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20 Cards in this Set
- Front
- Back
has the greatest potential
for prevention of disease in the United States? |
Although
environmental modification, genetic counseling, immunization, and screening tests are important elements of preventive health, changing personal health behavior has the largest potential for improving public health in the United States, where the leading causes of death include heart disease, cancer, AIDS, injuries, and chronic obstructive pulmonary disease. Thus, alterations in personal health behaviors—such as smoking, diet, exercise, use of seatbelts, and safe sexual behavior—need to be stressed. Priorities would be different in developing countries where infectious disease and malnutrition are leading causes of death. |
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The largest proportion of the
nations hospital bill is covered by |
Private insurance
pays for 35% of the nations total hospital bill. Medicare covers 27% and Medicaid, 11%. Out-of-pocket payments account for 5% and other private insurance covers 5.5%, with the remainder provided from a variety of sources. |
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is
likely to be the most important cause of underimmunization? of kids <2 y o |
Parental and provider attitudes
toward immunization are not barriers for the majority of underimmunized children. Children whose private health insurance does not cover immunizations are entitled to the federal Vaccines for Children (VFC) program at federally qualified health centers. Children on Medicaid or who are uninsured are covered by VFC. Children often fall behind because the parents do not know when the immunizations are due. Making the number of required health supervision visits does not guarantee adequate immunization, and missed opportunities abound because of failure to assess immunization status. |
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are effective in increasing immunization rates
|
There is sufficient evidence demonstrating that the implementation
of a recall/reminder system, provider-based tracking, and the performance of practice-based immunization assessments with feedback results are effective in increasing immunization rates |
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The End-Stage Renal
Disease (ESRD) Program |
The End-Stage Renal
Disease (ESRD) Program is funded through Medicare and was enacted in 1971. Eligibility requirements include having ESRD, applying for benefits, and (1) being fully insured for old age and survivor insurance benefits, or (2) entitlement to Social Security benefits, or (3) being a spouse or a dependent of a person who fits the description of 1 or 2. About 93% of all persons with ESRD are eligible |
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largest categories of expense in descending order were
|
largest categories of expense in descending order were
maternal and child health, environmental health, substance abuse, HIV/AIDS, and chronic diseases |
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A 75-year-old widowed patient
with multiple health problems and limited mobility is in need of nursing home care. Which of the following will be the first source of payment for these services? |
Medicare does not generally
cover nursing home expenses, and so patients must rely on their own resources until they are depleted, at which time they will be covered by Medicaid. Government remains the payer of last resort |
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Peer Review Organizations
(PRO) were initially developed to review care for |
This a federally mandated
program to review care provided for patients entitled to Medicare benefits for appropriateness of use |
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The National Committee for
Quality Assurance (NCQA) was created to accredit which of the following organizations? |
NCQA
is the accreditation body of HMOs. They are also responsible for developing the Health Employers Data and Information Set (HEDIS), a set of quality indicators in the delivery of health care, many points of which assess the performance in the provision of preventive services such as immunization, mammography, and Pap smear screening rates. Hospitals are accredited by JACOH, the Joint Commission on Accreditation of Health Organizations. If a hospital loses its accreditation, it would be grounds for third-party reimbursement agencies, such as Medicare, to refuse payment. Laboratories are generally accredited by the CAP, the College of American Pathologists. |
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The resource-based relative
value scale (RBRVS) was adopted in 1989 as a payment schedule for Medicare providers to address the imbalance between cognitive services and procedures. Which of the following factors is NOT part of this methodology? a. Physician time and mental effort b. Physician skill and judgment c. Practice expenses d. Malpractice costs e. Hospital costs |
The RBRVS is a system for
making doctors fees mor e equitable—it does not address hospital costs. It is meant to replace the usual and customar y rate (UCR) schedule, which strongly rewarded technical procedures at the expense of cognitive services. The practical effect is to lower the reimbursement for procedures such as repair of inguinal hernia and bypass surgery, and to increase reimbursement for an office visit. Family physicians would see an overall increase of 16% while thoracic surgeons would see a decrease of 55%. Proponents hope that the scale will discourage overuse of procedures and encourage physicians to spend more time with their patients. |
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Medicare does not cover
|
Medicare does not cover
