Intro Chapter 2 Flashcards
How do you describe the US healthcare delivery system
Multi tiered
What does the DHHS oversee
All health related concerns of the general public international
What subdivisions are included in the DHHS
WHO CDC HUD OSHA EPA FDA USDA Disaster response
What is the DHHS emphasis
Monitoring, policy development, and ensuring healthcare accessibility
What is Medicare and the parts of Medicare
Medicare is an insurance program funded by the US government for those over 65 who paid into Social Security
Includes Part A Part B part C part D
Describe Medicare part A
Free to everyone Eligible, covers essential hospital costs but has a limited number of days
Also covers disabled and end stage renal disease patients
Define premium
Amount of money paid each month to an insurance company
Define deductible
Specified amount of money the patient pays before an insurance company will pay a claim
Describe Medicare part B
Covers doctors visits and outpatient services
Requires premium and deductible only covers 80% of expenses
Frequently Used with private insurances
Describe Medicare part C
A combination of A, B, and D only has one premium
Describe Medicare part D
Covers prescribed drugs on formulary (restrictions)
has premium and deductible
many elder people drugs are not covered
What is Medicaid
We aid everyone
Health insurance for the poor pregnant and very young (under five)
Only has a premium if dental and vision added
WIC
At would level is Medicaid dispersed
STATE
What is CHIP and who is it available for
CHIP Was created for children to have a fordable means to access healthcare
If above poverty line
What is Texas Health steps
An early and periodic screening, diagnosis, and treatment program specifically for children under Medicaid
Private health insurance
Private or employer sponsored
“BCBS”
Premiums requires
May have Deductibles or co pays
Subcategories of private health insurance
HMO
PPO
HMO information dump
Coordinated through primary doctor
few plans out there
Specified amount of money for each patient
no reimbursement (prospective payment)
primary controls health care (i.e. referrals diagnostic test and health services)
PPO information dump
Patient selects from a list of approved doctors and specialists
in the majority
yes reimbursements for preestablished fees (retrospective reimbursement)
Affordable care act a.k.a. Obamacare
Intentions
Meant to improve quality of healthcare, improve access, and lower costs
Where are the three major shifts to the success of the law
Employers offering healthcare insurance
Increase participation in CHIP
Expended Medicaid coverage by state
What items on the affordable care act were revoked
- The mandated coverage in which people were being fined after not having insurance coverage
- Tax credits which reduce the cost burden to some individuals
Key provisions Of the affordable care act
Guaranteed coverage regardless of pre-existing condition
insurance companies must justify premium increases of more than 10% per year
preventative services at little to no cost yearly wellness exams screenings
How is healthcare delivery described
By the place it is being delivered
Primary care
In doctors offices
least expensive
Addresses problem before it gets worse
Secondary care
In hospitals
most expensive
Tertiary care
Skilled nursing facilities/ rehab
second most expensive
How would you describe disease prevention
Strategies for certain populations of people
Primary prevention
Target: healthy people
Done by: health promotion and disease prevention
(I.E: health education, of lifestyle vaccines, washing hands)
AVOID IT
Secondary prevention
Target: population at risk for disease
Done by: screenings (not diagnostic) early disease detection
examples: pap smears pelvic exams colonoscopies
REDUCE RISK
Tertiary prevention
Target: those who have the disease
Done by: health management and prevent complications
Examples: Education, strategies for compensation
ALREADY HAVE IT BUT MANAGE IT
Can primary prevention happened in tertiary care
Yes the setting and strategies do not have to match
Define screening
Assesses the need for further evaluation
What is the best screenings have
Strong reliability and validity
Define reliability
Repeatability with the same results every time
Define validity
Accuracy
High sensitivity and specificity
Sensitivity
True positive those who truly need a follow up
Specificity
Decrease in false positive show true negative
What is true in regards to disease
It is least expensive to prevent disease than to treat it
What are the major concerns of healthcare delivery
Cost
access
quality
What are things that drive healthcare costs up
Diagnostic tests
pharmaceuticals
specialists
increasing population of elder people (living longer with more disease
Why are diagnostic related groups a problem to health delivery
They interfere with quality healthcare by providing standardized non-individualized healthcare
dictating how much an insurance company will pay for hospitalizations and outpatient services
they stereotype diseases saying they all cost same and they all require the same tests don’t cover extra
Do nursing shortage is increased cost
Yes
Factors in Cost containment
Managed care: determine when and where insured can receive service (I.Einsurance companies)
•increases costs
Care management: advocacy for the ill moving through healthcare delivery system
•decreases costs
•hospice
Nurse case managers: assure continuity and quality of care move patient through healthcare delivery system
•decrease cost
Access to healthcare challenges
Time: hours of operation are limited
Transportation: long distance with no car
• there are volunteer groups that pick up and take patients to appointments
Insurance: many people don’t have insurance and do not have the money to go get seen
Quality of healthcare
Facility must be accredited by the joint commission (TJC) and the Center for Medicare Medicaid services (CMS) who provide funding; increase quality of care
Self-determination act
Patient has a right to:
Advanced directives
: documents saying what can and can’t be done to patient if a person cannot speak for themselves
(A WILL)
informed consent
: Full explanation of procedure (outcomes, complications) understanding of the procedure, treatments and what would happen if the patient didn’t receive treatment
• must be free from coercion
• must be able to understand
refusal to treatment
HIPPA
patient confidentiality, on a need to know basis Verbal written online leaving items out with information
Americans with disability act
Equal Access to opportunities to those with disabilities
Equal opportunity act
Provide services to those who do not have the same opportunities because of location or economic status
i.e. headstart
