Midterm Flashcards
The US has a ___________ insurance provision with employer, private insurance/managed care, and federal government payer
fragmented
US policy operated through ______________: small patch to solve fundamental problems
incrementalism
How has the pharmacist role transitioned
apothecary/compounding
dispensing
clinician
US healthcare system was shaped mostly by physicians’ desire to maintain ___________ _________ and _________ __________
economic control
career autonomy
AMA began to control and standardize what 3 things which led to medical profession
practitioners
licensure
education
What were the 4 societal forces entering the 1900s
urbanization
population communication and mobility
science and technology (knowledge)
corporations and hospitals/asylums
The pure food and drug act led to the convergence of what 3 things
consumer goods
journalism
federal bureau of chemistry
What policy used social pressure, relys on physicians’ prescriptions, and reduced consumer knowledge
toothless
Flexner recommended defined and experiential curriculum with what
lecture + clinical rotations
The great depression era spurred investigation into what
NHI (national health insurance)
Blue cross plans demonstrated ___________ _______ allowed for underwriting of medical costs, transition from strictly accident coverage
prepayment plans
The inclusion of health insurance in collective ___________ _________ made employers the largest providers of health insurance for the next decades
bargaining agreements
The national health insurance attempts that failed led to the beginning of multiple attempts for comprehensive healthcare coverage from multiple politicians in ______ political parties
both
What 2 insurances were signed into law as amendments to the social security act of 1935
medicare and medicaid
What were the environmental factors linked to passing medicare and medicaid
social
legislative
lobbying support
What insurance schemes are developed as a form of cost control
private
_____ became the driver of reimbursement policy and insurance schemes through its policy and implementation efforts
CMS
The pharmacist main role went from dispensing products or drugs to actual _______ _____
patient care
What are public health policy
policies are authoritative decisions made in the legislative, executive or judicial branches of government
-public policies that pertain to health are health policies
Regulations are usually directed to a executive branch ________ to create them
agency
What are operational decisions
once laws and regulations establish programs health agencies mange them
-made by govt officials
What are allocative health policies
distribute finite resources
provide net benefits to one group at expense of others to meet policy objective
What are regulatory health policies
directives that influence the actions, behaviors, or decisions of others
Problems that get on the agenda (window of opportunity)
important and urgent
issues/trends reach unacceptable level
widespread applicability
closely linked to other problems
-political will deems it necessary, this depends on competing issues on agenda
Ohio senate committees with health policy
health and human service
medicaid
insurance
finance
ways and means
Ohio house committees with health policy
health and aging
joint medicaid oversight
community and family advancement
insurance
finance H&H services
ways and means
When a committee decides to consider a measure, it usually take what 4 actions
committee requests written consent from agency
hearings are held to gather info
committee perfects measures by amending bill
committee votes on bill
Legislative hearings provide a forum where facts and opinions can be presented from witnesses with varied backgrounds, what are the backgrounds
govt officials
spokesperson for interest groups
researchers and other academics
interested citizens
Interest groups seek to influence policymaking to some advantage of the group’s members
increase demand for members services
limit competitors
permit members to charge max price for service
lower operating costs for members
How do interest groups influence policymaking
lobbying (communicating with makers)
electioneering (aid candidates for political office)
litigation (test cases, clarifications)
shaping public opinion (social media)
Implementation is a _____________ exercise
management
What is the difference between rulemaking and operation
rulemaking: est. formal rules to carry out intent of law
operation: activities of implementing an agency will carry out a law
How does the 3 branches implement roles
executive: implement laws formulated by legislative branch
legislative: standing committees (direct oversight)
judicial: review admin agency decisions and admin procedures act
What are the key factors in operation policy implementation
resources
management: leadership and personnel
