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Understanding Health Policy
by Thomas S. Bodenheimer and Kevin Grumbach
68
Health Care
Undergraduate 2
10/05/2008

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Cards

Term
What is the relationship between physicians and hospitals?
Definition
Both the hospital and physician are in a business to earn money by seeing patients. The physicians were the dominant power in the hospital because they admit the patients, and hospitals without patients have no income.
Term
Who provides health care services?
Definition
Three major forms:
1. Fee-for-service reimbursement with utilization review
(traditional type, a 3rd party payer authorizes or denies payment for expensive medical interventions)
2. Preferred Provider Organizations (PPOs)
(insurers contract with a limited number of physicians and hospitals)
3. Health Maintenance Organizations (HMOs)
(patients are required to receive their care from providers w/in that HMO)
Term
What is fee-for-service?

What is capitation?

What is salary?
Definition
Fee-for-service: doctors get paid by each patient they see. Thus the more visits the more money creating a tendency to over diagnose.

Capitation: getting paid "by the head" aka by how many patients you have by a check each month. Does not matter how many times the patient is seen. So they get a bonus for doing nothing, less quality work and minimal amount of work.

Salary: doctors belonging to organizations are paid by this. Best method of payment because their is no incentive to over/under treat.
Term
What does "Payment Per Episode" mean? (In regards to the physician)
Definition
1. Per Episode: Bundles together payments. Results in incentive to give less postoperative visits and more incentive to preform more surgeries.
EX:) surgeons receive a single payment for postoperative care and the surgery itself.
Term
What does "Payment Per Diem" mean? (In regards to the hospital)
Definition
Hospital receives a lump sum for EACH DAY a patient is in the hospital and is paid by their HMO. Hospital has less incentive to do expensive studies because they don't get extra money.
Term
What does "Payment Per Episode of Hospitalization: Diagnosis-Related Groups" mean?
Definition
Medicare pays a lump sum FOR ALL services performed by the hospital with the size of payment depending on patient's diagnosis. Long stays = financial loss to hospital, Short stays = profit
Term
What does it mean when an institution is paid by a "Global Budget"?
Definition
An HMO pays its hospitals a fixed payment for one year. The hospital must then find a way to stay within that budget for the entire year.
Term
Explain how capitation can shift the risk to a provider.
Definition
With capitation payment hospitals are at a risk for admissions, length of stay, and resources used because they get a set amount of payment per patient and that patient may remain healthy and never step foot in the hospital - OR they may contract a serious/lengthy illness that costs the hospital way more then they are getting for that particular patient.
Term
Who are the three major payers for healthcare in the US?
Definition
1. Patients: out of pocket
2. Insurance: HMO, Indemnity
3. Government: VA, IHS, Military
Term
What are the government insurance programs?
Definition
1. Indian Healthcare Services
2. Military
3. Government employees (teachers, politicians, etc.)
4. ANHC
Term
What are the eligibility requirements and benefits of Medicaid?
Definition
Requirements: Your income must be under a certain amount designated by the state because Medicaid is state run.

Benefits: There are no premiums or co-payments.
Term
What is the difference between Medicare Part A and Medicare Part B?

How is Medicare A financed? Medicare B?
Definition
Part A pays hospitals and Part B pays doctors.

Medicare A is financed through the Social Security system. Medicare B is financed by monthly premiums of $66 and general federal revenues.
Term
What is Primary Health Care?
Definition
Your average medical care that involves common health problems; it includes:

