Health Service Management

Front 1

How controls the National Practioner Data Bank?

Back 1

The Health Resources and Services
Administration (HRSA)

Front 2

Role of The Agency for Health Care
Research and Quality (AHRQ) is?

Back 2

improving the quality of health care
in this country.

Front 3

What are the key features of an HMO?

Back 3

Offers a standardized benefits package to
prepaid members
 Requires members to use specific physicians
 Requires use of primary care physician to
coordinate care and handle referrals
 Open—offer a point of service option (POS)

Front 4

Point of service plan

Back 4

 Indemnity-type option for HMOs or PPOs
 Primary care physicians typically refer patients to
other providers within the plan network
 Patients may refer themselves outside the
network and get some coverage
 If the physician refers the patient out of the
network, the plan still pays most of the costs
 If the patient self-refers, they pay a co-insurance fee

* participants must designate a network-based physician as their primary health care provider

Front 5

Examples of PPOs

Back 5

Private (Indemnity) insurance payment
systems
 Preferred Provider Organizations (PPOs)
 Self pay

 Physician, hospital, and other providers
of care agree to accept lower fees from
the insurer (discounting)
 Patients who see providers out of the
PPO pay more

Front 6

Utilization Management

Back 6

A cost-containment strategy that limits health
care expenditures by limiting reimbursement

Front 7

Disease Management

Back 7

a comprehensive effort to help clinicians plan
and deliver evidence-based care and to help
patients play an active and informed role in
caring for themselves. Most X components
are embedded in the delivery of usual primary
care; others are delivered by care managers
hired specifically to augment services for
patients whose conditions are poorly
controlled in usual care.

Front 8

What percent of Americans receive health insurance from their employer?

Back 8

70%

Front 9

Medicare part A

Back 9

Hospital inpatient services--partial payment
 Skilled nursing facilities--certain conditions
apply
 Home health services--immediately after
discharge from acute care hospital
 Hospice care
 Funded through payments made to the Social
Security Trust Fund by employed workers

Front 10

Medicare part B

Back 10

Fee for service
 Partial payment for physician services
 Hospital outpatient services
 Medical equipment and supplies
 Funded with premiums paid by
beneficiaries if they elect to participate (voluntary)

Front 11

Medicare part C

Back 11

Medicare+Choice: a managed
care product

*Most plans require a primary care physician

*some plans cover prescription drugs, dental care, vision care

Front 12

Part D

Back 12

Prescription drug benefit plan

Front 13

Act that created medicare part D

Back 13

Medicare Modernization Act of 2003

Front 14

Approx how many people are covered by medicaid?

Back 14

>62 million people

Front 15

True or false

States receive matching funds from the feds for SCHIP

Back 15

True

Front 16

True or False?

SCHIP funds are often used to expand existing
Medicaid supported health care plans

Back 16

True

Front 17

True or False

The ACA ends Pre-Existing Condition Exclusions for Children:
Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition.

Back 17

true

Front 18

True or False

The ACA:Keeps Young Adults Covered: If you are under 26,you may be eligible to be covered under your parent’s health plan.

Back 18

T

Front 19

True or False

The ACA ends Arbitrary Withdrawals of Insurance Coverage:
Insurers can no longer cancel your coverage just
because you made an honest mistake.

Back 19

T

Front 20

True or False

The ACA Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.

Back 20

T

Front 21

True or False?

The ACA ends Lifetime Limits on Coverage: Lifetime limits on
most benefits are banned for all new health
insurance plans.

Back 21

T

Front 22

True or False?

The ACA reviews Premium Increases: Insurance companies
must now publicly justify any unreasonable rate
hikes.

Back 22

T

Front 23

True or False?

The ACA helps You Get the Most from Your Premium Dollars:
Your premium dollars must be spent primarily on health care – not administrative costs.

Back 23

T

Front 24

True or False?

The ACA Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment.

Back 24

T

Front 25

True or False?

The ACA protects Your Choice of Doctors: Choose the primary
care doctor you want from your plan’s network.

Back 25

T

Front 26

True or False?

The ACA removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan’s network.

Back 26

T

Front 27

True or False?

The ACA the health reform law will require all businesses, even the smallest ones, to provide health insurance for their employees.

Back 27

False. The law does not require employers to provide health benefits. However, it does impose penalties in some cases on larger employers (those with 50 or more workers) that do not provide insurance to their works or that provide coverage that is unaffordable.

Front 28

True or False?

The health reform law will allow undocumented immigrants to receive financial help from the government to buy health insurance.

Back 28

False

Front 29

Top three expenditures by type of service

Back 29

Hospital, physician services, rx drugs, and other non-durable medical services
Source: Kaiser foundation.

Front 30

Diagnosis Related Group (DRG)

Back 30

What is a statistical system of classifying any inpatient stay for the purpose billing. Divided into body systems and subgroup for medicare reimbursement.

Front 31

Resource relative value scale

Back 31

payments to physicians are based on the resour.ces necessary to provided them. include practice, physician, and liability insurance. Conversion factor used to account for resource difference by geographic area.

Front 32

The Hospital Survey and ConstructionAct (The Hill-Burton Act--1946)

Back 32

First federal attempt to enact global health planninglegislation

 Aimed to improve the hospital bed ratio in rural areasand increase numbers of physicians in those areas.

 Required states to designate a single agency to plan andimplement hospital construction

 Limited outcome because end result was state based andfocused on beds rather than services

Front 33

Overarching health people goals

Back 33

Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death;

Achieve health equity, eliminate disparities, and improve the health of all groups;

Create social and physical environments that promote good health for all;

Promote quality of life, healthy development, and healthy behaviors across all life stages.

Front 34

Performance

Back 34

How a plan or provider is functioning with regard to specific standards, benchmarks, or measures. The measures are often indicators of value, quality, or both.

Front 35

Efficiency

Back 35

Maximization of the quality of a comparable unit of health care delivered for a given unit of health resources used

Front 36

Economy

Back 36

The total level of expenditure for healthcare, given realistic performance on quality andefficiency, and a realistic assessment of availableresources

Front 37

Structural measures

Back 37

The attributes of the settings in whichcare occurs

 Provide the basis for most currentregulations Often required by governmentprograms through accreditation,licensure, or certification requirements

 Ensure a minimal capacity for quality.

Front 38

Process

Back 38

Denotes what is actually done in givingand receiving careƒÞ Patient activities in seeking careƒÞ Patient activities in carrying out therecommended careƒÞ Physician activities in making a diagnosisand recommending or implementingtreatment

Front 39

Outcome measures

Back 39

 Assess the quality of the final product Used to capture the effect of anintervention on health status control of a chronic condition specific clinical findings patients’ perceptions of care.