competencies: policy, conceptual, technical, interpersonal
Continual modification of US health policymaking process is best described as incrementalism this allows for what
social and economic systems to adjust
limits economic disruption and alteration of status quo
more predictable and stable
What are the 4 parts of policy modification process
agenda setting (fact finding and window of opportunity)
development of legislation
rulemaking
operation (internal vs external)
During a window of opportunity what 3 things can occur
confluence of problems
possible solutions
political circumstances open
Sovereignty is constitutionally divided between the ______________ governing authority and constituent _________
central/federal
states
States use _____ ______ to regulate behavior and enforce order w/in their territory for the betterment of the general welfare, morals, health, and safety of their inhabitants
police power
What are the 3 parts of state health insurance regulation
licensing
solvency
rate regulation
State vs local protector of the public health and welfare
s: environmental regulations
l: restaurant inspections
state vs local healthcare services
s: purchaser (medicaid)
l: provider (hospital)
state licensing regulator
health professions, hospitals/nursing homes, health insurers
state vs local social safety net provider
s: hospitals, health clinic, mental institutions
l: locally run
s: manage federal programs like WIC
l: local offices and stores
state vs local health education provider
s: subsidize GME, loan repayment
l: GME providers
s: carry out public health education
l: support when needed
What are the 4 health care services
prevention
acute care (tx)
chronic and rehabilitation
palliation
What is primary, secondary, and tertiary services
pri: initial development of disease
sec: early detection of existing disease in order to cure or control the effects of an illness
tert: actions to prevent damage, slow progress, prevent additional complications from disease in people who have symptoms
What is acute care
short-term, intensive med care providing diagnosis and tx for disease, illness, or injury
Prehospital primary and secondary care in clinics
pri: most general source for routine tx of illness or disease (PCP, gatekeepers)
sec: specialists in med field (needs referral from PCP)
Emergency Care before ED (prehospital)
medic and or ambulance care
What are the 5 triage levels in ED
- critical
- emergent
- urgent
- nonurgent
- minor
ED short term stabilization
tx of individuals with acute needs immediately before delivery of definitive tx
What is tertiary care (relating to acute care)
specialty cause that requires highly-specialized equipment, expertise, and complex therapeutic interventions
What is quaternary care (relating to acute care)
extension of tertiary care
not offered in many places
Sub-acute care
inpt care by pt for non-acute care
(nursing home)
Chronic Care: long term care
assist with personal needs, for pts that have lost independence
Palliation: end of life care
final days of life care
hospice
What are the different types of hospital ownership
public (military, veterans, county)
not-for-profit (religious or secular)
for-profit (money given to shareholders)
physician-owned
What is the joint commission
accredits healthcare institutions
-must be accredited to get reimbursement
What is the drivers of costs in hospitals
highly trained personnel
medications
advanced technology
specialized services
What are the top 3 issues troubling hospital CEOs
workforce: personell shortage, burnout
finances: increase costs, medicaid/care
behavioral health/addiction issues
What is the advisory group that manages the formulary system
P&T committee (pharmacy and therapeutics)
What are the 3 government and charitable care services
community health centers (CHCs) - one stop shop
free charitable clinic - non-govt funded
local govt services - public health oriented services
What is complementary and alternative medicine (CAM)
c: used in conjunction with conventional medicine
a: used in place of conventional medicine
What are the 6 dimensions of patient-centeredness
respects pt values
coordination and integration of care
info, communication, education
physical comfort
emotional support
involvement of family and friends
What is the goal of NAM (national academy of medicine)
aims is to help those in govt and the private sector make informed health decisions by providing evidence open which they can rely
What is the goal of IHI (institute for healthcare improvement)
independent non-for-profit organization that is a leading innovator, convener, partner, and driver of results in health care improvement “world-wide”
What are the 5 dimensions in IHI
improve pt experience
improve population health
reduce costs
maintaining clinician well-being
advocating for healthy equity
What is the goal of NCQA (national committee for quality assurance)