Internal Medicine
Pediatrician
Family Practice (only true primary)
Gynecologist/Obstetrician
Term
What are the eligibility requirements and benefits of Medicare?
Definition
Eligibility Requirements: You have to be 65+ years and have been paying in the Social Security system for 10 years OR people who are permanently disabled and have been receiving disability benefits for 2 years. Benefits include: Cheap and does not change by location.
Term
What is a community rating?
Definition
How health insurance premiums are set by how many people had insurance in the community.
Term
What is an experience rating?
Definition
Health insurance is based on what type of health experience an individual or company has had. (Think Ben Stiller's job in "Along Came Polly")
Term
What is meant by regressive mode of financing?
Definition
A falling percentage of income is taken out of pocket as income increases. So if I make an income of $10,000 and have a health care bill of $1,000 I'm paying 10% of my income but if someone with an income of $100,000 has the same bill they only pay %1 of their income.
Term
How does HMO health insurance work?
Definition
No payment at time of service because you have been paying premiums to the company. There is a designated staff and a gate keeper (primary care physician who will tell you if you need to see a specialist or not).
Term
What agency has the goal to improve the health of the world's population?
Definition
World Health Organization
Term
What are the four causes of famine in the world?
Definition
1. Desertification/Flooding
2. Warfare
3. Poverty
4. Production of non-edible crops (tobacco, cotton, etc.)
Term
What is Germany's Health Care system like?
Physicians paid by:
Financed by:
Required to have health insurance?
Definition
Physicians are paid by fee for service.
Health Care is financed by sickness funds.
Everyone is required to have health insurance.
Term
How is health care structured in England?
Physicians paid by:
How are prices set?
Financed by:
Definition
Physicians are paid by capitation and salary.
Prices are set nationally.
Health care is financed by National Health Insurance.
Term
How is health care structured in Canada?
Physicians Paid by:
Financed by:
Prices set by:
Definition
Physicians are paid mostly by fee for service but some are paid by salary.
Financed by: Provincial government taxes
Prices set by the provincial government.
Term
How is health care structured in Japan?
Physicians paid by:
Financed by:
Prices set by:
Definition
Physicians paid by: Fee for service
Financed by: 3 insurance companies
Prices are government regulated.
Term
What is the United States ranking among nations in infant mortality rate?
Definition
37th (as of 2007)
Term
What is Secondary Health Care?
Definition
Specialists that can charge whatever they want (because you don't "shop" around for doctors. Also, no competition between doctors. Includes:

Surgeons
Orthopedics
Dermatologists
ENT (ear, nose, throat)
Term
What is Tertiary Health Care?
Definition
Tertiary Care is the most rare of all health care types and are teams of physicians. For example: heart transplant teams, burn center specialists, neonatology.
Term
What is preventive care?
Definition
Health care designed to maintain good health. Some examples are: early diagnosis, exercise/diet to prevent obesity, etc.
Term
What is a financial barrier to health care?
Definition
No insurance coverage (due to illness, to expensive, unemployed, etc.)
Term
What are some non-financial barriers to health care?
Definition
- Transportation
- Language
- Fear of diagnosis
- Cultural
- Location
- Lack of Education
- Illiterate
Term
What is a gatekeeper?
Definition
A gatekeeper refers you to a specialist if the problem can't be solved at a primary health care institution (for example Family Medicine).
Term
Why is our health care system so expensive?
Definition
Doctors set the prices for health care and tell you what you need.
Term
What is epidemiology and how does it affect health care?
Definition
Epidemiology is the study of FACTORS affecting the health and illness of populations.

It is the "backbone" of public health because by knowing how disease is spread we can prevent.
Term
What is the epidemiology triangle?
Definition
The study of diseases as they affect the population.

HOST
/ \
/ \
/ \
/ \
AGENT_________ ENVIRONMENT
Term
What is the PREVALENCE of a disease?
Definition
The number of people with a particular disease. (Snapshot of a population)
Term
What is the INCIDENCE of a disease?
Definition
Number of new cases of a particular disease OVER A PERIOD OF TIME.
Term
What factors are driving up the cost of health care?
Definition
1. Price inflation: recently, physician incomes increased much more rapidly than those of other workers (but this increase is not the only contributer to price inflation).

2. Unnecessary Surgeries: get more health "bang" for the health "buck"

3. Lack of adequate insurance and access to care.

4. Administrative Waste: to much money is spent toward the administrative overhead in the health care system.

5. Ineffective/Inappropriate Care: services provided by highly paid physicians can just as well be provided by their assistants, nurses, or nurse practitioners.
Term
Who pays for health care in Alaska?
Definition
The federal government pays for IHS. Employers and individuals pay for their own.
Term
How do large numbers of uninsured people affect health care costs?
Definition
Basically the healthy pay for the ill who can not pay. Health insurance premiums are upped to compensate those who are receiving free care.
Term
What is the difference between the two cost control strategies: financing and reimbursement.
Definition
Financing is the flow of dollars (by premiums or taxes) from individuals and employers to the health insurance plan (private health insurance or govt. programs) while Reimbursement is the flow of dollars from insurance plans to physicians, hospitals and other providers.
Term
What are the components of high quality health care?
Definition
-access to care
-adequate scientific knowledge
-competent health care providers
-separation of financial and clinical decisions
-organization of institutions to maximize quality
Term
How does understaffing affect health care?
Definition
Understaffed = risk for a serious error is increased
Term
What two factors drive up the cost of health care?
Definition
PRICE AND QUANTITY...

