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Final Review Flashcards

1
Q

Patient Centered Medical Home

A

Team-Based model of care led by leader physician who provides continuous coordinated care throughout a patients lifetime to maximize health outcomes
(New concept of providing care)
Proven to lower costs and improve quality

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2
Q

Health care policy triad

A

Cost Access Quality

Goal: to provide access to quality care at a reasonable cost

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3
Q

U.S. Health System

A

U.S. spends 18% of GDP on HC (double) (includes HC workforce of 16 mill)
When control for biases, U.S. fares similar to other countries in outcomes

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4
Q

Insurance models

A

Experience rating: rate based on risk (car)

Community rating: rate based on risk of entire community (health)

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5
Q

Universal HC

A

Everyone in the country is covered
(U.S. Was the only industrialized nation w/o universal coverage)

Medicaid: universal coverage for 65

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6
Q

Affordable care act

A

Requires all citizens to get health insurance
Written by task force of 40 fr both parties
Companies:
-tax credits to companies
-companies must provide insurance if have 50+ employees

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7
Q

HIPAA

A

First law to prevent insurance companies from denying people bc of pre-existing conditions

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8
Q

Individual mandate (ACA)

A

Law that requires American adults to obtain health insurance or pay a tax penalty

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9
Q

Why HC reform has always met opposition

A
  1. Fear of change
  2. Impact of interest groups
  3. Disagreement over whether or not HC is a universal right
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10
Q

Concierge medicine

A

Doctor doesn’t take insurance and is paid a retainer to provide care to a set of clients
(ACA deems unethical bc need cash to pay)

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11
Q

Employer-based coverage

A

$20,000 for family of 4

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12
Q

Why HC costs skyrocketed since Medicare

A
  1. Medicaid creators based cost on current (1965) elderly population but ppl started living much longer bc of advancements in medical tech
  2. Technology
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13
Q

Managed care

A 
Strategy to control HC costs
-HMOs
-health homes 
-PPOs 
-Gatekeepers 
Switched from fee-for-service to capitation
*main financing system of HC today*
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14
Q

Change in doctor-patient relationship

A

From paternal relationship (patients adhered to everything doctors said) to patients more actively participating in care

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15
Q

Health disparity

A

When 2 different groups have different health outcomes

infant mortality is the most important indicator of a community’s health status

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16
Q

Prevention

A

1) Primary: prior to onset of disease (vaccines)
2) Secondary: measures taken to identify disease early (screening test)
* *pap smear most effective screening test**
3) Tertiary: measures taken to minimize damage- mitigate factors of disease (rehab)

Heroic medicine (tertiary prevention) is favored over primary prevention; more paid for tertiary than primary care

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17
Q

Baylor University Hospital Plan

A

Enrolled 1,250 public school teachers at 50 cents/month for 21 days of hospital care
Created model for Blue Cross hospital insurance

(From Depression of 1929)

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17
Q

Nurses

A

Largest component of HC employment but now most unsatisfied = shift from mostly direct patient care to mostly paperwork (less time spent with patient)

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18
Q

First health reform

A

1935 SS Act (FDR): federal aid to states for HC
Articles 18-19: Medicare/Medicaid (1965) (Johnson)
-8% GDP when enacted

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19
Q

1980s form of managed care under Reagon

A

Prior to 1980s: doctors paid retrospectively
Reagon: changed payments to prospective (docs know what they will get paid ahead of time) through DRG
Diagnostic Related Groups: payments based on diagnoses
(Created role for medical biller)

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20
Q

Medicare Part D

A

Covers 80% of drug costs (seniors have 20% copayment)

Donut hole: coverage ➡️ coverage gap ➡️ catastrophic coverage

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21
Q

Oregon death with dignity act

A

Made it legal for adult resident of Oregon with terminal illness to voluntarily request prescription to take own life

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22
Q

ACA goals/benefits

A
  • reduce cost
  • improve quality
  • consumer protections
  • holds insurance companies accountable
  • increases access to affordable care
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23
Q

Health IT

A
  • instant access
  • share info
  • productivity (both increases and decreases)

Barriers: cost, training, ongoing maintenance
Issues: security breach

*efforts to become an electronically driven medical system has not been successful in achieving goals = costs still outweighing benefits

