Health Care Delivery System

Front 1

PSRO

Back 1

Professional Standards Review Organization

Developed by the federal government to review the quality, quantity, when cost of hospital care

Front 2

UR

Back 2

Utilization Review Committees

Identifies overuse of services ordered by physicians caring for Medicare patients

Front 3

PPS

Back 3

Prospective Payment System

Eliminated cost-based Medicare reimbursements

Front 4

DRG

Back 4

Diagnostic Related Groups

Inpatient hospital services for Medicare patients that have fixed reimbursements with adjustments based on case severity, regional costs, etc.

Front 5

RUG

Back 5

Resource Utilization Groups

Used in LTC in place of DRGs

Front 6

Capitation

Back 6

Providers receive a fixed amount per enrollee of a healthcare plan

Front 7

Managed Care

Back 7

Healthcare systems focusing on early intervention/prevention in which a provider receives a capitated payment for each patient enrolled in the program

Front 8

Medicare

Back 8

A federally administered national health insurance program for people 65+

Payment for the plan is deducted from the patient's social security check

Front 9

Medicaid

Back 9

A program that provides health insurance to low-income families, health assistance to low-income people with LTC disabilities, and supplemental coverage/LTC assistance to older adults and Medicare beneficiaries in nursing homes

Eligibility and benefits determined by the state.

State and federal funding

Front 10

Part A

Back 10

Medicare coverage for medical, surgical, and psychiatric care costs based on DRGs

Limited skilled nursing, family care, hospice, and home-health care

Front 11

Part B

Back 11

Voluntary medical insurance through Medicare

Physician coverage, certain other specified health professional services, certain outpatient services

Front 12

Part C

Back 12

Managed care provision that provides a choice of 3 insurance plans

Front 13

Part D

Back 13

Voluntary prescription drug coverage

Front 14

Private Health Insurance

Back 14

Fee-for-service plan, or "third party payer"

Payment is computed after patient receives services based on number of services used

Typically expensive with deductibles

Front 15

Managed Care Organizations (MCO)

Back 15

Provides comprehensive preventative and treatment services to a specific group of voluntarily enrolled patients

Monitors and controls access to services: all care is provided by PCP with referrals for specialists and hospitalizations

Front 16

PPO

Back 16

Preferred Provider

Type of MCO that limits an enroller's choice to a list of "preferred" hospitals and providers with higher out of pocket expenses when going out of network

Front 17

HMO

Back 17

Health Maintenance Organizations

Type of MCO with limited service provisions. Services are provided by a PCP. Fees are prepaid by enrollee in capitated rates

Front 18

State Children's Health Insurance Program

Back 18

Federally funded, state operated program that provides health coverage for uninsured children who are not poor enough for Medicaid

States determine eligibility and benefits

Front 19

Long term care insurance

Back 19

Supplemental insurance for coverage of LTC services

Policies provide a set amount of money for an unlimited amount of time or for as little as 2 years

Front 20

What is the driving force for change in the health care system?

Back 20

Cost

Front 21

What are the reasons behind the increasing cost of healthcare?

Back 21

- Oversupply of specialized providers

- surplus of hospital beds

- passive consumer

- inequitable financing of services

Front 22

Primary Care

Back 22

Basic healthcare needs, maternal/child, etc

Front 23

Primary Health Care

Back 23

Focuses on improved health outcomes for an entire population