Pub Health Exam 2 Flashcards
Who is eligible for Medicaid?
People of all ages with low income and resources
Who is eligible for Medicare?
program for the aged ( 65+) and certain disabled people
Different parts of Medicare and what each part covers.
a. Medicare Part A: Hospital Insurance Program (covers inpatients hospital services, skilled nursing facility benefits, home health visits and hospice care)
b. Medicare Part B: Supplementary Medical Insurance (covers DME-Durable Medical Equipment) (physician services, outpatient hospital services, cancer screenings, lab procedures, and durable medical equipment)
c. Medicare Part C: Medicare Advantage
d. Medicare Part D: Prescription Drug Program
What is state CHIP?
a. Provides health coverage to children in families with incomes too high to qualify for Medicaid, but can’t afford private coverage
b. Administered by the states
c. Jointly funded by the federal government and states
d. Copays based on federal poverty level
Private insurance and its role in the US healthcare system:
a. Bulk of US healthcare system
b. Primary source of coverage for most Americans
c. Administered by a central organization
d. Ex: employer, government agency, private business
e. Target of current healthcare reform
Different payment methods for reimbursing healthcare providers:
Fee for Service Today
a. Providers no longer determine own fees
b. State Medicaid programs set the amounts they are willing to reimburse for each service
c. Some providers do not take Medicaid patients due to low reimbursement rates
d. Medicaid reimbursement fees adjust for level of effort providers put into delivering service
e. Medicare fees usually higher than Medicaid
f. Private insurers followed lead of public insurance programs in reimbursement strategies
What is the main threat to the US healthcare system?
Main threat: rapidly escalating healthcare costs
How is the US doing in terms of healthcare costs versus health outcomes?
(Healthcare Reform)
a. Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies
b. Expand the array of health care providers consumers may choose among
c. Improve the access to health care specialists
d. Improve the quality of health care
e. Give more care to citizens
f. Decrease the cost of health care
IHI’s Triple Aim
a. Developed by the Institute for Healthcare Improvement (IHI)
b. Describes approach to optimize health system performance
c. Goals:
i. Improving patient experience of care
ii. Improving the health of populations
iii. Reducing the per capita cost of health care
What is Biostatistics?
Branch of statistics responsible for the interpretation of scientific data generated in biology, public health and other health sciences.
Different tools used by PBMs
a. Formulary Systems
i. List of drugs recommended for use by a health plan
ii. Run by P&T Committees
iii. Evaluated drugs for safe, efficacious, and cost
b. Drug Utilization Review (DUR)
i. Retrospective review-detect patterns of misuse, abuse, or fraud
ii. Concurrent review-review of current procedures
iii. Prospective review-review and approval of services before they are provided
c. Step Therapy
i. Plan may require use of a designated drug of choice as first-line therapy before other more expensive products can be prescribed
d. Prior Authorization-
i. Plan gives approval for an exception to the plan’s restrictions when there is a good reason for doing so
e. MTM- Assure appropriate use, optimize therapy, decrease adverse reactions
What is pharmacoeconomics?
a. Used to determine which alternative produces the best health outcome for the resource invested
b. Most impactful when making decisions about a population rather than individual
c. “Costs vs. Consequences of Alternatives”
What is the difference between quantitative and qualitative study methods?
a. Qualitative methods: Research methods designed to obtain descriptive data regarding the experiences, opinions, and observations of interested parties
b. Quantitative methods: Traditional experimental methods designed to determine relationships among numerically measured variable
What is epidemiology?
- A core public health discipline
a. Epidemiology is “the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.” –CDC
b. The basic science of public health
c. Greek roots (epi = on, upon, among; demos = the people, population; ology = study of)
d. “The study of what is upon the people”
e. The study of epidemics
f. Population-based study of disease occurrences
What are the objectives of epidemiology?
a. Identify the etiology, or cause, of disease
i. Identify relevant risk factors
ii. Identify methods of disease transmission
b. Determine the extent of disease found in the community
i. Burden of disease (important to know to help in allocating resources)
c. Study the natural history and prognosis of disease
i. Need to develop new modes of intervention and treatment
d. Evaluate preventive and therapeutics measures of healthcare delivery (new and existing)
e. Provide a foundation for developing public policy
What is meant by “burden of disease”?
a. Burden of disease (important to know to help in allocating resources)
___________ = the incidence of disease or disability; A diseased state or symptom
Morbidity
___________ = death rate
Mortality
___________ = normal occurrence of a condition in a specific population (Ex: Malaria in Africa)
Endemic
___________ = greater than normal occurrence of a condition in a specific population (Ex: Obesity in America)
Epidemic
