Term
| What is the Iron Triangle? |
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Definition
1. Access
2. Cost
3. Quality
-->Altering one will likely alter the others |
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Term
| What is the Medical Care System? |
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Definition
| System of arrangements which exist in our society for the purpose of mediating between man and his vulnerability to Dz |
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Term
| What is the Purpose of the Medical Care System? |
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Definition
-Cope with illness
-Prevent illness
-Maintain health |
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Term
| What are the Components of the Medical Care System? |
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Definition
-Person
-Professional
-Social |
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Term
| What are the levels of prevention? |
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Definition
1. Primary: prevent Dz process from ever getting started (immunizations; decreased 2* smoke)
2. Secondary: early detection (mammograms, pap smears)
3. Tertiary: Dz present, Tx it so as to prevent further complications (cardiac rehab post-MI, DMI mgmt) |
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Term
| What is the greatest preventable cause of Dz (COD)? |
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Definition
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Term
| Define the difference between Medical Care and Health Care |
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Definition
-Medical Care: care that a doctor or PA gives --> Clin Med
-Health Care: responsible for education/prevention, screening, social aspects |
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Term
| What is the Role of Personal Responsibility in health? |
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Definition
| Health is, to a large degree, a matter of personal responsibility that must be exercised within limits of genetic endowment. As a general rule, medical care has relatively little impact on health. |
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Term
| What are the top 3 causes of death in 1900? |
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Definition
-Infectious Dz causes
1. Pneumonia
2. TB
3. Diarrhea and enteritis |
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Term
| What are the top 3 causes of death Today (1999)? |
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Definition
-Lifestyle
1. Heart Dz
2. Cancer
3. Stroke |
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Term
| How much money goes into Dz prevention and Public health? |
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Definition
-Dz prevention/Health Promotion: 10%
-Public Health: 3% |
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Term
| Discuss Medical training between 1604-1860 |
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Definition
-Training through apprenticeships; no MD licensure
-No organized method for Tx |
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Term
| What percentage of Physicians are members of the AMA? |
|
Definition
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Term
| How did the Flexner Report impact medical schools? |
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Definition
Rated and eliminated medical schools not meeting expectations. Ratings based on:
-Entrance requirements
-Faculty
-Financial support
-Lab quality
-Relationship with hospitals |
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Term
|
Definition
| PCP controls all referrals; pts cannot see specialist or receive tests without PCP referrals; PCP provides preventative care |
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Term
| What is a Pt Centered Medical Home? |
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Definition
| Pt uses one doctor/facility as their "medical home"; medical home provider monitors all pts on panel and coordinates all care; pt has responsibility to inform medical home provider if she seeks care outside of the medical home |
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Term
| What are the Principle Problems in the US medical system? |
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Definition
-We are spending too much, not too little (wasteful Tx)
-We are spending too little, not too much (low access)
-The rise in costs has been uncontrollable by any interventions tried to date [Major factors: aging population, technology growth, increasing demands]
-Distribution of health services is highly variable throughout the population
-Much that could be done to prevent Dz and promote health using available knowledge and techniques is not done; not good at encouraging diets, exercise
-Many health needs are under-met while others are over-met |
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Term
| What are the Advantages and Disadvantages of a Regionalized Health Care Model? |
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Definition
Advantages:
-Provides better distribution of primary to specialty care providers and facilities
-Emphasizes multidisciplinary approach to primary care
-Strong planning focus
Disadvantages:
-May require pt to travel for tertiary care
-Doesn't allow patient self-referrals |
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Term
| What are the Advantages and Disadvantages of a Dispersion Health Care Model? |
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Definition
Advantages:
-Patient freedom of referral and convenience of service
-Greater role for primary care "specialists"
-May promote greater competition/innovation
Disadvantages:
-Weak planning focus
-Geographic mal-distribution fo hospital beds and providers and mal-distribution of generalists vs specialists |
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Term
| What are the Advantages and Disadvantages of a Solo Practice? |
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Definition
Advantages:
-Autonomy of practice style and parameters
-Personal relationships with pts
-Low level of bureaucracy
Disadvantages:
-Increased competition
-Full financial risk
-Time commitment
-Administrative responsibilities |
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Term