Front 40

staff model HMO

Back 40

physicians are employed and all premiums are paid to the HMO, which then compensates the physicians on a salary and bonus arrangemen -

Front 41

group model HMO

Back 41

Contracts with certain provider groups, with whom rates for medical care are negotiated. HMO then pays the negotiated rate for care provided to the policyholders. Contracts are also made with hospitals for care provided to the policyholders.

Front 42

network model HMO

Back 42

Under this model, an HMO contracts with several physician groups. Physicians may share in savings, but may provide care for other than HMO members.

Front 43

independent practice association

Back 43

a U.S. type of physician alliance in which the physicians own the practice, Physicians are legally organized as a corporation, partnership, professional corporation, or foundation to contract as a group to provide services. Economic risk is shared, but overhead is not. May contract with a healthmaintenance organization (HMO) to service enrollees but will usually still see non-HMO clients.

Front 44

JCAHO

Back 44

Accrediates: Acute and long-term care Ambulatory care Behavioral health care Home care, clinical laboratory services Managed care networks

Front 45

National Committee forQuality Assurance (NCQA)

Back 45

nationally recognized evaluation of managed careplans purchasers, regulators, consumers

Front 46

Health Plan Employer Data andInformation Set (HEDIS)

Back 46

introduced by NCQA in 1991

* Annual updates to help purchasers andconsumers compare the quality ofcommercial, Medicaid, and Medicaremanaged care plans.

*Standardized performance measuresfocusing on quality of care in cancer,heart disease, smoking, asthma, diabetes

* Used for MCOs

* Informs purchasers and consumers

Front 47

The American Medical Accreditation Program(AMAP)

Back 47

a voluntary accreditation programthat measures and evaluates individualphysicians against national standards, criteria,and peer performance in: Credentials Personal qualifications Environment of care Clinical process Patient 149outcomes

Front 48

National Practitioner Data Bank

Back 48

Purpose--facilitate a comprehensive review ofprofessional credentials Established by Title IV of Public Law 99-660, the Health Care QualityImprovement Act of 1986. Administered by the Bureau of HealthProfessions, HRSA, HHS

Front 49

Characteristics of uninsured

Back 49

Front 50

First health plan in the US?

Back 50

Blue cross (covered only hospitalizations)

Front 51

Title XVII

Back 51

Medicare

Front 52

Title XIX

Back 52

Medicaid

Front 53

True or false? Local public health dept are organized most frequently at the county level rather than at other local government levels.

Back 53

True

Front 54

Legislation required employers to contribute an amount equal to that contributed toward indemnity plan premiums for employes.

Back 54

Health maintenance act of 1973.

Front 55

How do PPOs earn money?

Back 55

By charging an access to the insurance company for use of their services

Front 56

Review types of health insurance plans.

Back 56

https://www.youtube.com/watch?v=25G9hFRmCM8

Front 57

What are the two basic categories of provider reimbursement?

Back 57

variable reimbursement arrangements

Fixed imbursement

Front 58

What are two major concerns with variable reimbursement models (e.g., RBRVS?)

Back 58

Upcoding, e.g., making a short office visit and extended one

Unbundling, billing separately for services for which a bundled coded exists.

Front 59

What are some examples of fixed reimbursement arrangements?

Back 59

*DRG

*Medical severity diagnosis related groups (MS-DRGs)

* Case rate/bundled case rate-predetermined, fixed payment for all services related to a defined episode of care, e.g., heart transplant (generally used for high cost/high risk proceedures)

*Global fee (a type of case rate). Flat rate negotiated for a set of multiple services, e.g., pre natal, deliver, and post-natal care.

* Per diem. Pay a fixed rate for each day of stay. Hospitals less likely to shorten stay. So insurance places tough length of stay guidelines.

*Capitation. Providers make $ when patients are health, e.g., providing low cost preventive services. Financial incentive is to minimize care.

Front 60

What is a risk pool?

Back 60

Money available for reimbursement after certain targets are met, e.g. hospital days per 1,000 pt. Can also involve with holding $.

Front 61

Who finances America's hospital bill?

Back 61

1) Private insurers

2) Medicare

3) Medicaid

4) Out of pocket

Front 62

What are two evidence based practices to increase immunization rates in children?

Back 62

Call/reminder systems

Physician based tracking

Front 63

How were physician practices structured in 2014 (AMA practice arrangment survey?)

Back 63

53% of physicians are self-employed

60% work in practices owned by physicians

23% work in practices partially owned by a hospital

Trends project more physicians will work for hospitals

Front 64

Title V

Back 64

MCH state block grants

Front 65

Title XXI

Back 65

SCHIP

Front 66

Title IIX

Back 66

Medicaid

Front 67

Title XVIII

Back 67

Medicare

Front 68

What drives the me median age of the population?

Back 68

Birth rate

Front 69

What is the difference between need and utilization of healthcare services?

Back 69

Unmeet need

Front 70

Adverse selection.

Back 70

Persons who are sicker are more interested in acquiring health insurance. This drives the cost up for other enrollees. Thus, insurers prefer to insure workers.

Front 71

How is medicare part B and D financed and subsidized?

Back 71

General taxes

Front 72

What laws does the federal government use to authorize public health actions?

Back 72

Interstate commerce

Welfare clause

Front 73

A health plan that is similar to those offered by PPOs, except use is restricted to in network providers

Back 73

Exclusive provider plan

Front 74

Setting insurances premiums based on a groups' health care expenses in a prior period. This allows groups to pay less.

Back 74

Experience rating

Front 75

Setting reimbursement based on actual cost incurred

Back 75

Retrospective payment.

Front 76

Reimbursement to a provider to cover cost plus a factor for capital?

Back 76

Cost-plus.

Front 77

Public health care programs only for select groups of people.

Back 77

categorical programs

Front 78

What drives the me median age of the population?

Back 78

Birth rate

Front 79

A classification to differentiate nursing home residents by their level of use?

Back 79

Resource utilization groups

Front 80

An aggregate of the severity of conditions requiring medical intervention. Categories are mutually exclusive and differentiate patients according to the extent of resource use.

Back 80

case-mix

Front 81

Method of determining health insurance premiums that takes into account demographic factors such as age, gender, geography, and family composition, while ignoring other risk factors.

Back 81

adjusted community rating

Front 82

An account set up and funded by an employer that can be used by an employee or a retiree to pay for health care expenses.

Back 82

health reimbursement arrangement

Front 83

What is the difference between need and utilization of healthcare services?

Back 83

Unmeet need

Front 84

Adverse selection.