preventive health services (except for mammography), routine medical visits, any services not related to the treatment of an illness or an injury, hearing aids, eyeglasses, dentures, and dental care . Medicare will pay for 100% of the approved amount for medically necessary clinical laboratory services. For other services covered by part B Medicare, such as outpatient hospital treatment, outpatient physicians medical and surgical services, and medical supplies, copayments and deductibles apply. Because of the limited coverage provided by part B and the substantial beneficiary disbursement for some services, more elderly have decided to enroll in managed care plans that cover more services and have lower copayments and deductibles. |
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The majority of uninsured
persons in the United States are |
Contrary to the belief of
many, the majority of the uninsured in the United States are working. They do not have health insurance because they choose not to purchase it or they cannot afford it; many times, it is not offered where they work. Over 85% of all uninsured are working Americans and their families. Many who are insured have limited coverage, often restricted to hospital care |
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best describes Medicare
|
Medicaid is a collaborative
federal and state program. Medicare is a federal program with two parts: A and B. Part A covers mostly hospital-related expenses and part B covers physician expenses. Part A is financed by an employee/employer tax, which is paid into a trust fund, while part B is financed partly through beneficiary premiums and partly from the U.S. general fund budget. Part A is reimbursed using DRGs, and part B is moving from usual, customar y, and prevailing reimbursement to the r esource-based relative value scale (RBRVS). Medicare covers persons over the age of 65 or those who are permanently |
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best describes Medicaid
|
Medicaid is financed by
both the federal and state governments. In order to receive federal funds, states are required to provide certain basic benefits such as inpatient and outpatient hospital services, family planning services and supplies, and to cover certain groups such as recipients of supplemental security income and Aid to Families with Dependent Children (AFDC). However, states do not cover all poor persons, and coverage will vary from state to state. Seventy-five percent of all Medicaid expenditures for the elderly went to pay for nursing home services. Medicaid will cover these services once a person has spent down to an eligibility level. |
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Measures
to control costs in HMOs include |
Measures
to control costs in HMOs include gatekeeping, which means that a person is assigned to a primary care provider who coordinates all the care for that person, as well as authorization for referrals and emergency room use. It promotes continuity of care and decreases excessive unnecessary care. |
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best describes diagnosisrelated
groups (DRGs)? |
The DRG is used to calculate
the reimbursement rate for part A of Medicare. This system was created to stem the rising costs of hospital care. A fixed amount of money is given to the hospital for the diagnosis for which the patient was hospitalized. This is calculated based on the average costs of a large number of hospitals to care for someone with a particular diagnosis. It is not based on the costs associated with the most efficient care, and it does not take into account severity of illness. For any hospital, the actual cost may be higher or lower than the DRG payment. Upgrading the DRG to obtain a higher reimbursement is called DRG cr eep; churning is readmitting the patient several times for related procedures or diagnoses, which results in additional DRG payments. |
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total quality
management (TQM)? |
The principle of TQM
was introduced by W. E. Deming and was initially applied to industrial management. The basis is to be customer-focused, to use data to better understand variations, and to work on improving the process of delivery |
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Preferred Provider Organizations (PPOs)
|
Preferred Provider Organizations (PPOs) are groups of
providers that make special arrangements with insurers to provide services to their customers on a discounted basis, that is, to accept lower levels of reimbursement than their usual rates. An example is the Blue Cross Prudent Buyer Plan, in which patients who are willing to obtain care from preferred providers can save on coinsurance and deductibles. |
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Health Maintenance Organizations (HMOs)
|
Health Maintenance Organizations (HMOs) provide comprehensive
health care services on a prepaid basis. First developed around the turn of the twentieth century, they were bitterly opposed by organized medicine. In the early 1970s, legislation encouraging their development was passed, which led to the establishment of 166 HMOs by 1975 and to 323 HMOs covering 15 million members by 1985. Independent Practice Associations (IPAs) are a more recent development. Whereas HMOs have traditionally served their patients by employing full-time physicians in their own clinics and medical centers, IPAs allow private physicians to contract with HMOs to provide services to enrolled patients. Professional Review Organizations (PROs) are federally mandated programs to review care provided for patients entitled to Medicare benefits for appropriateness of use (see question 434). Staff model HMOs employ salaried physicians, but these types of HMOs are decreasing in favor of other arrangements discussed previously (IPA, PPO) or mixed-model HMOs. |
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Professional Review Organizations (PROs)
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Professional Review Organizations (PROs) are federally mandated programs to review care provided for patients entitled to Medicare benefits for appropriateness of use
Staff model HMOs employ salaried physicians, but these types of HMOs are decreasing in favor of other arrangements discussed previously (IPA, PPO) or mixed-model HMOs. |