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24
Regional Health Information Organization (RHIO)
Agreement to share information between health systems (info only shared within not between rhios) NY RHIO: State Health Information Network of NY (wants to connect all NY RHIOs)
25
Most successful HIT system
VA
26
HITECH Trust Act (Health Information Technology for Economic and Clinical Health)
Component of the American Recovery and Reinvestment Act of 2009 that [created programs to incentivize physicians and HCOs to buy, install, and adopt EHR systems]
27
History of hospitals
Originally for poor and funded by charity/religious organizations (rich got care at home) **Creation of insurance + Medicare/Medicaid (1965) changed hospitals from charity to money-making industry
28
Hill-Burton Act of 1946
Created federal grants to construct new hospitals and expand existing ones in areas with a need (to close disparity in geographic location of hospitals when they first appeared) - attracted ppl to become HC workers - added 7,200 hospitals (too much) -> closing/consolidating -> 5,700 today * *Significant for underserved and rural areas** Abuse led to requirement to demonstrate need
29
Certificate of need (NY)
Requirement to demonstrate need to open a medical facility
30
Difference between Medicare and Medicaid
Medicare is strictly federal: benefits are the same in every state Medicaid is a federal program administered by the states: each state legislature determines benefits
31
Largest health system
VA (156 hospitals)
32
Balance Budget Act of 1997 (Clinton)
Reduced payments for Medicare/Medicaid services to the point that doctors were being paid less than it cost them to see patients ➡️providers dropped MM patients
33
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Visits hospitals that get Medicare/Medicaid (ONLY) to evaluate the standard of care Ways to evaluate care: -structure: equipment, rooms (eliminated) -process: what's done after admission (elim) -outcomes: pt. health outcomes (today); pt. satisfaction surveys are a new outcome measure
34
Medical error
Failure to complete an action
35
Near miss
Error occurred but had no impact (should still be reported to risk management)
36
HMO Act of 1973 (Nixon)
Provided loans/grants for implementation of combined insurance and HC delivery orgs and required primary/preventive care services be included in HMO arrangement *paved way for managed care principles
37
Types of hospitals
Not-for-profit: tax breaks in exchange for community service; must have main issues they address in community (70%) For profit: no legal responsibility to the community Government: VA
38
Medicare (Title 18)
``` Minimum level health insurance to: -65+ -disabled -ESRD -ALS Funds from payroll taxes levied on all workers ```
39
Medicaid (Title 19)
Joint federal/state program that provides insurance coverage for a prescribed scope of basic HC svs to: - children 133% FPL - pregnant women 133% FPL - adults
40
HC spending considered waste
30-40%
41
Aging population and Hospital stays
Aging pop is >1/2 all nights spent in hospitals
42
BCBS
BC: pays hospitals BS: pays doctors
43
Capitation
Managed care reimbursement method that prepays physicians for services on a per-member per-month basis whether or not svs used Transfers risk from hospital to provider
44
PPO
Guarantee a certain volume of business to hospitals/physicians in return for negotiated discounted fees - patients stay in network - docs paid FFS * most popular managed care model
45
Medicare Part A
Hospital, nursing home, hospice (20% copay)
46
Medicare Part B
Physician services (voluntary)
47
Medicare Part C
Medicare advantage: covers additional services (ex: dental) and can pay Part A copay (voluntary)
48
Diagnosis-Related Group (DRG)
Predetermined payments based on diagnosis Incentive for hospitals to spend only what's needed to achieve optimal patient outcomes *managed by gov (CPT codes are not)
49
Ryan White Act
Grants for last resort payments for AIDS patients Area must have enough positive residents to be eligible No last resort money for other diseases bc AIDS is deadly and transmissible
50
SCHIP
Insurance plan for children in families with incomes too high for Medicaid but too low for private insurance or don't get through employer Eligible:
51
Rand study
Study to determine what HC insurance model would be best for country. Found that: - Cost sharing reduced amount spent on HC bc it reduces abuse (moral hazard)= need copays - Cost sharing has no negative impact on outcomes
52
First concept of group practice
MayoClinic: - providers of different specialties - providers create a plan of action together * best outcomes (treat cases no one else gets) * cost efficient bc everything done w/in practice * *overall outcomes are better in group practice
53
Safety-net facility
Primarily treats people who can't afford care