Back 84

Persons who are sicker are more interested in acquiring health insurance. This drives the cost up for other enrollees. Thus, insurers prefer to insure workers.

Front 85

How is medicare part B and D financed and subsidized?

Back 85

General taxes

Front 86

What laws does the federal government use to authorize public health actions?

Back 86

Interstate commerce

Welfare clause

Front 87

A health plan that is similar to those offered by PPOs, except use is restricted to in network providers

Back 87

Exclusive provider plan

Front 88

Setting insurances premiums based on a groups' health care expenses in a prior period. This allows groups to pay less.

Back 88

Experience rating

Front 89

Setting reimbursement based on actual cost incurred

Back 89

Retrospective payment.

Front 90

Reimbursement to a provider to cover cost plus a factor for capital?

Back 90

Cost-plus.

Front 91

Public health care programs only for select groups of people.

Back 91

categorical programs

Front 92

A phenomenon in which individuals who are likely to use more health care services than others due to poor health enroll in health insurance plans in greater numbers, compared to people who are healthy.

Back 92

Adverse selection

Front 93

Separate payments to the providers for each separate service, such as examination, administering a test, and hospitalization

Back 93

Fee for service

Front 94

Separate payments to the providers for each separate service, such as examination, administering a test, and hospitalization

Back 94

Fee for service

Front 95

Determined by a spell of illness beginning with hospitalization and ending when the beneficiary has not been an inpatient in a hospital or a skilled nursing facility for 60 consecutive days

Back 95

Benefit period

Front 96

Separate payments to the providers for each separate service, such as examination, administering a test, and hospitalization

Back 96

Fee for service

Front 97

Determined by a spell of illness beginning with hospitalization and ending when the beneficiary has not been an inpatient in a hospital or a skilled nursing facility for 60 consecutive days

Back 97

Benefit period

Front 98

An organized approach to evaluating and coordinating care, particularly for patients who have complex, potentially costly problems that require a variety of services from multiple providers over an extended period

Back 98

Case-management

Front 99

An evaluation required under federal regulations, before a patient can be admitted to a Medicaid-certified nursing facility, to determine whether a nursing facility is the best alternative for individuals with serious mental illness or intellectual disability or whether their needs can be adequately met in community-based settings.

Back 99

Preadmission Screening and Resident Review (PASRR

Front 100

An evaluation required under federal regulations, before a patient can be admitted to a Medicaid-certified nursing facility, to determine whether a nursing facility is the best alternative for individuals with serious mental illness or intellectual disability or whether their needs can be adequately met in community-based settings.

Back 100

Preadmission Screening and Resident Review (PASRR

Front 101

A health plan that combines a savings option with a health insurance plan carrying a high deductible

Back 101

High deductible plan.

Front 102

A legal entity formed between a hospital and a physician group to achieve shared market objectives and other mutual interests.

Back 102

Physician hospital organization

Front 103

Stop-loss coverage that self-insured employers purchase to protect themselves against any potential risk of high losses.

Back 103

Reinsurance

Front 104

Factors that influence an individual and a population’s health

Back 104

Genetic make up

20% of premature deaths

Individual Behaviors

50% of premature deaths

Medical Practice

10% of premature deaths

Social and Environmental

20% of premature deaths

Front 105

In 2010, the healthcare workforce composed how much of the total workforce.

Back 105

3%

Front 106

What percent of health professionals work in hospitals(2010)?

Back 106

40 %

Front 107

What percent of health care professionals work in long term care/nursing homes?

Back 107

12%

Front 108

What percent of health care professionals work in physician offices?

Back 108

10%

Front 109

What percent of health care professionals work in physician offices?

Back 109

10%

Front 110

How many physicians are there per /100,000 people?

Back 110

28/100000 in 2009

Front 111

What percent of physicians are primary care and specialists?

Back 111

approximately 40.8% of the 40.8 %physicians are generalists and approximately 59.2% are specialists

Front 112

Health care information organization

Back 112

An independent organization that brings together health care stakeholders within a defined geographic area and facilitates electronic information exchange among these stakeholders with the objective of improving the delivery of health care in the community

Front 113

Required premarket notification to the FDA so the agency could assess the safety of a new drug or device.

Back 113

1938 Food, Drug, and Cosmetic Act

Front 114

Required premarket notification to the FDA so the agency could assess the safety of a new drug or device.

Back 114

1938 Food, Drug, and Cosmetic Act

Front 115

1962 Kefauver-Harris Amendments

Back 115

Premarket notification was inadequate. The FDA took charge of reviewing the efficacy and safety of new drugs, which could be marketed only once approval was granted.

Front 116

Safe medical device act of 1990. (FDA)

Back 116

Health care facilities must report serious or potentially

serious device-related injuries, illness, or death of patients and/or employees.

Front 117

Safe medical device act of 1990. (FDA)

Back 117

Health care facilities must report serious or potentially

serious device-related injuries, illness, or death of patients and/or employees.

Front 118

Food and Drug Administration Safety Innovations Act (2012)

Back 118

Allows the FDA to use markers that are thought to predict or that are reasonably likely to predict clinical benefit to qualify a drug for accelerated approval if the drug is indicated for a serious condition and fills an unmet medical need.

Front 119

Medical Device Amendments, 1976 (to the FD&C Act of 1938)

Back 119

Class I – only subject to controls over fraudulent claims of effectiveness

Class II – subject to labeling requirements, performance standards, and post-market surveillance

Class III – require premarket approval

Front 120

COBRA

Back 120

Employment-based coverage can continue for 18 months after separation from a job

29 month coverage for individuals declared to be disabled (HIPAA 1996)

Family coverage for 36 months if the former worker dies, enrolls in Medicare, or is divorced

The individual must pay 102% of the group premium

The ACA does not affect it

Front 121

Outpatient Prospective Payment System (OPPS)

Back 121

For services provided by hospital outpatient departments; OPPS for nonhospital ambulatory surgery centers

Ambulatory Payment Classifications (APCs):

300 procedural groups

New technology APCs

a bundled rate to include anesthesia, drugs, supplies, recovery

Physician services are reimbursed separately, based on RBRVS

Front 122

Case-Mix Methods

Back 122

Case mix: Aggregate severity of conditions

Determined through a comprehensive assessment

Mutually exclusive case-mix categories represent resource use

Resource Utilization Groups (RUGs) are used to determine per-diem reimbursement for skilled nursing facilities

Case-Mix Groups (CMGs) are used to reimburse inpatient rehabilitation facilities

Front 123

Outpatient Prospective Payment System (OPPS)

Back 123

For services provided by hospital outpatient departments; OPPS for nonhospital ambulatory surgery centers

Ambulatory Payment Classifications (APCs):

300 procedural groups

New technology APCs

a bundled rate to include anesthesia, drugs, supplies, recovery

Physician services are reimbursed separately, based on RBRVS

Front 124

What is a Critical access hospital ?

