Midterm Review from Quizlet Flashcards
Poorhouse
Provide food and shelter for people who are poor
Pesthouse
Facility to quarantine people with diseases
Dispensaries
Outpatient clinics with free care. Help the poor and give physicians experience
First hospitals
1850s, bad conditions, lack of resources, unhygienic practices, houses of death
What were some scary health care practices at the time (pre-industrial)?
no schooling, blood letting, no licensure, no real science
AMA
American Medical Association; 1847
What is the primary purpose of the AMA in the beginning
Protect the financial interest of physicians
Germ Theory of Disease
Louis Pasteur boiling technique
Medical education
Medical education reformed and licenses required
Domestic Character
family and home (a lot of families helping, home remedies, praying for you)
Biggest cost of health care
traveling expenses and low wages
Baylor plan
Dallas, 1200 teachers paid per month for hospital care
Blue Shield
Med expenses, nonprofit med care insurer in the US
Harry Truman
Wanted national HC program but AMA opposed (socialized med)
Union negotations
SC ruled health care can be an employee benefit - insurance grew
Deinstitutionalization
1940s and 50s psychotropic meds
Where exactly did people with mental illness receive treatment before and after psychotropic meds?
Before, they would go to jails or be like tied up and taken away. After meds, they went to community centers where we mange them and their meds
Amendment to the SSA and YEAR
1965 Medicare and Medicaid Progams
Medicare Expands
Allows ppl with disabilities (unable to work for 48 months) to be covered with insurance and also what other groups… this group has a specific condition?
Clinton
Wanted to reform the healthcare system, but ppl feared taxes
CHIP
Children’s Health Insurance Program, the program is funded both fed and by the states, it covers children whose parents make too much money to be covered Medicaid, but no enough money to afford private insurance
Medicare Part D
covers prescription drugs, worked with other insurances
Which is more politically charged and why? Medicaid or CHIP?
Medicaid is more politically charged, we don’t want to pay for adults
ACA (and YEAR)
ACA passed on 2010. Also known as Obamacare. Goal of this was to make affordable healthcare insurance available for more ppl.
Supreme court ruled on 2 aspects of ACA
Individual mandate and medicaid expansion. The individual mandate passed but the medicaid expansion didn’t
What group was the medicaid expansion targeted toward (hint: has to do with FPL)?
133% of fed poverty level
What was the AMA’s stand regarding the ACA? What was their position regarding earlier legislation aimed at healthcare reform?
The AMA supported the ACA but they haven’t always supported healthcare reform, like Clinton and Truman
Financing
Employer/Individual buys insurance
Insurance
Agency/government determines insurance package
Delivery
Provider delivers services
Payment
Reimbursement of the provider via insurance/out of pocket
What is the approx percent of GDP that we spend on healthcare?
17-18%
Why is the government successful in regulating private practice?
Because medicare and medicaid cover over half of healthcare expenditure so if medicare and medicaid won’t fund it you won’t do it, everyone wants to be reimbursed from medicare and medicaid
Managed Care
They have contracts with healthcare providers and medical facilities to provide care for members at reduced costs HMO, PPO
HMO
Health Maintenance Organization
PPO
Preferred Provider Organization and these are more popular
Military Tricare
Insurance arm of the military health care system
Veterans’ Health Administration
-Including hospitals, outpatient clinics, nursing homes and various other facilities
-Vulnerable populations
IHS
IHS services are administered through a system of 12 Area offices and 170 IHS and tribally managed service units
Medicaid
Finances healthcare for the indigent, but not all poor
Medicare
Finances medical care for those 65+, ppl with disabilities, those with end-stage renal disease
CHIP
to make sure that kids whose parents were making too much to qualify for Medicaid, but are burdened by the cost of the cost of premiums from their employer-based health insurance are covered
Long Term Care
Home health care, adult daycare, adult foster emergency response, skilled nursing facilities, subacute, specialized LTC
Third Party Payers
-an entity that pays medical claims on behalf of insured
-pt is first party, provider is second party, intermediary is third party
-the wall of separation between financing and delivery
Technology
-First world countries love technology and think it’s better than simple, preventive measures
-We want the best technology for healthcare and often don’t look at cost
Moral Hazard
-Behavior that increases the use of unnecessary technology, tests, services because the pt isn’t paying out of pocket
-The pt wants to get all they can from health insurance, medicare, medicaid, etc.
-Clinician wants to make the pt happy. Sometimes the clinician makes more money w/o impacting the pt
Imperfect Market
Interference of third party payers, ppl don’t shop for healthcare, pt’s don’t bear the cost directly which leads to overuse
Lobbyists
-Lobbyists for professional organizations, drug companies, employers, physicians, large health systems
-All protect their own financial interests and not always the interest of the pt
-Self-interests of payers are often at odds.
Defensive Medicine
Practice ordering unnecessary tests and procedures because of fear of litigation. The US is a more litigious society than other countries which basically means we will sue
Market Justice
-This approach to healthcare is very individualistic and on the terms of self-interest and personal effort.