| What are the Advantages and Disadvantages of a Group Practice? |
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Definition
Advantages:
-Improved contracting/negotiating
-More flexible time schedule
-Shared on-call, less administrative time, more CME
-Shared financial risk, expenses
-More peer interaction
-Availability of professional mgmt
-No direct financial concerns with pt
Disadvantages:
-Less individual freedom
-Shared risk
-Income distribution arguments
-Possible reduced pt relationships |
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Term
| What are the Pt Advantages and Disadvantages of a Group Practice? |
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Definition
Advantages:
-Care under one roof
-Improved emergency coverage
-Referrals simplified
-Peer interaction among providers
-Possible improved quality of care
-Better knowledge of costs/billing
Disadvantages:
-Possible reduced physician-pt relationship
-Possible high provider turnover
-Increased pt loads |
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Term
| What are the Three main types of Hospitals? |
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Definition
1. For Profit/Proprietary (17%)
2. Not-for-profit/Voluntary (60%)
3. Governmental (23%) |
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Term
| What is the most common type of hospital? |
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Definition
-By ownership: Not-For-Profit
-By Size: <100 beds
-By length of stay: Short term (<30 days)
-By Teaching status: Non-teaching |
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Term
| What are the benefits of Horizontal Integration (Multi-Chain Hospitals)? |
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Definition
1. Economic: access
2. Personnel: recruiting and retention
3. Organizational: regional focus; political clout |
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Term
| What are the basic characteristics of an HMO? |
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Definition
-Delivery System: organized
-Subscribers: enrolled voluntarily
-Financial plan: services on prepaid basis
-Administrative organization: ensures legal, fiscal public and profit accountability
-Organization bears financial risks |
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Term
|
Definition
-HMO employs providers directly
Advantages:
-No monetary investment in practice
-Regular hours
-Limited financial risk
-Limited other risk
Disadvantages:
-Limited input into mgmt decisions
-Limited income potential
-More regulation, cost containment, peer review |
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Term
|
Definition
-HMO contracts with a medical group for the provision of health care services
-The physicians run their medical practices |
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Term
|
Definition
-Individual physicians contract to provide care to enrolled members
-Physicians participating in IPAs retain their right to treat non-HMO pts on a FFS basis (open panel HMO) |
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Term
|
Definition
| -A managed care system analogous to the group-model health maintenance organization (HMO), but services are provided at multiple sits by multiple groups so that a wider geographic area is served |
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Term
| What is Point of Service? |
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Definition
-A type of managed care health insurance system. It combines characteristics of both HMO and the PPO.
-When the pt enrolls in a POS plan, they are required to choose a PCP to monitor the pt's health care. This PCP must be chosen from within the health care network, and become their "point of service" |
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Term
| What is the difference between Adverse and Favorable Selection? |
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Definition
-Adverse: Plan attracts members who are sicker than the general population because of the low out-of-pocket costs and generosity benefits (bad for MCO)
-Favorable: "Cherry Picking" or "Cream Skimming"; plan actively seeks out healthy enrollees who will use fewer services (good for MCO) |
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Term
|
Definition
-A plan that contracts with independent providers to provide services at a discount; the panel is limited in size and usually has some type of utilization review system associated with it
-Identifies "preferred" hospitals and physicians
-Charges consumers more for using outside providers
-Contract with providers at a discounted rate in exchange for a guaranteed pt flow and timely payment of bills |
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Term
|
Definition
| Long-term care is defined as a "range of health personal care, social and housing services provided to people who have lost or never developed the capacity to care for themselves independently as a result of chronic illness or mental or physical disability." It is an umbrella term that covers a lot of different concepts, services and people |
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Term
| What services are included with LTC? |
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Definition
1. Health and personal care
2. Custodial
3. Social and housing |
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Term
| Who perform most LTC services? |
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Definition
| Informal caregivers (80%) --> Majority are female |
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Term
| What are the Activities of Daily Living? |
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Definition
-A measure of a person's dependence on others
-Examples: bathing, dressing, eating, walking, toileting |
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Term
| What are the Instrumental Activities of Daily Living? |
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Definition
-A measure of a person's ability to perform household and social tasks
-Examples: Preparing meals, heavy housework, light housework, using phone, managing finances, shopping |
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Term
| What percentages of nursing homes are for profit? |
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Definition
| -66% --> (34% non-profit) |
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Term