Back 124

Authorized under the Balanced Budget Act, 1997

To save small rural hospitals from closure

Maximum 25 acute care or swing beds

Emergency services must be available

Must meet a distance test

Can have a 10-bed psychiatric unit, a 10-bed rehabilitation unit, and a SNF

Cost-plus reimbursement, not to exceed 101% of cost

Front 125

What is case management?

Back 125

Coordination of care for complex and potentially costly cases

A variety of services from multiple providers are needed over an extended period

Secondary and tertiary services are needed more often than primary care

(e.g., AIDS, spinal cord injury, transplants, severe injuries, cases, etc.)

Cost savings have been achieved with better delivery of care and reduced hospitalizations

Front 126

Disease management

Back 126

Population-oriented strategy for chronic problems

Evidence-based treatment guidelines

Focus on education, self-management training, monitoring of the disease process, and follow-up to ensure compliance–self-care with professional support

Goal: prevent or delay complications

Although cost savings are uncertain, better quality and disease control are achieved

Front 127

Staff model HMO

Back 127

Employ physicians on salary

Contracts for only uncommon specialties and hospital services

Advantages

Exercise control over physicians

Convenience of one-stop shopping

Disadvantages

Fixed salary expense can be high

Expansion into new markets is difficult

Limited choice of physicians

Front 128

Group model HMO

Back 128

Contract with a single multispecialty group practice

Separate hospital contracts

Group practice is paid a capitation fee

Advantages

No salary or facility expenses (as in staff model)

Well known practice may lend prestige

Disadvantages

Difficulty with service obligations if a contract is lost

Front 129

Network HMO

Back 129

Contract with more than one group practice

Variations

Contracts with only PCPs who are financially responsible for specialty services, or

Separate contracts with PCPs and specialists

Advantage

Wider choice of physicians

Disadvantage

Dilution of utilization control

Front 130

Advantages/ disadvantages of IPAs?

Back 130

Eliminates the need to contract with various providers

Transfers financial risk to the IPA

Choice of providers

Disadvantages

Difficulty with service obligations if a contract is lost

Dilution of utilization control

Generally, a surplus of specialists

Front 131

What are the features and advantages/disadvantages of a PPO?

Back 131

Discounted fees are used to pay providers (no direct risk sharing)

Generally, no gatekeeping and other controls

PPOs enjoy the highest enrollment (in employment-based insurance market) of all managed care plans

Front 132

What is a POS plan?

Back 132

Cross between HMO and PPO

HMO features are retained (utilization controls, capitation)

PPO feature: Open access option available at the point of service

Front 133

Case-Mix Methods

Back 133

Case mix: Aggregate severity of conditions

Determined through a comprehensive assessment

Mutually exclusive case-mix categories represent resource use

Resource Utilization Groups (RUGs) are used to determine per-diem reimbursement for skilled nursing facilities

Case-Mix Groups (CMGs) are used to reimburse inpatient rehabilitation facilities

Front 134

Home Health Resource Groups (HHRG)

Back 134

The PPS is fixed, predetermined for each 60-day episode of care regardless of specific services delivered

Services are bundled under one payment on a per patient basis

Durable medical equipment (DME) and drugs not included

Outcome and Assessment Information Set (OASIS) is used to assign patients to one of 153 HHRG categories

Front 135

Health Care Service Frequency

Back 135

Primary Care

75−85% of population requires only primary

Secondary Care

10−12% requires referral to short-term secondary care

Tertiary care

5−10% require tertiary

Front 136

Discharges/ 1000 population

Back 136

An indicator of access and utilization

Number of overnight patients a hospital serves in a given time period

Include newborns and deaths

Front 137

Average length of stay definition?

Back 137

Days of care/Discharges

An indicator of severity of illness and resource use

Highest in federal hospitals, followed by state and local government hospitals

Private nonprofit and for profit hospitals had the same ALOS in 2010

Front 138

Occupancy rate

Back 138

Percent of capacity occupied

Calculation: average daily census / number of available beds (capacity) × 100

A measure of performance

Front 139

Rehab hospital characteristics

Back 139

Therapeutic services to restore maximum function in patients

Medicare rule: 75% of the inpatients must require intensive rehabilitation (at least 3 hours of therapy per day)

PT, OT, Speech/language pathology

Approximately 80% are hospital-based units rather than freestanding

Front 140

Acute length of stay definition

Back 140

ALOS of 25 days or less

Treat acute conditions

Front 141

Approximately what percent of U.S. Hospitals are on rural areas?

Back 141

40%

Front 142

Benefits of managed care organizations ?

Back 142

*provides better value than indemnity insurance

*Good access to primary care and preventive services in certain key areas

On a larger scale, impact on access is not well established

*quality is equivalent to indeminty plans if not better

Front 143

Types of service integration

Back 143

Management services organizations (MSOs)

Physician-hospital organizations (PHOs)

Provider-sponsored organizations (PSOs)

Front 144

MSO

Back 144

Supply management expertise, administrative tools, and information technology to physician group practices

Mainly used by small groups that cannot employ full-time managers

Front 145

Types of highly integrated healthcare systems

Back 145

Integrated delivery systems (IDSs)

Accountable care organizations (ACOs)

Payer−provider integration

Front 146

Integrated delivery system

Back 146

A network of organizations

Coordinated continuum of services

Willing to be held clinically and fiscally accountable

Managed care promoted the formation of IDSs

Cost effective for MCOs to contract with a full service provider

Preference by MCOs to seek cost-efficient providers who will take responsibility for quality

Providers strengthened their bargaining power with MCOs and protected their autonomy

Front 147

Accountable care organization

Back 147

Integrated group of providers who take responsibility for delivering services to a defined population

Take responsibility for improving health status

Provide cost-efficient care

Focus on satisfaction with care

*use mechanisms already used by MCOs and IDSs (disease management, care coordination, sharing cost savings with providers, etc.) to improve cost, quality, and population health

Front 148

True or false. 2/3 of all long te care is paid by Medicare

Back 148

False. Medicaid is the largest payer

Front 149

True or false: white women have the highest and Hispanic women the least utilization of mammograms?

Back 149

True

Front 150

True or false: white women have the highest and Hispanic women the least utilization of mammograms?