-It’s based on the individual resources and choices for the distribution of healthcare with the smallest sense of gov collaboration
Social Justice
Allocates goods and services according to the individuals needs, it stems from the shared responsibility and concern for communal well being
What are magnet hospitals?
hospitals that attract top nursing talent, great nursing
Access
Access to healthcare is very important, and access itself means the timely use of personal health services to achieve the best health outcomes
Indicators of health
health indicators are quantifiable characteristics of a population, such as low birth rate, obesity or diabetes
Examples of health indicators
Spirituality, death rates, mental health, physical wellbeing
Determinants of Health
The range of personal factors that influence the health status of individuals or populations
EX: genetics, behavior, environment or physical influences
Illness
a person’s perception of how he/she feels
Disease
Diagnosis based on a clinician’s determination
Acute
Relatively severe, episodic, often treatable. Myocardial Infarction or aneurysm
Subacute
Between acute and chronic, has some acute features.
Artificial ventilation, head trauma care
Chronic
less severe, long and continuous duration, person may not fully recover. Asthma, arthritis, diabetes, and COPD
Primary
Immunizations and education - upstream
Secondary
BP screenings, cholesterol testing
Tertiary
Glucose monitoring/control for pt with diabetes; wheelchair cushion to prevent pressure ulcers
Incidence
the number of new cases of disease in a defined population within a specific period, such as month or a year. High levels of incidence could indicate an epidemic
Prevalence
the number of cases of a given disease in a given population at a certain point of time
What does non-profit really mean in regards to non-profit hospitals?
funded by charity; religion or research education funds. They benefit the community; they don’t pay federal income or state and local property taxes
Clinical information systems
electronic health records
Administrative Information Systems
payroll
Decision Support System
Workload management, predict pt volumes
Internet/E-health
learning about health on the web
Class I
Bandabes and gauze
Class II
Wheelchairs and crutches
Class III
Pacemakers and breast implants
Inpatient
defined as on overnight stay in the hospital
Hill Burton Act
fed grant to the states to increase number of hospitals in the 50s/60s
Medicare reimbursement change in the 1980s reverse effects of Hill Burton Act
less hospital beds
Primary Care
refers to the first contact providers of care who are prepared to handle the great majority of common problems for which pt’s seek care
Secondary Care
Medical specialist and other health professionals who typically don’t have initial contact with pts, but provide secondary care
Tertiary Care
pt’s being treated require a higher level of care in a hospital
Primary Prevention
an intervention that occurs before onset of the disease
Secondary prevention
early detection of disease or risk factors and intervention during an asymptomatic phase
Tertiary prevention
an intervention that occurs after the initial occurrence of symptoms but before irreversible disability occurs
What idd the ACA mandate for nonprofit hospitals?
they have to prove they are actually helping the community
Gatekeepers
1st contact; control access to services and refer specialists
Coordination of care
organizing and sharing pt information, ensure high-quality referrals
Outcomes of primary care
better overall health, less doctor vists
ADLs
Activities of Daily Living- basic self care - eat, bathe, etc.
IADLs
Instrumental Activities of Daily Living - more complex - shopping, driving
Palliation
relieve or alleviate - such as pain management - in quality of life
What are the options for people who make too much money for Medicaid, but would struggle to pay the $6,000 per month LTC facility bill?
The family has to take care of them, sell or give away all assets for Medicaid to pay or go broke paying for it
HHS
Community LTC is overseen by the Department of Health and Human Services
What agency organizes MOW?
SS, Churches and senior centers
People who are admitted to LTC facilities see a greater _____ than those who age in place and receive community LTC
declines in ADLs and IADLs
ALF
Assisted Living Facility - provides personal care, 24 hour supervision, social services, recreational activities, nursing & rehab services
-appropriate for ppl who can’t function independently but don’t require SNF.
SNF
Skilled Nursing Facility - typical nursing home at the higher end of institutional continuum
-Pt’s generally transferred from hospital to SNF after acute episode, & the care needs of the pt’s have become more complex, requiring higher levels of staffing for SNFs
Subacute
Post acute services for ppl who remain critically ill during post acute phase of illness/injury or who have complex conditions that require ongoing monitoring & treatment/intensive rehab.
-4 categories of subacute care services: extensive care, special care, clinically complex, intensive rehab
Specialized
Provide services for individuals w/ distinct medical needs. Some examples: specialized units for pt’s requiring ventilator, wound care, intensive rehab, closed head trauma, or dementia care
Primary care providers (PCP) education
focuses on a variety of areas in health care
Specialized providers education
focuses on tech and dealing w/ illness episode
Stark Laws
-Prohibit a physician from doing self-referral to facilities in which they have ownership interest.
-Prohibit physicians who have a financial relationship w/ a third-party from referring to a third party
Hospitalists
specialize in care of hospitalized pt’s results: higher quality of care and improved pt satisfaction
Maldistribution of HC workers
-refers to surplus/shortage of HC workers geographically: urban areas have more PCPs per 100,000 ppl than rural areas
-speciality: 58% specialists and 42% PCPs result: high volumes of expensive care; not enough care for vulnerable pop; not enough preventative care
Critical access hospital reimbursement
101%
What provisions of the ACA are critical access hospitals exempt from?
the readmissions, they allow readmission without losing money
HMO
Healthcare Maintenance Organization, usually cheaper premiums, capitation, typically need a referral, out of network providers may not be covered
What aspects of primary care are not reimbursed and likely should be?