independent organization that works to improve health care quality through the admin of evidenced-based standards, measures, programs, and accreditation
What are the 5-star ratings of CMS
adherence w/ statins
adherence w/ BP meds
adherence w/ DM
MTM completion rate of CMRs (# of MTM pt/pt in plan)
What are the 3 organizations focused on quality
NAM, IHI, NCQA
What are the 3 ambulatory organizations focused on quality
IDN, ACO, PCMH
What is the IDN (integrated delivery networks)
a formal system of providers and sites of care
-health insurance plan, healthcare services
in a defined geographic area
(increased pt satisfaction, communication, pt outcomes, cost-reduction)
What are the problems with IDNs
overpay for some physician practices
lack of single structure
improve in quality of care, but costs not decreasing
increased security risk with increased sharing of info technology
What is ACO (accountable care organizations)
healthcare providers work together
-collective accountability for quality and cost of care delivered to a specific pop of pts
Difference btw medicaid ACO and commercial
medicaid: exist and vary in implementation and payment structures
commercial: follow different financial and quality requirments
Eligibility for medicaid ACO health homes
pt has 2 or more chronic conditions
pt had 1 chronic condition and are at risk for another
pt has 1 serious and persistent mental health condition
What are the 5 key functions of PCMH
comprehensive care
pt centered
coordinated care
accessible services
quality and safety
Why are ACOs an improvement
medicare reward health care organizations that meet qoc and cost reduction goals
robust tech are being used to track and implement cost-control
large focus on reducing costs
What are the ACO trends
use telehealth has increased
removes structural barriers
reshaping delivery models
healthcare platers work together
Difference between PCMH vs ACO
healthcare delivery
-PMCH is a model that can be used by ACOs
reimbursement
-PCMH providers are not accountable for entirety of care, ACO entity has accountability
What is risk pooling
The larger the pool, the lower the cost, the better the coverage
Health insurance information asymmetry
One side of transactions has more info than the other side
The less info a party has, the harder it is to communicate
Health insurance perils of moral hazard
The trend towards more risky behavior when a person knows they are protected from future consequences
Copay, coinsurance, and deductibles are attempts to prevent moral hazard
Health insurance adverse selection
People at high risk for a health related event are more likely to seek health insurance coverage for that risk
Capitation
A fixed payment for health care regardless of the amount or types of services eventually rendered in the care of an individual
Help control healthcare costs
Collective buying power
The polling of resources by individuals to purchase goods and services at a discount
Difference between beneficiary, payer, dependent
Beneficiary: any individual enrolled in a health insurance plan
Payer: person who purchases the plan
Dependent: any other individual on the plan
Insurance companies are only allowed to adjust rates based on
Age
Geographic location
Family composition
Tobacco use
Admin cost for insurance companies
Medical loss ratio
Percent of premiums insurance company spends in clinical services and activities that improve quality
Copayment vs coinsurance
Pay: fixed dollar amount the beneficiary must pay for certain services
Insurance: percent of a bill the beneficiary must pay
Indemnity insurance plan
Simplest and most popular prior to managed care revolution
Beneficiary pays set premium and coinsurance to provider after deductible is reached
Insurance company pays majority of medical bills
Managed care organizations (MCO) insurance plan
Staff model: physicians employed and facilities owned by insurer, services for enrollees are limited to those HMO physicians/facilities
Group Model: lump sum payment
Open Panel: independent provider practices contracted
Cost control by HMO
Capitation annual prospective payment
pcps coordinated hmo pt care
Obtain prior authorizations for some services
Issues with hmos
Limited selection physicians and facilities
Pt disliked gatekeeping
Prior auth were burdensome
What are PPOs (preferred provider organizations)
Contacts with physicians called preferred providers
Beneficiaries pay lower out of pocket costs for using preferred providers
Point of service (POS)
Combo of HMO and PPO systems
Requires beneficiary to identify their PCP
Least common
Consumer driver healthcare plans
Encourage individuals to be more cost conscience of facilities, providers, and services
Most freedom is at the highest financial risk
Flexible spending accounts (FSA)
Employer provided funds for employers to use for out of pocket medical expenses
Unused funds do not roll over