Back 150

True

Front 151

True or false? Heart disease and stroke account for a higher percentage of deaths among women than men at all stages of life: 42% of women with heart attacks die within the year, but only 24% of men do

Back 151

True

Front 152

True or false? Until the age groups 65 and older, women have higher physician utilization rates than men

However, hospitalization rates are comparable for men and women

Back 152

True

Front 153

Accessibility

Back 153

fit between the locations of providers and patients (transportation, convenience)

Front 154

Accessibility

Back 154

fit between the locations of providers and patients (transportation, convenience)

Front 155

Accommodation

Back 155

how resources are organized to provide services and the patient’s ability to use the services (timely appointments, quick service, walk-ins, etc.)

Front 156

Accessibility

Back 156

fit between the locations of providers and patients (transportation, convenience)

Front 157

Accommodation

Back 157

how resources are organized to provide services and the patient’s ability to use the services (timely appointments, quick service, walk-ins, etc.)

Front 158

Acceptability

Back 158

compatibility (waiting time, race, culture, gender, etc.)

Front 159

In the Omnibus Budget Reconciliation Act of 1986, Congress provided rural hospitals three important provisions:

Back 159

Separated urban and rural pools of funds used to pay for outliers, or cases in which excessive expenditures above the prospective payment system allotment are incurred.

Provided early payments to those with less than 100 beds.

Changed criteria for rural referral centers to allow more hospitals to qualify for funds.

Front 160

In the Omnibus Budget Reconciliation Act of 1986, Congress provided rural hospitals three important provisions:

Back 160

Separated urban and rural pools of funds used to pay for outliers, or cases in which excessive expenditures above the prospective payment system allotment are incurred.

Provided early payments to those with less than 100 beds.

Changed criteria for rural referral centers to allow more hospitals to qualify for funds.

Front 161

Has sole jurisdiction over Medicare Part A, Social Security, unemployment compensation, public welfare, and health care reform

Back 161

House ways and means committee

Front 162

In the Omnibus Budget Reconciliation Act of 1986, Congress provided rural hospitals three important provisions:

Back 162

Separated urban and rural pools of funds used to pay for outliers, or cases in which excessive expenditures above the prospective payment system allotment are incurred.

Provided early payments to those with less than 100 beds.

Changed criteria for rural referral centers to allow more hospitals to qualify for funds.

Front 163

Has sole jurisdiction over Medicare Part A, Social Security, unemployment compensation, public welfare, and health care reform

Back 163

House ways and means committee

Front 164

Has jurisdiction over Medicaid, Medicare Part B, matters of public health, mental health, health personnel, HMO’s, foods and drugs, air pollution, consumer products safety, health planning, biomedical research, and heath protection

Back 164

House energy and commerce committee .

Front 165

Has jurisdiction in most health bills

Back 165

Committee on labor and human resources

Front 166

Has jurisdiction over taxes and revenues, matters related to Social Security, Medicare, Medicaid, and Maternal and Child Health

Back 166

Committee on finance

Front 167

Provided greater increase in reimbursement to rural hospitals than to urban hospitals

Allowed rural hospitals located adjacent to metropolitan statistical areas to be defined as urban hospitals

Authorized a rural health care transition program to provide assistance to hospitals and others wishing to adopt new service delivery strategies

Back 167

The OBRA of 1987 included provisions that

Front 168

Cont...The OBRA of 1987 included provisions that:

Back 168

Required a report in the appropriateness of separate urban and rural rates

Authorized small rural hospitals to serve as residency training cites for physicians

Front 169

The leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed

Back 169

balance billing

Front 170

The leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed

Back 170

balance billing

Front 171

occurs when high-risk individuals, that is, people who are likely to use more health care services than others because of their poor health status, enroll in health insurance plans in greater numbers, compared to people who are healthy

Back 171

adverse selection

Front 172

adjusting premiums to reflect health status and making potential high-cost enrollees pay more

Back 172

Risk rating

Front 173

Provisions in the ACA related to primary care include

Back 173

(1) increasing Medicare and Medicaid payments to primary care providers, (2) creating new incentives such as funding for scholarships and loan repayment for primary care providers working in underserved areas, (3) expanding the health center program and bolstering the capacity of health centers, and (4) establishing additional training programs such as establishing 11 Teaching Health Centers for training primary care providers

Front 174

8. How does hospital utilization vary according to a person’s age, gender, and socioeconomic status?

Back 174

< 1 years of age has the highest utilization, females > men, low SES.hgiher SES, western states have the lowest utilization

Front 175

a model that requires a Medicaid enrollee to choose a PCP, who is responsible for coordinating the enrollee’s care and paid a monthly fee for doing so, on top of the payment for providing medical services. In general, all medical services are reimbursed on a fee-for-service basis

Back 175

primary case management

Front 176

2. What are the three main payment mechanisms managed care uses? In each mechanism, who bears the risk?

Back 176

Fee for service: MCO

Capitation: provider

Discounted fees: MCO

Salary: Shared (physicians bonuses tied to performance.

Front 177

does case management differ from disease management?

Back 177

Case management targets high-risk patients--those who, because of diverse combinations of health, social and functional problems, are likely to need hospitalization. Disease management targets patients who have one major diagnosis and who, because of their major diagnosis, have a relatively standard set of needs.

Front 178

What three sources do health ecomonist use to guage over spending in the US healthcare sustem?

Back 178

1. International comparisons

2. Rise of premiums

2. Spending on public programs

Front 179

What are some supply side (regulatory) cost containment strategies?

Back 179

Restrictions on capital expenditures (new construction, renovations, and technology diffusion)

Example: Certificate of need

Restrictions on supply of physicians

Example: Entry barriers for foreign medical graduates

Front 180

NQS, Priority 1: Making care safer by reducing harm caused in the delivery of care

Back 180

Reduce preventable hospital admissions and readmissions.

Reduce the incidence of adverse health care-associated conditions.

Reduce harm from inappropriate or unnecessary care.

Front 181

Critical pathway

Back 181

Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.

Front 182

Priority 2: Ensuring that each person and family members are engaged as partners in their care

Back 182

Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings.

In partnership with patients, families, and caregivers—and using a shared decision-making process—develop culturally sensitive and understandable care plans.

Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.

Front 183

Priority 3: Promoting effective communication and coordination of care

Back 183

Improve the quality of care transitions and communications across care settings.

Improve the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.

Establish shared accountability and integration of communities and health care systems to improve quality of care and reduce health disparities.

Front 184

Priority 4: Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease

Back 184

Promote cardiovascular health through community interventions that result in improvement of social, economic, and environmental factors.

Promote cardiovascular health through interventions that result in adoption of the most healthy lifestyle behaviors across the lifespan.

