Final Exam Study Guide (Exam 3 Results) - Seminar to HC Admin Vincennes University - 2023

Name at least one major efficiency of a managed care system.

- A good answer would be that it eliminates insurance and payer intermediaries because it brings them together under one organization. - Another possible answer is that it implements risk sharing with providers to reduce provider-induced demand.

Discuss at least four of the common fraud schemes in healthcare.

- Billing for services not rendered. - Incorrect reporting of diagnoses or procedures. - Overutilization of services, kickbacks, and bribery. - False or unnecessary issuance of prescription drugs. -Misrepresenting the provider of service. - Waiving of deductibles and/or co-pays.

Identify at least four common mental health diagnoses as defined by the National Institute of Mental Health.

- Bipolar depression - ADHD - Multiple personalities disorder - Anxiety

Name the quad functions of healthcare.

- Delivering medical care. - Finance. - Insurance. - Payment.

Name the four parts of Medicare and describe them.

- Part A covers hospitalization. - Part B covers ambulatory services. - Part C is an alternative to traditional Medicare; it packages Parts A and B (and often Part D and Medigap coverage) into a managed care plan provided by several insurance companies. - Part D covers prescription drugs.

List at least two of the most important organizations for administrative professionals.

- The American Society of Administrative Professionals (ASAP). - The Healthcare Information and Management Systems Society (HIMSS).

What are some steps that organizations can take to reduce racial and ethnic disparity in healthcare?

A few things that they can do is to: make health equity a strategic priority. and develop structures and processes that are strategic for doing health equity work.

The Council of Accountable Physician Practices (CAPP) set out to explore the issue of accountable care in detail. Based on its research, what constitutes accountable care and what were their findings?

Accountable care is care that is carried out by a coordinated care team. It focuses on prevention and is provided in settings that offer 24/7 access. Practitioners engage in evidencebased medicine (treatments based on proof), and the care is enabled by robust technology. CAPP concluded that the healthcare system needs to continue its efforts to educate and share information with patients to support quality care. It also encourages payment reform to move toward value-based reimbursement; improved access to 24/7 care; greater "system-ness" and clinical integration; better technology for the sharing of information between providers, patients, and families; and the standardization of measures in language that patients and families can understand.

What are the functions of a nurse practitioner?

After they are licensed they are able to diagnose and treat patients with licensed physicians.

What governing body licenses physicians to practice in any jurisdiction?

All 50 states require physicians and medical providers to have a license. The licensing of medical providers is carried out under the auspices of a medical examining board in each state. The board is also responsible for disciplining physicians. The board issues the general right and privilege to practice medicine.

Interprofessional education (IPE) and interprofessional practice (IPP) have emerged as important elements of healthcare education. Why?

Because it allows the two groups to emerge together and discuss events that could be happening or have happened in the past to know how to approach them and fix them as best as the organization can.

Discuss some of the issues around the serious problem of physician burnout.

Burnout can cause patients to complain or be disappointed with the care they are receiving. It causes many issues in the workplace as the providers feel that they are not doing any good at their job. And lastly, burnout increases the risk of malpractice.

Name three functions of a physician.

Diagnosing their patients. Prescribing treatments. Providing treatments.

"All practicing nurses are licensed by the nursing examining board of the federal government."

False.

"Dental care is a luxury and has little to do with a patient's overall health."

False.

"The United States has a highly educated population and one of the highest rates of health literacy in the world."

False.

The Affordable Care Act (ACA) sought to remedy some of the flaws in the fee-for-service system. Discuss TWO flaws that have been identified in the fee-for-service system and how ACA sought to remedy them.

Fee-for-service plans, at least prior to passage of the ACA, did not cover wellness services to any great degree. Given the typically less-urgent nature of preventive services, they can be highly sensitive to price; if the services are not covered, the patient will often avoid them. The ACA requires that insurance plans cover preventive services 100 percent. The US healthcare system has developed in such a way that sick care is more lucrative than well care. Services and procedures to treat illness simply cost more than those geared toward wellness, and they represent a greater economic gain for providers. The traditional fee-for-service model offers no controls on utilization, which creates a moral hazard both on the provider side and on the patient side. Overutilization of specialty care is especially prevalent. Provider-induced demand occurs when a provider influences a patient's demand for care even though this demand goes against the provider's own interpretation of the patient's best interest. Most medical providers are in a unique position to influence patient behavior, given the vast information disequilibrium between the patient and provider. The provider must therefore act as an agent for the patient and take the utmost care to always work in the patient's best interest. The ACA sought to remedy some of these problems by changing the payment structure, focusing on outcomes of service (value) rather than simply paying for the number of services provided (volume).

Name at least three utilization control mechanisms.

