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Exam 2 Study Exam

by: Alexandra Ruth

Exam 2 Study Exam REHSCI 1240

Alexandra Ruth
GPA 3.78
Issues in Health Care
Debora Miller

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About this Document

This covers material from Week 6 through week 9 of the course!
Issues in Health Care
Debora Miller
Study Guide
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This 10 page Study Guide was uploaded by Alexandra Ruth on Friday January 9, 2015. The Study Guide belongs to REHSCI 1240 at University of Pittsburgh taught by Debora Miller in Fall2014. Since its upload, it has received 227 views. For similar materials see Issues in Health Care in Health and Human Services at University of Pittsburgh.

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Date Created: 01/09/15
Financing and Reimbursement lUnderstand the primary means by which healthcare is nanced public and private Private health insurance public program MedicareMedicaid charity ER free clinics Private Group Financed by employer union professional organization 1 Self no dividend 2 Individual private 3 Managed careMCO Both payer and provider HMO and PPO 4 Highdeductible health plans HDHPs HRA employer financed HAS employee financed Public is financed though Government lUnderstand the most common methods of reimbursement for healthca re services 0 Fee for servicecharges set by providers each service billed separate 0 Package pricing number of related services in one price 0 Resourcebased relative value scale Medicare developed an initiative to reimburse physicians according to a relative value assigned to each service 0 Managed Care alternatives 0 Capitation per member per month fee to cover all needed services 0 Retrospective reimbursementrates set after evaluating cost 0 Prospective reimbursement preestablished criteria I Used under Medicare part A since 1983 lldentify and de ne the 3 primary cost sharing strategies used by health plans and their enrollees insured persons Premiums amount insured pays for healthcare coverage usually monthly Deductibles amount the insured pays first before benefits are paid by the plan annual paid out of pocket each time health services are received Copays money paid out of pocket each time health service received Function reduce misuse of insurance coinsurance and stoploss provision Federally Funded Healthcare Programs lldentify federal entity responsible for oversight of HC programs agencies amp regulations Department of Health and Human Services 1 National Institutes of Health NIH FDA Indian Health Services Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services Administration on Aging 2 Department of Defense 3 Miitary personnel dependents retirees and their families Civilian care purchased through TRICARE Veterans Administration separate federal division One of world s largest HC delivery systems IONUIP lldentify primary federal agencies involved inresponsible for healthcare programs Centers for Medicare and Medicaid Services CMS an agency under the US Department of Health and Human Services DHHS Department of Veterans affair for Tricare Department of Defense for Active Military lldentify the primary federally funded health care programs Medicare Medicaid SCHIPs Military tricare VHA veterans lDefine Medicare Parts A B C and D Medicaid and SCHlPs Medicare A hospital insurance includes inpatient services short term convalescence and rehab in skilled nursing facilities SNF mandatory Medicare B physician services outpatient services diagnostic testing radiology emergency department ambulance Voluntary Medicare C Medicare Advantage Balanced Budget Act Which allows for establishment of Medicare managed care organizations as an alternative health insurance plan to traditional Medicare part B 1 Enrollees can enroll in 1 of 3 programs Medicare Managed Care Plans HMO Medicare Private Fee for Service Plans or Medicare Preferred Provider Organization Medicare D prescription drugs Medicaid Title XIX of SS Act finances health care for indigent but not all poor each state establishes its own eligibility of medically needy according to incomeresources and administers own program State Children s Health Insurance Program SCHIP Title XXI of SS Acts coverage for children under 19 mostly national funding lUnderstand how federally funded public health care programs are funded Government via taxes Social Security payroll taxes Medicare Part A Managed Care Organizations and Integrated Delivery Systems lDefine Managed Care Organizations MCO A mechanism of providing health care services Where a single organization takes on the management of financing insurance delivery and payment lldentify the primary goals of MCOs lldentify the 3 major types of MCOs and their primary characteristics 1 HMOs 4 models 1 Staff Model employs own xed salaried physicians exercises greater control over practice patterns and an better monitor utilization least popular type with high operating expenses and limited providers 2 Group Model contracts with a multispecialty group practice and separately with one or more hospitals to provide comprehensive services to its members 1 Physicians employed by practice not HMO 2 HMO pays all inclusive capitation fee to the practice 3 Network Model HMO contracts with more than one medical group 1 Adaptable to large metropolitan areas amp widespread geographic regions 2 Group practices responsible for providing all physician services 3 Able to offer more choices 4 Disadvantage dilution of utilization control 4 Independent Practice Association Model 1 Most successful in terms of enrollment 2 