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Health Care Management > Midterm 1 > Flashcards

Midterm 1 Flashcards

1
Q

HMO

A

integrated delivery systems, tightly managed network of providers, typically with a primary care gatekeeper

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2
Q

PPO (What is it)

A

Preferred Provider Networks; insurers create special networks of hospitals and physicians

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3
Q

Tax exclusion

A

Workers think it’s more valuable that they pay rather than having to of into the market

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4
Q

Who benefits the most from the tax exclusions?

A

People in higher tax brackets

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5
Q

Who is medicare for?

A

people over 65 and select disabilities/conditions (about 67.2 million enrolled as of July 2024)

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6
Q

Who is medicaid and CHIP for?

A

low-income individuals (about 82.7 million in March 2024 went down over 10 million from 2023)

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7
Q

Why did medicaid and CHIP go down?

A

people were re evaluated after the pandemic and found to not qualify

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8
Q

Who qualified for the “Old Medicaid”?

A

the deserving poor (had certain determinations)

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9
Q

Who qualifies for the “New Medicaid” (passed as part of ACA)?

A

all of the poor

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10
Q

Who’s the big majority of the uninsured?

A

the working poor

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11
Q

Hill-Burton Act (1946)

A

federal funds given to private community hospitals to expand; in return no discrimination, minimum requirement of uncompensated care for poor, emergency care open to all

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12
Q

About how many hospitals (non profit, for profit, state municipals) do we have?

A

5000

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13
Q

How many hospitals are non for profit?

A

about 3000

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14
Q

How many hospitals are for profit?

A

1200

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15
Q

Why are about half of all hospitals nonprofit and defined as charitable with a tax exemption?

A

they’re supposed to give back to the community

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16
Q

Which year had the highest hospital admissions?

A

1981 (peaked at 40 million); people don’t stay overnight as much

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17
Q

Payment Structure of Hospitals (1970s and 1980s)

A

Diagnosis-related groups (DRG); depended on a product not what the hospital said; anything that went from the hospital standpoint was given a flat free; specific to ICD diagnoses

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18
Q

Payment Structure of Hospitals (1950s and 1960s)

A

Cost based reimbursement; depended on what the hospital said

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19
Q

What does a DRG incentivize?

A

getting people out quickly and more efficiently

20
Q

What was a consequence of DRGs?

A

hospital admissions became shorter; LOS (length of stay)

21
Q

Where did DRGs come from?

A

developed in the 1970s at Yale

22
Q

What are the 6 different payment rated for hospitals?

A

1) Chargemaster Rate (retail price)
2) Usual, Customary, and Reasonable Rate (UCR)
3) Commercial Insurer and Blues Rate
4) Medicare Rate
5) Medicaid Rate
6) Actual Cost

23
Q

Which of the 6 rates does the insurance company pay?

A

commercial insurer and blues rate; they negotiate the rest (commercial insurer rate is what a private plan will negotiate)

24
Q

Where do physicians earn the most?

A

South Dakota because few physicians work in rural areas

25
Q

Physicians are more likely to:

A

be employed by health systems

26
Q

Name 3 Payment Structures for Doctors

A

Fragmented, Fee for Service, Bias to Procedures

27
Q

How do they determine the price for physicians that get paid FFS?

A

1) Medical Coding
2) Medical Billing
3) RVU System

28
Q

Why will there be a big nursing gap?

A

because the population is getting older

29
Q

How have previous staffing patterns contributed to the current nursing shortage?

A

Contractors are expensive and they have no loyalty

30
Q

What is path dependence and how does it affect health care?

A

decisions made before shape circumstances and possibilities of decisions today

31
Q

What are the 3 streams of policy change?

A

1) Problems (wide recognition of a problem; has to be affirmed)
2) Policies (have to be solution proposed to solve those problems; have to be vetted)
3) Politics (something that will push that problem and solution over the finish line; ex. an election)

32
Q

Earliest American Coverage Legislation (First Congress)

A

(1790) Required shipowners with 150 tons or crew of 10 to have onboard medicine or provide care without deduction from seamen’s wages

33
Q

Why did they pass the Earliest American Coverage Legislation (1790)?

A

They don’t want the seamen to spread any infections; they lose money if they go into hospitals

34
Q

What is the revised version of the Earliest American Coverage Legislation (1798)

A

Required every shipowner coming into port to pay 20 cent per seamen for every month each worker had been employed

35
Q

Originalism

A

Go back to the constitution and find what they meant (looking backwards)

36
Q

What did Otto von Bismarck do?

A

Instituted comprehensive set of welfare programs, including health coverage (funded through payroll deductions from employers and employees)

37
Q

Why does a conservative politician want health care coverage (Otto von Bismarck, 1883)?

A

Communism, Marxism; Industrial Revolution is causing workers to rebel (did it to appease the workers)

38
Q

Who was the first president to attempt to enact comprehensive health reform (1912)?

A

Theodore Roosevelt (didn’t actually propose it while president)

39
Q

Why was Teddy Roosevelt’s health reform killed?

A

WW1 and opposition from organized labor

40
Q

Why was labor against Teddy Roosevelt’s health reform

A

worried it will undercut their position

41
Q

Health Care Reform during FDR presidency (1933-1936)

A

Debated whether to include health insurance in the New Deal programs; didn’t include it because they feared they wouldn’t pass social security

42
Q

Who introduced the first bill for comprehensive health insurance through social security?

A

Sen Wagner, Murray and Rep Dingell

43
Q

Why did they exclude dental care and other things in the first bill for comprehensive health insurance through social security?

A

Because medicine was cheap at the time

44
Q

In 1947, who sponsored a plan to create a government subsidized, non-profit insurance system with premiums scaled to subscribers incomes?

A

Nixon

45
Q
A

Health Care Management (3 decks)

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