Midterm Review from class Flashcards
Medicare expands
in 1972, covered the disabled, ppl with end-stage renal disease requiring dialysis or kidney transplant, & ppl 65+ that select Medicare coverage
Poor house
also called Almshouse, provided general welfare by providing food and shelter to the poor
Pesthouse
Operated by local governments to act as a place of quarantine for contagious disease. Its main function was to isolated ppl and contain the spread of disease
Dispensaries
the 1st one was in 1786. They were created to act as out pt clinics. Provided free care to those who couldn’t pay. Provided basic medical care and dispensed drugs to ambulatory pts
First hospitals
it was developed in the 1850s. Poor sanitation and inadequate ventilation led to not great conditions. They were seen as houses of death
AMA
American Medical Association. It was founded in 1847. Founded to create a barrier between orthodox practitioners and “irregulars”
Germ Theory of Disease
Louis Pasteur is credited with creating it. Microorganisms called germs can lead to disease. By boiling things and washing hands, we can prevent the spread of disease causing germs
Medical Education
In 1756, one fo the first colleges for med school was established at the college of Philadelphia. Medical Education in the US was not as great as in Europe
Biggest cost of healthcare
The biggest cost of healthcare was traveling to get the care. This was the reason many people didn’t willingly go to receive healthcare
Clinton
Focused on the economy in 1992 due to recession and ran on school choice, balanced budget amendment, opposition to illegal immigration and support for NAFTA.
CHIP
provides federal matching funds to states to provide health coverage to children in families with incomes too high to qualify for Medicaid, but who can’t afford private coverage
Medicare Part D
Prescription drug, improvement, and modernization act of 2003 became law in Dec. 2003. Among other provisions, the MMA created the Part D drug benefit, which became available to Medicare beneficiaries on Jan 1, 2006. Voluntary out pt prescription drug benefit for people with Medicare, provided through private plans approved by the fed gov
Quad Function Model
Financing - having to finance for insurance
Insurance - pays the hospital or clinic
Delivery - developed health service delivery models to contain costs and provided quality and accessible care
Payment - philosophy of everyone contributing to the cost of health care according to their capacity to pay
Managed Care
Developed to contain healthcare costs & expenditures, seeks to achieve efficiency by integrating basic functions of healthcare delivery, employs mechanisms to control or manage utilization of medical services, determines the price at which services are purchased and how much providers are paid, most dominant healthcare delivery system in the US
Military
available free-of-charge to active-duty military personnel, well-organized & highly integrated system, combines PH with medical services, in general the military medical care system provides high-quality health care
Vulnerable populations
poor, uninsured, minority of immigrant status, live in geographically or economically disadvantaged communities, receive care from “safety net” providers and pt’s have to forego care or seek care in hospitals emergency departments, subsystem faces enormous pressure
Integrated delievery
the hallmark of US healthcare industry over the past decade and becoming larger, org integration to form integrated delivery systems or networks
Long Term Care
Medical and nonmedical care that is provided to individuals who are chronically ill or who have a disability, healthcare, and support services for daily living, not covered by Medicare, LTC insurance if offered separately
Third party payers
pt is first payer, provider is second payer, intermediary is third party
Imperfect Market
Factors limit pt’s decision, item-based pricing, phantom providers, package pricing
Defensive medicine
a way to avoid litigation
Access
the ability of individuals to obtain health care services when needed
Indicators of health
things you can measure (life expectancy, mortality, morbidity, etc.)
Determinants of Health
environment, behavior and lifestyle, hereditary, medical care
illness
a feeling, an experience of unhealth
disease
a pathological process, most often physical
3 phases of disease
normal state, pre-disease state, disease state
primary prevention
activities undertaken to reduce the probability that a disease will develop in the future (handwashing)
Secondary prevention
the early detection and treatment of disease (screening for cancer)
Tertiary prevention
interventions that could prevent complications from chronic conditions and prevent further illness, injury, or disability (rehab therapies can prevent permanent disability)
Incidence
the total number of cases at a specific point in time, in a defined population
Information systems
clinical info systems, admin info systems, decision support systems, internet and e-health
Class I medical devices
pose the lowest risk, require general controls regarding fraudulent claims
Ex: box of bandaids
Class II medical devices
subject to labeling and performance standards, and post-market surveillance
Ex: wheelchair
Class III medical devices
Devices that support life, or present a potential risk of illness or injury. Require premarket approval regarding safety and effective. Most regulated
Ex: pacemaker or breast implant
Inpatient
Overnight stay in hospital. Hospital has to have at least 6 beds
Hill Burton Act
Federal grant to the states to construct hospitals. growth of hospitals in the 50s and 60s
Medicare reimbursement change in 1980
In 2018: 2.4 beds per 1000 ppl
Since the mid 1980s due to: change in reimbursement (medicare switches to PPS), managed care - cost containment, hospital closures
Reimbursed
Total payment to the hospital is fixed at 101% of reasonable costs
Critical access hospitals
medicare designation for small rural hospitals with 25 or fewer beds that provide emergency medical services in addition to short-term hospitalization for pt’s with noncomplex healthcare needs.