Coordination or care and educating patients and preventive care
What pays for most institutionalized LTC
Medicaid and out of pocket
PPO
Preferred Provider Organization, higher premiums, uses discounted fee-for-service, offers more choice of providers
Insured
Being covered by insurance
Enrollee
A person signed up for something
Beneficiary
A person who gains advantage of something. Like a trust, will, or life insurance policy
Underwriting
The act of seeing how much risk the person may be, such as underlying illnesses and charging them more for the services they may need
What is the largest reimbursement system for HC in the US?
Employer based health insurance
Cost sharing
sharing of costs of health care so that the insurer assumes at least part of the risk
What can cost sharing theoretically prevent?
Overutilization of HC services
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
this is the same as the annual out of pocket maximum
-Its the maximum amount of money required to be apid each year by the unsured
Means-tested
limited eligibility to the people below a predetermined income level
What is a means-tested program in the US?
Medicaid
Which of the above percents does the enrollee typically pay?
20-25%
Medicare overview
covers who, 65+, ppl with end stage renal disease, and certain younger ppl with disabilities
-doesnt cover dental, vision, hearing aids, and many long term care systems Administered by - Centers for Medicare and Medicaid Services
-Financed by Fed government
Medicare A
-hospital care; covers inpatient services, home health, hospice, and rehabilitation in a SNF All working individuals pay this tax. Paid on all income earned.Paid equally Covers - inpatient hospital services to those that are: 65 and older People with disabilities that are entitled to Soc. Security those with end stage renal disease
Medicare B
- covers certain screening and preventative services; funded by general taxes Outpatient Coverage such as doctor’s office visits and outpatient hospital services
Medicare C
- covers vision, hearing, and dental; combination of part A & B
Medicare D
- covers prescription drugs; offered by private insurance companies
Why are there new restrictions, with the ACA, that require more documentation and quality reporting of home health services?
There are now more restrictions because people that were utilizing home health services were not reporting and documenting the services and were getting thousands, sometimes millions of dollars of care for free.
Are there premiums for Med B?
-Medicare recipients have an income-related premium, this means the rich will pay more per month in medicare B premiums
How did the ACA address the donut hole?
They phased out the coverage gap by gradually reducing the share of the total drug costs
Donut Hole
coverage after your initial coverage period. You enter the donut hole when your total drug costs including what you and your plan have paid for your drugs reaches a certain limit.
Who is entitled to IHS benefits and why?
An individual who has not reached the age of 19 years old and is a child of Indigenous American/ alaskan native an eligible in. I am not positive of why this is, but I assume it is because the parents of the child are, and for example the kid may have been adopted by its guardians.
Per capita, expenditures for inmates are ____ than expenditures for IHS beneficiaries
Greater
Prospective Payment System
A method of reimbursement in which medicare payment is based off of a fixed, predetermined amount. Examples are how much a hospital is paid for an MRI for a Medicare patient.
Retrospective payment system
The amount paid is determined by what the provider charges or says it is to cost after tests and services have been administered (fee-for-service)
Distributive
benefits everyone, not only certain groups of ppl
Redistribute
take money or power from one group and give it to another, this makes health policy politically chargedExample Medicare and medicaid
Decentralized
the fed government isn’t in power, typically states have more power
Medical Model
This can contribute to higher cost of healthcare if the pt got a test done that didn’t need to be done
Admin costs
Billing and insurance makeup the largest part of administrative health care costs.
Defensive medicine
overutilization of tools to protect oneself
Shopping
compare international expenditures, assess private sector insurance premiums and government spending to maintain expense levels and prevent unnecessary spending
Quality assurance
Refers to activities and programs intended to “assure” or promise improvement in quality of care in a defined medical setting or program.
Risk management
the goal is to reduce and prevent adverse events in a healthcare setting
AHRQ
Agency for Healthcare Research and Quality, clinical practice, protocols, improving
Federally Qualified Health Centers
Community based health care providers that receive funds from HRSA to provide primary care in underserved areas.
Hospital Readmission Reduction Program
This is a medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans and reduce avoidable readmissions.
Individual mandate
all legal residents of the United States either have what the law had designated as “minimum essential coverage” or pay a penalty tax
Categories of Maldistribution
geographical and specialty vs PCP
Asynchronous
not real time, x-rays
17% of GDP
healthcare expenditure
What is the function of the NIH
med research
What happened when their was a decline in hospital procedures
outpatients clnics boomed
Joint Commission
certifies hospitals, they receive reimbursement from government
If you are uninsured, how much HC services do you use?
less, barely any
Synchronous
live and happening in real time
what drove employer based HC
union negotiations after WWII
State licensure
the hospital gets to open its doors
Who is legally responsible for hospital operations
board of trustees
“Does the ACA mandate the federal government to control healthcare services”
False
What was the ACA’s purpose
Insurance reform