54
Federally Qualified Health Center
Safety net clinics paid for by the government to improve health outcomes and keep patients out of hospitals Qualifications: -address all areas of care -high % pts MM or uninsured -pts pay fee on sliding scale to prevent fraud/abuse
55
Standard medical curriculum created by
Johns Hopkins
56
Flexner Report
Report on quality of US medical schools | Named Johns Hopkins the model school
57
Academic health centers/teaching hospitals
University-affiliated facilities that are principal places of education and training for physicians and other HC personell, sites for basic medical research, and settings for clinical trials *more likely to save pts -better technology -more specialists -more docs *however more likely to die of med error (More expensive to run)
58
Hospitalists
Attending physicians who care for pts in a hospital (paid by hospital)
59
MD licensing
Licensed after year long internship post med school Residency: years learning specialty Fellowship: subspecialty
60
Dentistry and payments
Resisted managed care and capitated payments = inequity in dental care for poor
61
Conventional medicine
Evidence-based
62
Alternative medicine
Medicine not taught in med school; not evidence-based
63
Allied health services
Professionals exclusive of doctors, nurses, dentists that are experts in therapeutic, diagnostic, preventative health interventions *decrease costs and improve quality of care
64
Moses of regulating HC personnel
Licensing (managed at state level) Certification Registration
65
DSRIP
Partnerships of entities that agree to work together to keep Medicare patients out of hospitals to reduce costs
66
Omnibus Budget Reconciliation Act of 1987
- guidelines/restrictions on use of physical/chemical restraints - nursing home resident bill of rights - mandated quality assurance standards - standard survey process (pts and fams) - training/edu requirements for staff
67
Licensed nursing facility requirements
-licensed medical staff on site 24/7 -provide medical care on site -licensed administration -certified by Medicare* = joint commission visit ~80,000/yr/pt
68
Assisted living
- doesn't take insurance (no Medicare = no JC) - doesn't require medical staff - costs 1/2 as much as nursing home - assists with ADLs - no federally required license
69
Home care agencies
Much cheaper than nursing home/assisted living (more ppl get home care than both com) Aging in place = happier, fams together, better outcomes **Paid by Medicare** DRGs ➡️ push pts out hosp ➡️ home care
70
Requirements to receive home care
- ordered by physician - health care plan in place - agency meets quality standards
71
Family Medical Leave Act (FMLA)
Unpaid family/medical leave from work with medical benefits -1yr off unpaid -keeping all medical benefits -job protected Business must have 50+ employees Created to allow pregnant women to return to work
72
Hospice
Facility that provides end of life care from a multidisciplinary team Requirement: terminal illness w/ 6m prognosis Paid for by Medicare since 1982 = JC visits Provide palliative care
73
Palliative care
Comfort care: relieving symptoms instead of treating underlying cause of disease
74
Respite care
Relief to caretakers | Not covered by Medicare
75
Lifespan Respite Care Act 2006
State grants to develop respite care programs
76
Senior centers
Keep seniors productive and healthy Goal: to prevent institutionalization (nursing home/assisted living) Paid by person or municipality
77
National Institute of Health
Provides 2/3 of all funding for medical research
78
Health Resources and Services Administration (HRSA)
Funds programs such as WIC and Ryan White
79
Centers for Medicare and Medicaid Services (CMS)
Administers Medicare and oversees Medicaid programs administered by the states
80
Food and Drug Administration
Regulates safety and efficacy of drugs and safety of food
81
CDC
Agency for health promotion, disease prevention, preparedness, and public health
82
USDHHS
Fed governments principal concerned with Heath protection and promotion
83
ACOs
Group of HC providers that care for Medicare patients and work together to coordinate care Shared savings program: money saved from improved outcomes is shared with providers (needs 5,000 pts) [if outcomes not improved, no money and may be penalized]
84
Meaningful use
Providers must show that they are meeting standards for improved outcomes for HITECH Act grant money
85
Evidence-based medicine
Use of scientific data from research to determine treatment procedures
86
Institutional Review Board (IRB)
Expert groups that judge the merit of research and ensure use of ethical safeguards to protect research subjects
87
Operation Restore Trust (Clinton)
Federal program to eliminate fraud and abuse in MM | Returned money to programs

Economics (16 decks)

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