| Who pays for nursing home care? |
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Definition
-47% by Medicaid
-37% out of pocket fees
-3% private insurance
-4% by Medicare (not custodial care) |
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Term
| How many people are uninsured in the US? |
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Definition
49.9 million (2010)
-US Congress Office of Technology Assessment conducted a comprehensive study to determine whether health insurance makes a difference in the use of health care and its health outcomes. The finding were that people who lacked insurance receive less care and have worse health outcomes. |
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Term
| What is the most important determinant of health care services? |
|
Definition
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Term
| What are the causes of Small Area Variation? |
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Definition
1. Scientific Uncertainty: Not all doctors practice the same way; a lot of medicine isn't evidence based
2. Practice Style
3. Differences in incidence and prevalence of Dz
4. Differences in SE/Ethnicity
5. Supply of health care resources available |
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Term
| What is the difference between Labor and Non-Labor inputs? |
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Definition
-Labor: anything that has to do with a person (salary, wages, fringe benefits)
-Non-Labor: any inanimate objects (scalpels, hospital bed) |
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Term
| What is the definition of malpractice? |
|
Definition
-"Failure of a planned action to be completed as intended"
-"Use of a wrong plan to achieve an aim" |
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Term
| What are the two main reasons for increased demand? |
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Definition
1. Insurance and prepayment of health care
2. Technology |
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Term
| What is Demand-Pull inflation? |
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Definition
| When consumer willingness to purchase services is greater than the supply offered at constant dollars. This is the CONSUMER side |
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Term
| What is Cost-Push inflation? |
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Definition
| Originates with the increased factor costs for the provider of services. This is on the PRODUCER side |
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Term
| What is the difference between Quality Assessment and Quality Assurance? |
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Definition
-Assessment: measurement of quality of care at some point in time
-Assurance: measurement of quality provided, and when necessary the attempt to improve it: conducting on-going quality measurement activities and combining these with feedback mechanisms aimed at continual quality improvement |
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Term
| What is the Structure-Process-Outcome Paradigm? |
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Definition
| An approach to quality assessment that encompasses 3 components of medical care (structure, process, outcome) |
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Term
| What are the relationships between the three elements in the continuum? |
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Definition
1. Structure: involves evaluation of the settings and instrumentalities available and used for the provision of care
-measures the qualification of providers and the appropriateness of facilities and organizations to provide the services
2. Process: specific way in which care is provided
-evaluation of the activities of physicians and other health professionals in the mgmt of pts
3. Evaluation of the end results in terms of health and satisfaction
-final evidence of whether care has been good or bad |
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Term
| What are the ways to measure each of the elements in the continuum? |
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Definition
1. Structure: licensure, certification, accreditation
2. Process: (A) Implicit: subjective; person bases their judgement on his/her own training/background
(B) Explicit: Objective; there is a "checklist"; standards are predetermined (national criteria)
3. Outcome: mortality/survival rate; residual disability; sick days; birth wt |
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Term
| What are some of the ways we've attempted to deal with quality? |
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Definition
1. Quality improvement organizations
2. Clinical competencies/credentialing
3. National Practitioner Data Bank (NPDB)
4. Licensure and accreditation (JCAHO, NCQA)
5. Public reporting (CAHPS)
6. Par-for-Performance
7. Rankings
8. HEDIS: Health Plan Employer Data Information Sheet |
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Term
| How much money was spent on healthcare in 2010? What was the total GDP? |
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Definition
-2.6 trillion
-17.9% of GDP |
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Term
|
Definition
-Passed in 1965, Title XVIII of the Social Security Act of 1935
-Administered by the CMS
-Largest US government health care insurance program
-Medicare is an entitlement
-# of people who support Medicare is declining, expected to be broke in 2024 |
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Term
|
Definition
-High poverty rates among the elderly
-Insurance coverage as part of retirement benefits uncommon
-Private insurers reluctant to offer insurance to the elderly |
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Term
| Who is eligible for Medicare? |
|
Definition
-65 and older who qualify for SS
-Disabled, regardless of age (must have been eligible for SS benefits for 2 previous years unless diagnosed with ALS)
-Those with End stage renal Dz
-Some transplant patients |
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Term
| What are the Parts of Medicare? |
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Definition
1. Part A: hospital insurance (entitlement)
2. Part B: supplemental medical insurance
3. Part C: Medicare advantage (Parts A and B)