Promote cardiovascular health through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Front 185

Priority 5: Working with communities to promote wide use of best practices to enable healthy living

Back 185

Promote healthy living and well-being through community interventions that result in improvement of social, economic, and environmental factors.

Promote healthy living and well-being through interventions that result in adoption of the most important healthy lifestyle behaviors across the lifespan.

Promote healthy living and well-being through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Front 186

Priority 6: Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models

Back 186

Ensure affordable and accessible high-quality health care for people, families, employers, and governments.

Support and enable communities to ensure accessible, high-quality care while reducing waste and fraud.

Front 187

6. What are the main provisions of HIPAA with regard to the protection of personal health information? What provisions were added to HIPAA under the HITECH Act?

Back 187

To accelerate the adoption of EHRs, some major policy initiatives were launched during the George W. Bush administration. These initiatives culminated in the enactment of earmarked an estimated $19 billion in direct grants and financial incentives to promote the adoption of EHRs by hospitals and physicians (Wang et al. 2013). Beginning in 2011, Medicare and Medicaid started offering financial incentives of up to $44,000 for Medicare providers and $63,750 for Medicaid providers for “meaningful use” of health information technology (CDC 2012). To demonstrate “meaningful use,” health care providers have to meet a range of metrics in areas such as quality, safety, efficiency, reduction of health disparities, patient engagement, care coordination, and security of health information (Halamka 2010). Meaningful use criteria are being phased in over three stages between 2011 and 2015. To qualify for incentive payments, eligible providers must meet a set of objectives at each meaningful use stage (CMS 2013). Starting in 2015, hospitals that fail to meet the meaningful use criteria will be subject to financial penalties (DesRoches et al. 2013b).

also established the State Health Information Exchange Cooperative Agreement Program, which awarded more than $540 million to states to establish mechanisms that would facilitate the exchange of clinical information (Blumenthal 2011). One approach states are employing is to establish HIOs.

Front 188

According to the federal government, what are the components of meaningful use?

Back 188

Improve care coordination

Reduce healthcare disparities

Engage patients and their families

Improve population and public health

Ensure adequate privacy and security

Front 189

based on a group’s own medical claims experience. Under this method, premiums differ from group to group because different groups have

Back 189

experience rating

Front 190

spreads the risk among members of a larger population. Premiums are based on the utilization experience of the entire population covered by the same type of health insurance. Under pure community rating, the same rate applies to everyone regardless of age, gender, occupation, or any other indicator of health risk (Goodman and Musgrave 1992). For example, a person who has a life-threatening condition would pay the same premium as someone who does not. When premiums are based on community rating, the good risks, that is, healthy people, actually subsidize the insurance cost for the poor risks (Somers and Somers 1977). In other words, costs shift from people in poor health to people in good health and make health insurance less affordable for those who are healthy

Back 190

Community rating

Front 191

also known as modified community rating, overcomes the main drawbacks of experience rating and pure community rating. Under this method, price differences take into account demographic factors such as age, gender, geography, and family composition, while ignoring other risk factors. In the past, state laws have governed health insurance, including premium rate setting, with different states adopting one of the three methods discussed earlier.

Back 191

Adjusted community rating

Front 192

the employer acts as its own insurer instead of obtaining insurance through an insurance company.

Back 192

Self-insurance

Front 193

Resource ultilization groups (RUGs)

Back 193

This method is used for paying SNFs. Implemented in 1998, the PPS provides for a per diem prospective rate based on the intensity of care needed by patients in an SNF. The case mix is determined through a comprehensive assessment of each patient, using an assessment instrument called the Minimum Data Set (MDS). The MDS consists of a core set of screening elements used to assess the clinical, functional, and psychosocial needs of each patient admitted to an SNF.

Front 194

occurs when healthy people disproportionately enroll into a health plan

Back 194

Risk rating or favorable risk

Front 195

The leftover sum by the provider to the patient after insurance has only partially paid the charge initially billed

Back 195

balance billing

Front 196

occurs when high-risk individuals, that is, people who are likely to use more health care services than others because of their poor health status, enroll in health insurance plans in greater numbers, compared to people who are healthy

Back 196

adverse selection

Front 197

adjusting premiums to reflect health status and making potential high-cost enrollees pay more

Back 197

Risk rating

Front 198

Provisions in the ACA related to primary care include

Back 198

(1) increasing Medicare and Medicaid payments to primary care providers, (2) creating new incentives such as funding for scholarships and loan repayment for primary care providers working in underserved areas, (3) expanding the health center program and bolstering the capacity of health centers, and (4) establishing additional training programs such as establishing 11 Teaching Health Centers for training primary care providers

Front 199

8. How does hospital utilization vary according to a person’s age, gender, and socioeconomic status?

Back 199

< 1 years of age has the highest utilization, females > men, low SES.hgiher SES, western states have the lowest utilization

Front 200

a model that requires a Medicaid enrollee to choose a PCP, who is responsible for coordinating the enrollee’s care and paid a monthly fee for doing so, on top of the payment for providing medical services. In general, all medical services are reimbursed on a fee-for-service basis

Back 200

primary case management

Front 201

2. What are the three main payment mechanisms managed care uses? In each mechanism, who bears the risk?

Back 201

Fee for service: MCO

Capitation: provider

Discounted fees: MCO

Salary: Shared (physicians bonuses tied to performance.

Front 202

does case management differ from disease management?

Back 202

Case management targets high-risk patients--those who, because of diverse combinations of health, social and functional problems, are likely to need hospitalization. Disease management targets patients who have one major diagnosis and who, because of their major diagnosis, have a relatively standard set of needs.

Front 203

What three sources do health ecomonist use to guage over spending in the US healthcare sustem?

Back 203

1. International comparisons

2. Rise of premiums

2. Spending on public programs

Front 204

What are some supply side (regulatory) cost containment strategies?

Back 204

Restrictions on capital expenditures (new construction, renovations, and technology diffusion)

Example: Certificate of need

Restrictions on supply of physicians

Example: Entry barriers for foreign medical graduates

Front 205

NQS, Priority 1: Making care safer by reducing harm caused in the delivery of care

Back 205

Reduce preventable hospital admissions and readmissions.

Reduce the incidence of adverse health care-associated conditions.

Reduce harm from inappropriate or unnecessary care.

Front 206

Critical pathway

Back 206

Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.

Front 207

Priority 2: Ensuring that each person and family members are engaged as partners in their care

Back 207

Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings.

In partnership with patients, families, and caregivers—and using a shared decision-making process—develop culturally sensitive and understandable care plans.

Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.