IPA establishes contracts with solo and group practices 3 Functions as an intermediary representing many physicians 4 Disadvantage If a contract is lost the HMO loses a large percentage of participating physicians 2PPOs 1 lnstead of capitation PPOs make discounted fee arrangements with providers 2 Range between 25 35 off providers regular fees 3 Point of Service Plans P05 1 POS plans combine features of HMOs With patient choice found in PPOs 2 POS plans overcome restricted provider choice but retain the benefits of tight utilization 3 Free choice of providers is a major selling point for P08 4 POS peaked in 19981999 but has declined due to high outofpocket costs 5 Define Integrated Healthcare Delivery Systems IDS Integration of several organizations under the same ownership Provides an array of health care services to a large community lUnderstand factors that contributed to the development of IDS Formed in response to growing power of managed care Organizations had pressure to reduce costs which was hard for small providers so integration into networks became a rational choice for survival WEEK 7 Health Policy and Public Health lldentify the primary roles of the Federal government in public healthpolicy making Monitors health needs sets policies amp standards supports research supports state and local initiatives 1 lldentify the primary roles of the State government in public healthpolicy making States have broad legal authority to regulate the health care system Financial support care and treatment for the vulnerable populations poor disable and disadvantaged children Medicaid SCHIP Quality assurance practitioner and facility oversight Licensure and Regulation Regulation of health care costs and insurance carriers 1 Restrict content marketing and price of health insurance Health personnel training operate medical schools Authorization of local government health services Set and enforce environmental quality standards Operate mental institutions and health departments Enforces codes licensing Coordinates health with social service aging and other services lldentify the primary roles of the local government in public healthpolicy making Direct services prevention epidemic surveillance and control Public Hospitals Special services for medically needy Health of Populations report track trend infectious diseases Vaccination immunizations public education Voluntary agencies are considered local public health and fill gaps in govntprivate services ie not for profit hospitals lUnderstand the process by which health care policy law is enacted by Congress and the President 1Bi introduced in House 0 Assigned to committee by the Speaker 0 Reassigned to subcommittee 0 Sent to agencies to hold hearings markups to get testimony and possible amendments 2 Committeessubcommittees may recommendnot recommendtable the bill 3 Full House hears the bill 0 May further amend it 0 May approve it 4 Send to Senate if approved 5 Same process in Senate as in House 0 If amended in senate must go back to House for approval Policy a bill may start in the house senate or both simultaneously 6 Forwarded to President for signature 0 If identical form approved in house and Senate 7 President signs I becomes law 8 Forwarded to appropriate agency for implementation 0 New regulation posted in the Federal Register 0 Hearings held to see how law will be implemented 0 The agency publishes gathers comments and rewrites regulations If appropriate program goes to 50 states for enabling legislation lRecognize the primary categories of health policy Access to care providers public nancing access and the elderly access and the minorities access and the rural areas access and the low income Cost containment Quality of care lDe ne distributive and redistributive healthcare policies Distributive policies spread bene ts throughout society Redistributive take money or power from one group and give it to another Quality De ned lBe able to de ne quotQualityquot and relate it to healthcare The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge lldentify and understand the 3 domains by which quality is measured Outcomes effectiveness and appropriateness of health care services and procedures Accreditation Agencies and Regulatory Bodies lldentify the most widely recognized accreditation agency that evaluates the quality and safety of care provided across the healthcare continuum and its primary attributes The joint Commission TJC lndependent Accrediting Agency recognized by Medicare and other payers which establishes performance standards for measuring quality of care 3 year accreditation period following an onsite survey Demonstrates commitment to quality Offers a consultative and educational experience Supports and enhances CQI efforts Enhances the image to the public purchasers and payers May help secure MCO contracts Done by Administrator Physician and Nurse lUnderstand the 2 primary methodologies by which it measures quality and safety of care System Tracers Medication management data management safety amp infection control Patient Tracers Selected from Day 1 consensus report Major service areas highrisk areas problemprone areas critical focus issues Average of 11 patients per 3day survey Review patient chart on unit Interview staff on units RevieWtrace patient care throughout the system Review other standards ie communication environment of care lRecognize key categories of qualitysafety standards by which healthcare organizations are evaluated Ethics Rights and Program Responsibilities Leadership Provision of Care Treatment Environment of Care and serVices Human Resources 39Pain