Outpatient Care
-used interchangeably with ambulatory care
-Term initially meant diagnostic and therapeutic services and treatments provided to the ‘walking’ ambulatory patient
Outpatient services
any healthcare services that don’t require an overnight stay in an institution of healthcare delivery
Primary reasons for growth of out pt services
the payers like it because it costs less, technology, and pts want ot be at home
Types of out patient care
physician offices, hospital out pt departments, hospital emergency dep, home health agencies, surgery centers, chiropractors, mobile diagnostic, and screening services, telephone triage, community health centers and free clinics, alternative medicine clinics, hospice
Primary care
basic and routine care provided in an office or clinic by a provider who takes responsibility for coordinating all aspects of a pt’s healthcare need, an approach to healthcare delivery that is the pt’s first contact with the healthcare delivery system and the first elements of a continuing healthcare process
Secondary care
Routine hospitalization, routine surgery, and specialized out pt care, such as consultation with specialists and rehab. Compared to primary care these services are normally brief and more complex, involving advanced diagnostic and therapeutic procedures
Tertiary care
the most complex level of care, which is typically institution based, highly specialized and highly technological.
Ex: burn treatment, transplantation, coronary artery bypass surgery
Primary Prevention
In a strict epidemiological sense, the prevention of disease
Ex: health education, immunization, and environmental control measures
Secondary prevention
efforts to detect disease in early stages to provide a more effective treatment
ex: screening
Tertiary prevention
interventions to prevent complications from chronic conditions and avoid further illness, injury, or disability
gatekeeper
pt’s come “through” primary care physicians to hospitals and specialists
Coordination of care
PCP coordinated the delivery of care from many sources
outcomes of primary care
1st contact, gatekeepers, longitudinal, holistic, focus of education is variety
What is long term care?
A variety of individuals, well-coordinated services that are designed to promote the maximum possible independence for people with functional limitations. These services are provided over an extended period to meet the patient’s physical, mental, social, and spiritual needs, while maximizing quality of life.
Reimbursement of LTC
-Medicare doesn’t cover most LTC services
-Medicaid requires spending down most of one’s assets to poverty levels to qualify for LTC coverage
-As the cost of LTC rises, most ppl are likely to have few options for paying for such care
-Most are unprepared to cope with high risk of needing LTC in their retirement years, a period when incomes from most ppl also dwindle
-Public policy created few incentives to spur LTC insurance growth
-ACA did little to address LTC dilemma
-Medicaid and Medicare expenditures for LTC will be unsustainable in long term
ADLs
-Activities of Daily Living
-The most commonly used measure of disability, which includes whether an individual needs assistance to perform basic activities such as eating, bathing, dressing, toileting, and getting into/out of bed/chair
IADLs
-Instrumental Activities of Daily Living
-A person’s ability to perform household and social tasks, such as home maintenance, cooking, shopping, and managing money
Palliation
Serving to relieve or alleviate, such as pharmacologic pain management and nausea relief
Adult day care
a daytime program designed to meet the needs of functionally and/or cognitively impaired adults and to provide partial respite to family caregivers so they can work during the day. Designed for ppl who live with their families but can’t remain alone during the day
Adult foster care
a service characterized by small, family run homes providing room, board, and levels of supervision, oversight, and personal care to non-related adults who are unable to care for themselves. Community based dwelling in an environment that promotes the feeling of being part of a family. 10 beds per family
MOW
Meals-on-Wheels is a home delivered meal system for homebound persons who cannot prepare a nutritionally balanced noon meal for themselves
Emergency response
provide at-risk elderly persons with an effective & convenient means to summon help if an emergency occurs. Using a transmitter unit, the individual can activate an alarm that sends a medical alert to a local 24 hr response center
primary care
physician is a specialist in family medicine, general internal medicine or general peds
hospitalists
physicians who specialize in the care of hospitalized pts
physician-owned hospitals
prohibits physician-owned hospitals from expanding their facilities capacity
HMO - health maintenance organizations
a type of managed care organization that provides comprehensive medical care for a predetermined annual fee per enrollee
PPO (preferred provider orgnaization)
a type of managed care org that has a panel of preferred providers who are paid according to a discounted fee schedule. The enrollee have the option to go to out-of-network providers, but incur a higher level of cost sharing for doing so.