Health savings account
Beneficiaries deposit into a health savings account
Tax free deposits and qualified withdrawals
Balances roll over
Health reimbursement account
Employer provide funds for employees to use for medical expenses Unused
Tax free
Employer manages fund
Finds roll over
Pros for societal perspective on ESI
Large proportion of Americans receive healthcare without government funding for directly insuring them
(Con: not universal, people pay more)
Medicare eligibility
65 yo and older
Disabled
Suffer from specific disease (ESRD, ALS)
Medicare part A coverage
hospitals, SNF, home health care, hospice
Transitional Medicare unlimited choice of facilities
Medicare part B coverage
Medical expenses, clinical lab services and screening, home health care, outpatient hospital treatment
Unlimited choice of physicians
Medicare part C coverage
Medicare + choice and Medicare advantage
HMO or PPO plan
Medicare part D coverage
Prescription drugs
Saves money
Objective of Medicaid
Provide port with financial assistance to meet their medical needs
Difference between federal and state govt for Medicaid
Federal: broad guidelines, promote and monitor program, provide financial assistance through matching agents
State: control scope and structure of program
Mandatory eligibility for Medicaid
Below 75% federal poverty level: elderly, disability
Below 133% poverty: pregnant women, children under 6
S-CHIP
Extends Medicaid coverage to children with family incomes above the 100% FPL minimum
US healthcare market is what 3 things
institutionalized, bureaucratized, extensively regulated
Problems of economic drivers of free market inefficiencies
information asymmetry
insurance as insulation
conflicting interests
tax subsidies
failure of competition
regulation
US healthcare is _________ rationed
economically
What is cost-shifting
an economic situation where one entity underpays for a good or service resulting in another entity overpaying (providers increase price to compensate for lost revenue)
Consequence of cost-shifting
to ensure insurer revenue margins remain sam they may raise premium or reduce/cut insurance benefits
Reimbursement models for physicians
fee for service
salary
per diagnosis
per patient
Reimbursement models for hospitals
fee for service
per diagnosis (DRG)
per patient
per year
per day
DRG (disease-related group)
flat rate paid for treatment linked to a diagnosis
hospitals are rewarded for tx of pt
Relative value units
method of quantifying physican’s work
-DIRECT work
-INDIRECT expense to practice
-INDIRECT cost of malpractice insurance
Each reimbursement system alters behavior
encourage certain provider behavior
discourages other behavior
Pay for performance (P4P)
method for quality improvement and cost control
reimbursement based on measure of clinical impact
combined with other forms of reimbursement
Value-based payment (VBP)
medicare scheme (provider must participate if want reimbursement)
modify payment based on quality measures
If value is not included in cost reduction, _______ will suffer
quality
Cost-driver waste in healthcare
med error
ADE
pt healthcare transitions
hospital acquired infections (HAIs)
overtreatment
overconsumption
overprices inputs
Some areas for improvement for healthcare waste
revising healthcare cost perspective
research
capitation (fixed amount for procedures)
reduce end-of-life cost
using electronic medical records (EMR)
What is health information technology (HIT)
the applications of electronic systems to organize and use health data
Goals of HIT
increase efficiency and reduce errors
transform healthcare delivery
General purpose of HIT
organizing and storing information
facilitate communication (reduce prescribing errors)
Computerized provider order-entry (CPOE)
document and submits order electronically
communicate issues with orders to provider
allows all providers with access to see care decisions being made by others
automate prior authorizations
Clinical decisions support (CDS)
monitor and alert providers to pt specific issues
help guide safe decision making
goals to prevent error, improve efficiency, enhance health outcomes, increase quality
Patient engagement tools
intended to increase pt participation in their care
What are the two basic communication needs in communicating health data
exchange health information
-evolved EMRs to EHR
interoperability
-ability of system to communicate w/ others
What was the American Recovery and Reinvestment Act of 2009 that incentivized programs to adopt EHRs implementation of 3 stages
starting/obtain EHR
meaningful use of EHR
reporting from EHR
Class 1, 2, and 3 for FDA (CRDH) devices
Class 1: low risk
Class 2: intermediate risk
Class 3: high risk
What are the 3 potential approval needs for classification of devices
A. registration
B. substantial equivalence
C. premarket approval
Class 1: A
Class 2: A+B
Class 3: A+B+C
