more employees limitations on cost sharing

Answer 46

adult dental care and vision care long term care CAM

Answer 47

difference in "actuarial value"(average %paid by plan) considers deductibles, copays, and coinsurance

Answer 48

bronze: 60% silver: 70% gold: 80% platinum: 90%

Answer 49

NY's own market place

Answer 50

Purchasers insurers providers suppliers

Answer 51

theme: providers push reimbursement; payers have little power

Answer 52

purchasers began pushing for funding | DRGS's., fee schedules, capitation, and selective contracting developed

Answer 53

provider -insurer relationship becomes more antagonistic insurers power increases, tremendous conflict btw providers

Answer 54

insurers began pushing for rteimbursement

Answer 55

providers consolidate. limit competition, improve contract negotiating power

Answer 56

power counter revolution hospitals and clinicians push back against aggressive decreases in reimbursement by MCO's and other insurers growth of specialists and specialty srvices pharma targeted for criticism

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Final Exam Flash cards

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