Gatekeepers, case management, utilization review, tiered benefits, and negotiated pricing.

___ can be defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Health Literacy.

What do you consider to be the overall purpose of the healthcare system?

I consider the overall purpose of the healthcare system to be working together to protect and improve the health status of people in our world.

Discuss some of the central features of managed care.

Managed care organizations exercise formal control over patient utilization, seek to streamline the delivery and payment of care, and provide behavioral incentives to patients and providers. It uses an insurance mechanism, and the functions of financing are integrated through information technology. 2. Name the quad functions of healthcare.

What do nurses do?

Nursing does many things in the healthcare field. They are found assisting with surgeries and are also found working with community health services.

What is the primary function of obstetricians?

Obstetricians focus on prenatal care. This question can be altered to refer to any specialty (or group of specialties) and could be turned into a multiple-choice question that would ask which healthcare specialties deal with certain age groups and would include obstetrics, neonatology, pediatrics, adolescent medicine, family medicine, and gerontology.

______ occurs when an abnormality or disease is discovered through a diagnostic procedure or test, but treat treating the condition would provide no real benefit to the patient.

Overdiagnosis.

___ occurs when an abnormality or condition is treated even though it is self-limiting in nature or poses no harm to the patient.

Overtreatment.

Compare palliative care and hospice care.

Palliative care is when a patient is seeking care to control the pain from an illness (such as cancer) they are going through treatment or not seeking treatment. While hospice care is to help make the patients comfortable and at peace as the patients have stopped treatment and are close to passing away.

This is a term used in experience rating, which looks at a person's previous medical history with consideration for any condition that might cause high utilization of healthcare.

Pre-existing Conditions

A system for determining payments for various medical services, has become a fundamental aspect of healthcare funding. Virtually all payers use it. This system seeks to provide a consistent methodology for valuing medical services.

Resource-based relative value scale (RBRVS).

What is the Nuremberg Code?

The Nuremberg Code is a list of ten ethical guiding principles regarding experimental procedures. It came to be during the court case U.S. versus Brandt after the second world war.

What do physician assistants do?

The do most of the same things that NPs do, after being licensed they are able to diagnose and treat patients when coordinating with a licensed physician.

Discuss some of the important functions of the healthcare executive.

The important function of healthcare executives is that they are professionals that work hard towards the set goals of the organizations. The characteristics of these people are: honor, integrity, ethics, and able to develop and practice programs that have self-improvement and life long learning.

What is the function of the Accreditation Counsel of Graduate Medical Education (ACGME)?

The main function of ACGME is to set the standards for all medical education programs. Most physicians will be required by their place of work to be voluntarily put under evaluation and review to continue providing care.

Provide a general perspective on the nature of the healthcare workforce in the United State.

The nature of the healthcare workforce in the US is that they are sections of the economic system that is coming together to provide and treat patients with curative, preventive, rehabilitative, and palliative care.

Please discuss some of the issues and challenges facing the nursing profession in the United States now and in the future.

The nursing profession faces several challenges and areas of concern, many of which are like those that are facing physicians. With the aging of the population, general population growth, and retirement of existing professionals, demand for medical services is expected to increase significantly in the years ahead. The United States will likely face the need for an additional 1 million nurses by 2022, according to the US Bureau of Labor Statistics. Nursing shortages exist not simply because of the number of nurses but also because of nurses' uneven distribution. Many localities experience shortages, whereas other localities seem to have a surplus. The healthcare setting is a hazardous one, and nurses regularly face injury risks and the potential for exposure to blood-borne pathogens and infectious diseases such as the COVID-19 virus. Also of concern is the alarming increase in violence in the workplace. Harassment and physical and emotional abuse are issues that are unfortunately all too common for nurses.

What are: Ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services and behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

The ten required healthcare services that all insurance plans must now offer under the Affordable Care Act.

Blum discusses a multidimensional concept of health and well-being. Describe Blum's concept

There are four things included in Blum's concept of health and well-being. The first one is the environment of the patients. The second lifestyle the patient is living. The third is heredity, so the genes of the patients. And lastly, the medical care they are receiving.

"All physicians are required to complete medical school—either an allopathic medical school, which grants an MD degree, or an osteopathic school, which grants a DO degree—and can then be licensed to practice in all 50 states."

True.

Provide at least two examples of a vulnerable population.

Two examples of the vulnerable population is the people living in poverty and people not able to receive health coverage due to being the high-risk pool.

___is an outcome of all the aspects of life coming together in a meaningful way.

Well-being.

In a few words, describe why your zip code is often said to be more important than your genetic code in determining your health.

Your health status is more related and revolves around the environment in which you live in, than what your genes tell your doctors.