4. Part D: Prescription Drug Benefit |
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Term
| How does Medicare pay for SNF? |
|
Definition
-Up to 100 days in the benefit period
-Pays full cost for first 20 days
-21st-100th day, pt pays $144.50 per day co-pay
-101+ days, pt responsible for all charges
-Does NOT cover custodial care |
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Term
| How does Medicare pay for Home Health? |
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Definition
-Medicare pays entire bill for covered services as long as they services are medically reasonable and necessary
-Full cost for some medical supplies
-80% of the approved amount for DME (hospital bed, wheelchair, O2, walkers, etc) |
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Term
| How does Medicare pay for Hospice? |
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Definition
-An option for the terminally ill
-Up to 210 days (sometimes longer)
-May be a small ($5) co-pay for each prescription drug
-Respite Care: Small (5%) co-pay |
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Term
| What does Medicare Part B cover? |
|
Definition
-Physician services
-Hospital outpatient care
-Home health not covered by Part A
-Lab tests
-Medical Equipment
-->This is an optional enrollment plan for those eligible for Medicare Part A |
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Term
| What are the gaps in coverage with Medicare? |
|
Definition
-Medicare is less generous than most employer plans
-Outpatient prescription drugs
-No Stop Loss Coverage: Covers <1/2 of all beneficiaries total health spending
-On average, >20% of household income goes toward: Direct payment of health services premiums, and supplemental insurance premiums; this does NOT include additional long-term care expenses |
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Term
| How can beneficiaries fill the gaps in Medicare coverage? |
|
Definition
-Enrollment in managed care
-Additional private supplemental insurance
-Medicaid |
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Term
|
Definition
-Voluntary supplemental insurance
-Follows federal and state laws
-May cover: most to all co-insurance amounts; some of the deductible; services not covered by medicare
-12 standardized Medigap policies to choose from |
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Term
| Is Medicaid an entitlement program? |
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Definition
-NO
-A transfer/welfare program
-It is a Federal and State program: the federal government sets eligibility and minimum service requirements; the states distributed Medicaid or can choose not to accept it |
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Term
| Who is it intended to cover? |
|
Definition
-Children and pregnant women
-NOT single adults |
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Term
|
Definition
-Children's Health Insurance Program
-Title XXI of SS Act
-CHIP provides insurance for kids whose parents' income is above what qualifies for Medicaid
-States determine the program design, eligibility, benefits, and payments
-CHIP can be added on to Medicaid |
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Term
| What were the expansions to CHIP in 2010? |
|
Definition
-NY children up to 400% of poverty and other states up to 250%
-Expanded to pregnant women
-No waiting for legal immigrants
-Documentation of SSN compared to matching database will provide child with coverage |
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Term
| What are the reasons for the increase in purchase of insurance? |
|
Definition
-Increase in real income, and thus increase demand for "peace of mind"
-Increase in real wages via non-taxable fringe benefits
-Increase belief by consumers and providers that insurance is a more efficient and convenient way to pay |
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Term
| What are the classical principles of insurance? |
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Definition
-Risk is significant
-Risk is definable: the insurance company can predict how many events
-Infrequent incidence: not happen or hardly ever happen
-Service is unwanted: shouldn't be elective
-Event is beyond control of they individual |
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Term
|
Definition
-Fee-for-Service: the traditional health care payment system, under which physicians and other providers receive a payment for each unit of service provided. The provider sets the payment level
Paid for By:
-Uniform fees
-Price discrimination/Sliding scale |
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Term
| Discuss Indirect Payments |
|
Definition
-Pre-Payment (insurance premiums): the amount paid to an insurance carrier for coverage provided under a contract (a health insurance policy)
Paid for By:
-Reimbursement for expenditures or indemnification
-Service benefits
-Through business firms
-Taxes (individual) |
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Term
| What is the difference between Community Rating and Differential/Experience Rating? |
|
Definition
1. Community: everyone in the group (or community) is charged the same premium no matter what their health risks are
2. Differential/Experience: each individual is charged a different premium based on their risk factors and expected use of health care |
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Term
| What are some moral hazards associated with health insurance? |
|
Definition
1. Dishonesty in an individual that increases the frequency or severity of loss
-Example: Faking an accident to collect from an insurer
2. Carelessness or indifference to a loss because of the existence of insurance
-Example: leaving your care unlocked, going to the MD for a cold, cosmetic surgery |
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Term
| What are some of the attempts to protect against Moral hazards? |
|
Definition
-Add or increase deductibles
-Increase copay
-Increase coinsurance rates
-Exclude elective services and procedures |
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Term
| Why are small firms less likely to purchase insurance? |
|
Definition
-Premiums are too high
-Can't qualify for group rates
-Fear they will have to take away benefits in the future
-Profits too uncertain
-Premium increases too uncertain
-Not needed to attract workers