Front 208

Priority 3: Promoting effective communication and coordination of care

Back 208

Improve the quality of care transitions and communications across care settings.

Improve the quality of life for patients with chronic illness and disability by following a current care plan that anticipates and addresses pain and symptom management, psychosocial needs, and functional status.

Establish shared accountability and integration of communities and health care systems to improve quality of care and reduce health disparities.

Front 209

Priority 4: Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease

Back 209

Promote cardiovascular health through community interventions that result in improvement of social, economic, and environmental factors.

Promote cardiovascular health through interventions that result in adoption of the most healthy lifestyle behaviors across the lifespan.

Promote cardiovascular health through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Front 210

Priority 5: Working with communities to promote wide use of best practices to enable healthy living

Back 210

Promote healthy living and well-being through community interventions that result in improvement of social, economic, and environmental factors.

Promote healthy living and well-being through interventions that result in adoption of the most important healthy lifestyle behaviors across the lifespan.

Promote healthy living and well-being through receipt of effective clinical preventive services across the lifespan in clinical and community settings.

Front 211

Priority 6: Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models

Back 211

Ensure affordable and accessible high-quality health care for people, families, employers, and governments.

Support and enable communities to ensure accessible, high-quality care while reducing waste and fraud.

Front 212

What are the standards used in CDCs evaluation framework?

Back 212

Standard 1: utility, Standard 2: feasibility, Standard 3: propriety, and Standard 4: accuracy.

Front 213

What are the standards used in CDCs evalutation framework

Back 213

Standard 1: utility, Standard 2: feasibility, Standard 3: propriety, and Standard 4: accuracy.

Front 214

What are three groups of stakeholders identified by CDC for program evaluation ?

Back 214

those involved in program operations (e.g., sponsors, collaborators, coalition partners, funding officials, administrators, managers, and staff); those served or affected by the program (e.g., clients, family members, neighborhood organizations, academic institutions, elected officials, advocacy groups, professional associations, skeptics, opponents, and staff of related or competing organizations); and primary users of the evaluation.

Front 215

Engage stakeholdersThose persons involved in or affected by the program and primary users of the evaluation. Describe the programNeed, expected effects, activities, resources, stage, context, logic model. Focus the evaluation designPurpose, users, uses, questions, methods, agreements. Gather credible evidenceIndicators, sources, quality, quantity, logistics

Justify conclusionsStandards, analysis/synthesis, interpretation, judgment, recommendations. Ensure use and share lessons learnedDesign, preparation, feedback, follow-up, dissemination

Back 215

Steps in CDCs evaluation framework

Front 216

Read about the CDC evaluation framework

Back 216

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.361.8594&rep=rep1&type=pdf

Front 217

6. What are the main provisions of HIPAA with regard to the protection of personal health information? What provisions were added to HIPAA under the HITECH Act?

Back 217

To accelerate the adoption of EHRs, some major policy initiatives were launched during the George W. Bush administration. These initiatives culminated in the enactment of earmarked an estimated $19 billion in direct grants and financial incentives to promote the adoption of EHRs by hospitals and physicians (Wang et al. 2013). Beginning in 2011, Medicare and Medicaid started offering financial incentives of up to $44,000 for Medicare providers and $63,750 for Medicaid providers for “meaningful use” of health information technology (CDC 2012). To demonstrate “meaningful use,” health care providers have to meet a range of metrics in areas such as quality, safety, efficiency, reduction of health disparities, patient engagement, care coordination, and security of health information (Halamka 2010). Meaningful use criteria are being phased in over three stages between 2011 and 2015. To qualify for incentive payments, eligible providers must meet a set of objectives at each meaningful use stage (CMS 2013). Starting in 2015, hospitals that fail to meet the meaningful use criteria will be subject to financial penalties (DesRoches et al. 2013b).

also established the State Health Information Exchange Cooperative Agreement Program, which awarded more than $540 million to states to establish mechanisms that would facilitate the exchange of clinical information (Blumenthal 2011). One approach states are employing is to establish HIOs.

Front 218

What are the focus areas of the Partnership for Patients (safety) initiative?

Back 218

Adverse Drug Events

Catheter-Associated Urinary Tract Infections

Central Line Associated Blood Stream Infections

Injuries from Falls and Immobility

Obstetrical Adverse Events

Pressure Ulcers

Surgical Site Infections

Venous Thromboembolism

Ventilator-Associated Pneumonia

Readmissions

Front 219

Module on patient safety

Back 219

http://patientsafetyed.duhs.duke.edu/module_e/module_overview.html

Front 220

Read about root-cause analysis.

Back 220

http://psnet.ahrq.gov/primer.aspx?primerID=10

Front 221

Read about diagnostic error

Back 221

http://psnet.ahrq.gov/primer.aspx?primerID=12

Front 222

Medication errors that do not cause any harm—either because they are intercepted before reaching the patient, or by luck

Back 222

Potential Adverse drug event

Front 223

the patient experienced harm from a medication that, while not completely preventable, could have been mitigated

Back 223

Ameliorated adverse drug rxn

Front 224

a certain percentage of patients will experience ADEs even when medications are prescribed and administered appropriately

Back 224

Non-preventable adverse drug event

Front 225

Two screening tools for prescribing safety in the eldery?

Back 225

Beers

STOP/START

Front 226

contains 21 patient perspectives on care and patient rating items that encompass nine key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, quietness of the hospital environment, and transition of care. The survey also includes four screener questions and seven demographic items, which are used for adjusting the mix of patients across hospitals and for analytical purposes. The survey is 32 questions in length

Back 226

Hospital consumers assessment of Providers and systems

Front 227

Name Two patient satisfaction surveys

Back 227

Short form Patient Satisfaction survey (PSQ 18)

Consumer Assessment Health plans (overseen by CMS)

Front 228

According to the federal government, what are the components of meaningful use?

Back 228

Improve care coordination

Reduce healthcare disparities

Engage patients and their families

Improve population and public health

Ensure adequate privacy and security

Front 229

an ordinal scale used to measure performance in activities of daily living (ADL). Each performance item is rated on this scale with a given number of points assigned to each level or ranking.[1] It uses ten variables describing ADL and mobility. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital. The amount of time and physical assistance required to perform each item are used in determining the assigned value of each item. External factors within the environment affect the score of each item. If adaptations outside the standard home environment are met during assessment, the participant’s score will be lower if these conditions are not available

Back 229

Barthel ADL index

Front 230

What are consider instrumental ADLs?

Back 230

SHAFT: shopping, housekeeping, accounting, food preparation/meds, telephone/transportation.

Front 231

What three federally mandated assessments capture functional status?