Assessment and nformation Management Management Nursing Standards nfeCt0n contm39 Physician Standards Performance Improvement lldentify the most widely recognized accreditation agency that evaluates the quality and safety of care provided in rehabilitation facilities Commission on Accreditation of Rehab Facilities CARF lldentify the agency the accredits the quality of services offered by health insurance companies and their credentialed health care providers National Committee for Quality Assurance NCQA WEEK 8 Cost Qualitv and Access lldentify key factors that have contributed to the rising cost of healthcare Hospital Services prescription drugs and physician services Third party payment shielded from true cost lmperfect Market Driven by need not demand Growth of Technology ncrease in Elderly Population Medica Model of HC Delivery focus on medical intervention rather than prevention Multipayer System and Administrative Costs management of following regulations Defensive medicine Waste and Abuse billing cost reports intentionally falsi ed service provided not medically necessary Practice Variations lldentify key factors that have contributed to or attempted to reduce the rising cost of healthcare Health Planning alignmentdistribution of HC resources by govnt to achieve health outcomes for all Price Controls 1 HMO act Prospective Payment System PPS for Acute care hospitals DRG 1997 Balanced Budget Act required PPS for the entire HC continuum Peer Review reasonable appropriate quality necessary MKWN Competitive Approaches among sellers for customers and in HC delivery try to attract patients with several different providers 1 Demand side incentives cost sharing mechanism place a larger burden on consumer 1 Supply side incentives antitrust laws which prohibit business practices that sti e competition among providers Price fixing mergers to force HC organizations to be costefficient 2 De ne programs or initiatives aimed at increasing access to healthcare andor reducing disparities in access to care SheppardTowner Act of 1921 provide direct primary care to economically disadvantaged mothers and children Social Security Amendments screening and preventative programs Great Society programs access among disadvantaged populations Medicare cancer screenings and immunization SCHIPS lRecognize factors that contribute to enhanced quality of care Structure relatively stable characteristics of the providers of care the tools and resources they have at their disposal and the physicalorganizational setting where care is provided Process the specific way in which care is provided iecorrect diagnostic test prescription main developments clinical practice guidelines critical pathways risk management Outcomes effectsfinal results obtained from utilizing the structure and processes of HC delivery viewed as measure of effectiveness of HC delivery system suggests overall improvement in health status measures include infection rates rates of rehopsitalization patient satisfaction Critical pathways reduce variation for optimal outcomes lldentify the law passed by Congress that fundamentally changed the means by which health providers are reimbursed by developing prospective payment systems across the healthcare continuum 1997 Balanced Budget Act WEEK 9 Populations with Special Health Needs Underserved lDefine populations identi ed as underserved with respect to access to affordable quality healthcare Racial and ethnic minorities uninsured children women those living in rural areas homeless mentally ill chronically ill and disabled HIVAIDS patients lUnderstand factors that contribute to these populations being deemed as underserved Unequal social economic health and geographic conditions lldentify the 3 factors that are the best predictors of access to healthcare Socioeconomic status Individual assets Mediating factors health insurance access Healthy People 2020 National Healthcare Priorities DDWhat is Healthy People 2020 by whom was it developed and what is its Vision Sciencebased 10 year national objectives to improve the health of all Americans by encouraging collaboration and coordination measuring impact of preventative measures and guiding individuals with informed HC decisions Developed under the leadership of the Federal lnteragency Workgroup FIW with US Department of Health and Human Services HHS and other federal agencies public stakeholders and the advisory committee Visions A society in which all people live long healthy lives lRecognize the National Healthcare priorities established in HP 2020 l Maternal Infant and Child I Health Global Health Early and Middle l ChlldhOOd l HealthcareAssociated l Adolescent Health Infections Older Adults Medical Product Safety I l Preparedness l Public Health and Infrastructure Quality of Life and Well being Education and Communitybased Programs Health Communication and Health Info Technology Family Planning Genomics Social Determinants of Heath Environmental Health Sleep Health Vision Food Safety Nutrition and Weight Status Physical Activity Oral Health Substance Abuse Tobacco Use Disability and Health HealthRelated Quality of Life amp WellBeing Injury amp Violence Prevention Occupational Health and Safety Arthritis Osteoporosis amp Chronic Back conditions Cancer Heart Disease amp Stroke Diabetes Chronic Kidney Disease Respiratory Diseases Blood Disorders and Blood Safety Dementia incl Alzheimer s Hearing and Other sensoryCommunication Disorders Sexually Transmitted Diseases HIV LGBT Health Immunization amp Infectious Diseases Mental Health and mental disorders


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