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20 Cards in this Set

  • Front
  • Back
has the greatest potential
for prevention of disease in the
United States?
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.
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
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.
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
The End-Stage Renal
Disease (ESRD) Program
The End-Stage Renal
Disease (ESRD) Program is funded through Medicare and was enacted in
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
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
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
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
The National Committee for
Quality Assurance (NCQA) was
created to accredit which of the following
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
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.
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.
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
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
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.
to control costs in HMOs include
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.
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
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
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.
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.
Professional Review Organizations (PROs)
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.