Back 231

1)IRF Patient Assessment Instrument (hospital rehabs

2)The Home Health Outcome

Outcome and Assessment Information Set (OASIS)

3) Minimum data set (for SNF, info gathered on admission and transfer to state database).

Front 232

What is disease management?

Back 232

a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant."[1][2][3]

For people who can access health care practitioners or peer support it is the process whereby persons with long-term conditions (and often family/friend/carer) share knowledge, responsibility and care plans with healthcare practitioners and/or peers. To be effective it requires whole system implementation with community social support networks, a range of satisfying occupations and activities relevant to the context, clinical professionals willing to act as partners or coaches and on-line resources which are verified and relevant to the country and context

Front 233

based on a group’s own medical claims experience. Under this method, premiums differ from group to group because different groups have

Back 233

experience rating

Front 234

spreads the risk among members of a larger population. Premiums are based on the utilization experience of the entire population covered by the same type of health insurance. Under pure community rating, the same rate applies to everyone regardless of age, gender, occupation, or any other indicator of health risk (Goodman and Musgrave 1992). For example, a person who has a life-threatening condition would pay the same premium as someone who does not. When premiums are based on community rating, the good risks, that is, healthy people, actually subsidize the insurance cost for the poor risks (Somers and Somers 1977). In other words, costs shift from people in poor health to people in good health and make health insurance less affordable for those who are healthy

Back 234

Community rating

Front 235

also known as modified community rating, overcomes the main drawbacks of experience rating and pure community rating. Under this method, price differences take into account demographic factors such as age, gender, geography, and family composition, while ignoring other risk factors. In the past, state laws have governed health insurance, including premium rate setting, with different states adopting one of the three methods discussed earlier.

Back 235

Adjusted community rating

Front 236

the employer acts as its own insurer instead of obtaining insurance through an insurance company.

Back 236

Self-insurance

Front 237

Resource ultilization groups (RUGs)

Back 237

This method is used for paying SNFs. Implemented in 1998, the PPS provides for a per diem prospective rate based on the intensity of care needed by patients in an SNF. The case mix is determined through a comprehensive assessment of each patient, using an assessment instrument called the Minimum Data Set (MDS). The MDS consists of a core set of screening elements used to assess the clinical, functional, and psychosocial needs of each patient admitted to an SNF.

Front 238

occurs when healthy people disproportionately enroll into a health plan

Back 238

Risk rating or favorable risk

Front 239

Fundamentally, how it is the feds or the state who are responsible for the public's health?

Back 239

States, under the 10th admendment

Front 240

What is the IOM's definition of quality?

Back 240

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional standards

Front 241

How are need, unmet need, and utilization related?

Back 241

Unmet need = need - utilization

Front 242

National quality forum

Back 242

Panel of experts focused on developing metric. Works with AHRQ to develop adverse events reporting standards

Front 243

Public-private parternship focused on improving quality within organizations by identifying and sharing management best practices, principles, and strategies

Back 243

Baldridge program

Front 244

Non profit

Creating will to change

Creating new models

Million lives campaign: implement bundles of improvements

Back 244

Institute for healthcare improvement

Front 245

Accrediates accountable care organizations and patient centered medical homes

Back 245

Nationals committee on quality assurance

Front 246

What is failure mode and effects analysis?

Back 246

Failure Modes and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change. FMEA includes review of the following:

Steps in the process

Failure modes (What could go wrong?)

Failure causes (Why would the failure happen?)

Failure effects (What would be the consequences of each failure?)

Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process.

Front 247

What is valuable based purchasing?

Back 247

Medicare payment tied to quality metrics

Front 248

IOM dimensions of quality

Back 248

Quality care is:

1) safe-RCA and FMEA apply

2) timely/ efficient- lean or six sigma

3) pt centered - surveys and value based purchasing

4) evidence based

5) equitable

Front 249

What is a federally qualified health Center?

Back 249

Federal government repayment designation.

* Create as a health care safety net to serve medically underserved populations regardless of ability to pay.

* Created to free up ERs

*Expansion: Health Center initiative (Bush); ACA

* Medicare pts utilize (CMS doing demonstration projects on incorporating pt centered medical homes)

*Non-for-profits controlled w/ board of directors

Front 250

The majority of local health departments are under the jurisdiction of what authority

A)

City

Correct answerB)

County

C)

Multi-county

D)

State

Back 250

Answer: B. According to the National Association of County and City Health Officers, 60% of local health departments fall under the jurisdiction of counties. 11% fall under combined city and county jurisdiction and another 11% fall under town and township jurisdiction. The remaining local health departments fall under multi-county district, regional or city jurisdiction

Front 251

51. A physician orders a thyroid stimulating hormone (TSH) test on a patient. The test result comes back indicating the TSH is elevated. No action is taken and the patient develops complications as a result of hypothyroidism. Which class of medical error does this represent

Correct answerA)

Diagnostic Error

B)

Equipment Failure

C)

Translation Error

D)

Misinterpretation of Medical Orders

Back 251

Answer: A. Diagnostic Errors occur when a wrong action is taken or when there is failure to take an indicated action. Other common forms of medical error include: Equipment Failure, which occurs when a specific device (such as a defibrillator or an IV pump) fails; Translation Error, which occurs when the provider and patient do not speak the same language and important clinical information such as how to take a prescribed medication is not communicated properly; and Misinterpretation of Medical Orders, which occurs when a physician order is acted upon incorrectly. (Reference is “To Err is Human,” www.nap.edu.readingroom

Front 252

91. The primary objective of utilization management is:

Correct answer: A)

You chose: A)

Correct answerA)

Cost containment

B)

Quality improvement

C)

Reduction of regional disparities in use of health care resources

D)

Regulation of health insurance industry

Back 252

Answer: A. Utilization management is a cost-containment strategy that limis health care expenditures by limiting reimbursement. It includes preadmission certification, concurrent (during admission) review, case management and disease management. It is linked to quality improvement, but quality improvement is not its primary objective.

Front 253

A patient requiring an emergency hospital stay does not have health insurance. In the months following the stay, the patient receives bills for hospital and physician services that total $10,000. In terms of health economics, these bills represent?

Back 253

A)

Cost

Correct answerB)

Price

C)

Reimbursement

D)

Value

Answer: B. The price is what the consumer is asked to pay for a good or service. Cost is the actual monetary value of the the resources consumed in

producing a good or service. Reimbursement is what the payor provides for the service.

Front 254

What offices are contained under HRSA?

Back 254

Vaccine injury compensation

Bureaus of MCH/ primary care/HIV(Ryan white)/ health workforce

Organ and transplant