Moral hazard
the overuse of healthcare services on forgoing of prevention because the insured individual doesn’t bear the full costs of the consequences
risk
refers to the possibility of a substantial financial loss from an event
insured/enrollee
an individual who is protected by insurance against the possible risk of financial loss is called the insured. The insured is also referred to as the enrollee or the beneficiary
Underwriting
systematic technique for evaluating, selecting or rejecting, classifying and rating risks
cost sharing
sharing costs of healthcare so that the insurer assumes at least part of the risk
deductible
the amount the insured must first pay before any benefits by the plan are payable
copayment
the amount that the insured has to pay out of pocket each time health services are received after the deductible amount has been paid
coinsurance
cost sharing in the form of a percent amount 80/20
stop-loss provisions
called reinsurance to decrease the high losses so they wont go broke
means-tested
government programs available only to individuals below the poverty line
medicare covers
65+, ppl with end-stage renal disease, certain younger ppl with disabilities
Medicare doesn’t cover
vision, glasses, dental care, hearing aids, many long-term care services
medicare is administered by
fed agency - CMS
medicare is financed by
fed gov through tax dollars, premiums, deductibles, and coinsurance payments
Medicare A
hospital insurance; covers inpatient hospital stays, care in skilled nursing facilities, hospice care, some home health care
Medicare B
medical insurance - covers certain doctors’ services, outpt care, medical supplies, and preventative services
Medicare C
Medicare Advantage - covers routine dental care, vision care, hearing care, and wellness programs
Medicare D
Prescription drug coverage - helps cover the cost of prescription drugs
Medicare A covers…
inpatient services, short-term convalescence and rehab in an SNF, home health and hospice
Medicare A benefit period
begins on the day the pt is hospitalized. End when the pt has not been in a hospital or SNF for 60 consecutive days. After - new benefit period begins
Medicare A: hospital understand the graphs
deductible paid for in the first 60 days, copay is required from 61-90 days, after 90 days the copayment increases, after 150 days the pt pays. Starts back at 0 after 60 days out of hospital
Medicare A: SNF understand the graphs
starts after 3 nights in the hospital, first 20 days free, after 20 days pay a copayment, after 100 days pt pays. Starts over at 60 days out
Medicare A: Hospice
Pt must be terminally ill, only a small copayment required
Medicare A: Home health
pt must be homebound and require nursing care or rehab care
Medicare B covers
physician services, ED services, OP surgery, OP therapies, OP mental health services, medical equipment and supplies, rural health clinic services, annual physical exam
Medicare B doesn’t cover
dental services, hearing aids, eyeglasses, services not related to treatment or injury
Medicare C covers
includes additional benefits such as dental and vision, still includes part A and B.
Medicare C doesn’t cover
prescription drugs
Medicare D covers
prescription drugs
Medicaid
covers ppl under the poverty line, jointly financed by state and fed gov, each state administers its own medicaid program
CHIP covers who
those with income up to 200% of the poverty level, but just for children
CHIP is financed by
fed and state funds
CHIP is administered by
each state administers their own programs
IHS covers
American Indians and Native Alaskans
IHS: why?
to serve the healthcare need of native ppl, and to provide funds for tribal and urban indian health programs
IHS issues
lack of clarity and understanding regarding the IHS’s formal structure, policy, and roles
Prospective Payment System Jude
Ex: diagnosis-related groups (DRG) for inpatient services
Retrospective payment system
the amount paid is determined by what the provider charged or said it cost to provide the service after tests or services had been rendered to beneficiaries
Harry Truman
1946, made an appeal for national healthcare program
Union negotiations
1948, US Supreme Court ruled that health insurance is legitimate in union-management negotiations
Deinstitutionalization
1963, Community Mental Health Centers Act passed supporting “deinstitutionalization” of ppl with mental illness