COST = PRICE X QUANTITY
Term
What is continuous quality improvement?
Definition
An ongoing effort to reduce waste, rework, and complexity in an organization.
Term
How is quality measured in health care?
Definition
By Processes (following guidelines & meeting requirements) and by Outcomes (morbidity and mortality).
Term
In regards to medical care, what is rationing?
Definition
A conscious policy of equally distributing needed resources that are in limited supply.
Term
What are the four principals of medical ethics?
Definition
1. Beneficence: a health care providers obligation to help those who are in need.
2. Nonmaleficence: Duty of a health care provider to not harm the patient.
3. Autonomy: the right of a person to decide and follow their own plan of life and action.
4. Justice: treating everyone fairly.
Term
How is medical care rationed in national health systems?
Definition
The more costly procedures are rationed to people who meet a certain quota (age, health history, etc.). Surgery is rationed by limiting the number of physicians and/or putting people on wait lists.
Term
How is medical care rationed in the U.S.?
Definition
Rationed by MONEY. If you got the $, you'll receive the treatment.
Term
Uninsured people are discriminated against in these health care components:
Definition
-Probably won't receive preventive care
-Surgery will take longer
-Rehabilitation/Physical Therapy/Nursing Home, etc. will all not be funded or received.
Term
What is Eustress?
Definition
A positive stress that presents oppurtunities for personal growth. Can be just as distressful as "distress".
Term
What is Distress?
Definition
Negative form of stress which results from extreme anxiety, sorrow, or pain.
Term
What are 3 techniques to managing stress?
Definition
1. exercise
2. massage/spa
3. relax (read, watch T.V.)
Term
What are 4 treatable mental illnesses?
Definition
1. Schizophrenia
2. Depression
3. Post traumatic stress disorder
4. Bipolar
Term
Back before the 1970's people were ___1___ away because people didn't know that mental illness is a ____2___. After the 1970's there was a change in attitude toward mental institutions because of new _____3_____ on the market which led to ___4_____.
Definition
1. locked
2. disease
3. medications
4. treatment
Term
When a mentally ill person is deinstitutionalized, what are the social effects on that person?
Definition
They may become homeless, have to survive for their life, or they'll wind up in a mental health clinic.
Term
What are the three stages that occur in our general adaptation syndrome to stress?
Definition
Alarm, resistance, and exhaustion.
Term
How does mental illness affect your ability to get health insurance?
Definition
If you are mentally ill your chances for getting health insurance are significantly low.
Term
Identify the four signs of addiction?
Definition
1. Obsession
2. Loss of Control
3. Negative Consequences
4. Denial
Term
What kind of effects does alcohol have on the developing brain?
Definition
-Interferes with connections the brain is making.
-Mental retardation
-Intellectual impairment
-Physical/Mental impairment
-FAS/FAE
Term
What does "enabling" mean?
Definition
Enabling is helping/protecting a person from the negative consequences of their behavior in an addiction.
Term
What kind of impact does tobacco have on health?
Definition
Causes:
-Cancer
-Heart strokes
-Chronic Obstructive Pulmonary Disease
-Emphysema
-Chronic Bronchitis
-Cardiovascular Disease
Term
List 5 ways drugs are administrated into the body:
Definition
1. INJECTION
2. ORAL INGESTION
3. INHALATION
4. INTRAVENOUS INJECTION
5. ABSORPTION THROUGH SKIN (INJUNCTION)
Term
What are the social/health effects of:
Cocaine:
Meth:
Opiates:
Marijuana:
Definition
Cocaine: increased heart rate and blood pressure, loss of appetite, convulsions, muscle twitching, decreased fatigue, alertness, talkativeness

Meth: elevates heart rate, decreased appetite, increased physical activity, alertness, high state of irritability and agitation

Opiates: relieves pain, lowers heart rate, respiration and blood pressure lowered, hallucinations

Marijuana: blood shot eyes, cotton mouth, increased thirst and appetite, lowered blood pressure, drooping eyelids, anxiety, panic, hallucinations, magnified color, sounds & speed of which things move.
Term
What does YPLLs stand for and what is it?
Definition
Years of Potential Life Lost: it is a measurement of the impact of a specific disease or societal event/condition on a given population.
Term
What is the leading cause of death of people between 15 and 45?
Definition
INJURIES.

::Intentional:: ::Unintentional::
-Homicide -Auto Accidents
-Suicide -Drownings
-Bicycle Accidents
-Falls
Term
What are three evidence based measures that can reduce mortality and morbidity from Motor Vehicle Injuries?
Definition
1. Reduced Speed
2. Reduced Alcohol Limit
3. Children's Car Seats
Term
What is the difference between ACTIVE INTERVENTIONS and PASSIVE INTERVENTIONS for injury prevention?
Definition
Active Intervention is something YOU have to initiate (seat belts, bike helmet, etc.) while Passive Intervention is something automatic for your safety (Guardrails, smoke alarms, air bags, etc.).
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