Study guide for the final, part 8 Flashcards
CHIP is under what legislation?
Title XXI of SSA
Aspects of CHIP
Federal block grants to states to expand Medicaid eligibility
First enroll in Medicaid if qualify
No federal income threshold, but typically for children (up to age 19) in families with incomes up to 200% of federal poverty level
Purpose of CHIP
Cover children whose families’ income exceeded the Medicaid threshold levels
Reimbursement definition
Determination of methods and amounts of reimbursement in advance of delivery
Disbursement defintion
Actual payment after services have been rendered
Charge definition
A price set by provider
Rate definition
A price set by a 3rd party payer
Fee schedule definition
An index of charges listing individual fees for each type of svc
Aspects of capitation
Per member per month (PMPM) fee to cover all needed svcs
Monthly fee = PMPM rate x number of enrollees
Minimizes provider induced demand and promotes prudence
Aspects of primary care
Plays a central role in a HC delivery system
Basic, routine, continuous, coordinated and comprehensive care
An approach to delivering HC rather than a set of svcs
Address personal HC needs
Develop a partnership with pts
Practice in the context of family and community
What does primary care focus on?
Prevention
Diagnostic
Therapeutic svcs
Health education
Counseling
Minor surgery
What types of prevention does primary care include?
Primary
Secondary
Sometimes tertiary
What are the 3 elements in the WHO definition of primary care?
Point of entry
Coordination of care
Essential care: primary HC as essential HC
How is primary care a point of entry into the HC system?
The first contact a pt makes with the delivery system
Role of a gatekeeper
Aspects of coordination of care of primary care
Delivery of health svs between the pt and the different components of the delivery system
Refer pts to sources of specialized care
Give advice regarding various dx and therapies
Discuss tx options
Providing continuing care of chronic conditions
What is the goal of primary care?
To optimize pop health
What aspects of primary care are part of the IOM’s definition?
Integrated
Comprehensive
Coordinating
Continuity: care over time
Accessibility
Accountability
Reasons for growth in outpt svcs
Changes in reimbursement
Fewer payment restrictions
Development of new tech
Utilization controls by managed care
Social factors
What does home health care include?
Nursing care
Medication monitoring
Bathing
Short-term rehab (PT, OT,ST)
Homemaker service (meal prep, shopping, transportation, medical equipment, chores)
Durable medical equipment (DME): wheelchairs, oxygen, beds, walkers, commodes
Aspects of case management
Coordination and referral
To find the most appropriate care
Definition of a hospital
An institution with at least 6 beds whose function is to deliver pt svcs that include diagnostics and tx
What contributed to the hospital downsizing from the mid-1980s onward?
Changes in reimbursement
Impact of managed care
Hospital closures
What is ALOS an indicator of?
Severity of illness and resource use
Details about hospital certification
Not mandatory: required only if a hospital wants to participate in Medicare and Medicaid- most do
A federal function
Hospitals must comply with the “conditions of participation”, federal standards for health, safety, and quality
Currently focus on quality of care delivered and the outcomes of that care
Details about hospital accreditation
By the Joint Commission of American Osteopathic Association
A private undertaking
Voluntary
It confers deemed status on hospitals: met certification standards