-Workers prefer higher wages rather than insurance
-Workers covered by spouse's insurance
-Administrative hassles
-Employee turnover too high |
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Term
|
Definition
-Set by the physician
-Negotiated
-Set by government or other payer (CPR/UCR, RBRVS)
-Encourage providers to do more because they get paid for each service they provide |
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Term
|
Definition
-Surgeons have an economic incentive to limit he number of post-op visits because they do not receive extra payments for extra visits
-However, they have the incentive to perform more surgeries
-By bundling fees together, a portion of the risk is shifted from the payer to the physician: if a doc sees someone more times than he normally would for a certain procedure, he does not get more money |
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Term
|
Definition
-Voluntary variable enrollment
-Monthly payments made to a physician for each pt signed up
-This frees insurers of risk by transferring risk to the provider
-An HMO that pays physicians per capita has little to fear in the short run for people who become ill
-Risk adjusted capitation -- pts with serious illnesses and the elderly require a great deal more time without additional payment -- this type of capitation provides higher monthly payments for elderly and those with chronic illness
-2 or 3 tiered systems
-This type of system give providers the incentive to do less |
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Term
|
Definition
-Civil service style
-These physicians are at risk for not getting paid for extra hours
-HMO and medical groups may offer bonuses to salaried physicians if overall expenses are les than the amounts budgeted for these expenses or if the physician performs a high quality of care (pay per performance) |
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Term
|
Definition
-Diagnosis Related Groups
-Separate pts into groups by problem for which they are admitted
-Hospital assigned basic fee for standard case
-Payment is basic fee |
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Term
|
Definition
-Usual, Customary and Reasonable
-Usual: physician Hx
-Customary: average for locality
-Reasonable: determined by carrier |
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Term
|
Definition
| Authoritative decisions made in legislative, executive, or judicial branches of government intended to direct or influence the actions, behaviors, or decisions of others |
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Term
|
Definition
| Decisions, usually developed by government policy makers, for determining present and future objectives pertaining to the health care system |
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Term
| What are the principle features of health policy? |
|
Definition
-Government as subsidiary to the private sector
-Fragmented, incremental, and piecemeal reform
-Pluralistic and interest group politics
-Decentralized role of the states
-Impact of presidential leadership |
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Term
| What is the difference between Allocation and Regulatory Policies? |
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Definition
1. Regulatory: government prescribes and controls behavior of particular target group
2. Allocation: government officers direct provision of income, services or goods to certain groups or individuals |
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Term
| What are the two types of Allocative policies? |
|
Definition
1. Distributive: spreads benefits to society in general
2. Redistributive: takes money or power from one group and gives it to another group |
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Term
| What are the roles of interest groups in the legislative process? |
|
Definition
-Private interest groups drive policy creation
-Often bills are written by these interest groups and introduced by Congressman allied with these organizations
-For successful passage of a bill, a coalition of interest groups are needed to support a bill
-Interest groups are part of the "Iron Triangle" and there influence is both revered and loathed |
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Term
| Why is the US increasingly interested in national health insurance? |
|
Definition
-RISING COST
-Gaps in present health insurance coverage
-Geographic mal-distribution of personnel and facilities
-Access to service by ability to pay, social class, age group, and geography
-Anticipated impact of national health insurance on population health status |
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Term
| What are the features of Clinton's Health Security Act? |
|
Definition
-Universal coverage for all citizens
-Coverage had to be provided by employer plans or purchased through alliances
-Subsidies would be available to employers to cover costs of providing health insurance to employees
-Benefits federally defined minimum health insurance coverage
-Choice of plans rather than choice of provider
-Financing through payroll taxes and employer/employee contributions
-Other federal programs would eventually fold into Clinton's program |
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Term
| Why didn't Clinton's Health Security Act pass? |
|
Definition
-People worried about freedom of choice
-Loss of jobs because employers would fire employees because they could not cover health care costs
-Costs
-Increased bureaucracy |
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Term
| What is the "Pay or Play" mechanism? |
|
Definition
1. Play: Employer must provide insurance under the employer mandate portion of the Affordable Care Act
2. Pay: Employer will be required to pay a penalty for not providing employees with insurance or if employee gets subsidy for purchasing insurance on the individual exchange |
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Term
| What is included in the essential benefits package? |
|
Definition
-Emergency services
-Ambulatory patient services
-Hospitalization
-Maternity and newborn care
-Mental health and substance abuse disorder services
-Prescription drugs
-Rehabilitative and habilitative services and devices
-Lab services
-Preventative and wellness services and chronic Dz mgmt
-Peds services including oral and vision care |
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