HCDS final
Healthcare Blue Book and the Leapfrog Group's Hospital Safety Score is a good example of what
- Clear and accurate quality standards, - price transparency, and - more easily accessible outcome information
When can you enroll for Medicare Part D?
-3 months before/after 65th birthday -within 63 days of losing creditable coverage
Why is the US good at treating cancer compared to other countries?
-Early dx -Effective tx options -Continued screening in older adults
How is Medicare Part A financed?
-Employers and employees pay percentage of wages/salaries to social security (higher rates for higher incomes due to ACA) -NO monthly premiums
What are the unique features of a HMO?
-Focus on wellness care -Strict use of in-network providers -Capitation to pay providers -Gatekeeping
What are the benefits of Bundled Payments?
-Greater patient engagements -Reduced administrative costs
What does Medicaid cover?
-Hospital -Physician -Labs and X-rays -Prenatal care -Preventive care -Nursing home -Home health services
What does Medicare Part A cover?
-Hospitalization (partly up to 150 days) -Skilled nursing facility (for first 20 days free) -Home healthcare (up to 100 days) -Hospice care (if physician certified terminal illness)
What factors influence cross-cultural patient interactions?
-Level of education -SES -Degree of assimilation into US culture
What can providers do to lower costs of Medicare Part D for patients?
-Recommend generics (or cost-effective brands) -Prescribe 90 days supply for dual eligible or low-income subsidy pts -Consult with pharmacists about switching meds -Ask pts if they can afford meds
What are the types of Financing Cost controls?
-Regulatory = government imposes limits on how much people pay for health services -Competitive = health insurance plans retrain costs in order to attract members who are aware of costs
Why did national healthcare proposals fail in the US?
-World War I (anti-german feelings against social insurance) -American values (self-reliance) -AMA suggests it is a threat to private practice -Stigmatized as government interference
What are the types of Private Insurance?
1. Individual private health insurance 2. Self Insurance 3. Group Insurance
What is a premium? Who pays it?
Amount charged by insurer for beneficiaries to be insured against risk In employement-sponsored plans: both employer and employee pay part of premium
What does HIPAA say about EMR?
Must have: -Secure connection -Secure servers -Storage back ups
What is the first step in becoming culturally competent?
Self-awareness
Who is eligible for Medicaid?
"Means Tested" = must be low income -Low-income families with children who meet certain eligibility requirements -Elderly, disabled, and blind individuals receiving cash assistance from SSI (supplementary security income) -Children < 6 yr and Pregnant women with family income below 133% of federal poverty level -Children 6-18 yrs old with family income below federal poverty level -Other eligibility according to States
Why latinos dread to go to doctor
- language barrier - can't afford - immigration status - a long history of preferring non-Western medicine - a cultural uneasiness with the American style of healthcare, and - a tradition of privacy and individual pride
Who is eligible for Medicare Part A?
-65 years old and paid 10 years of social security (automatically enrolled) -Disabled and receiving social security benefits for 2 years -End stage kidney disease (dialysis/transplant requirement)
What are the basic assumptions of Public Health?
-A healthy population is in the best public interest -Health is strongly determined by community and society-level factors -Working at a community level can improve public health (i.e., public policy is health policy)
Which modes of healthcare financing with respect to income levels does the US healthcare system use?
-About half is regressive -About half is proportional Very little is progressive
How has access, affordability, and healthcare spending changed between 2007 and 2012?
-Access declined among adults < 65 -Affordability declined among adults < 65 -Healthcare spending increased
What are the types of Utilization Cost controls?
-Aggregate units of payment (DRGs, capitation, global budgets) -Patient cost-sharing -Utilization management (i.e., denial of payment to physicians who perform unnecessary services) -Supply limits (e.g., limiting number of beds)
What are the typical characteristics of a concierge practice?
-Around $1,000 annual fee -Patients range from blue collar to CEOs -Small patient pool (around 300) -9-5 work hours -4-6 patients per day (appointments 1-3 hours long) -Patients must have insurance
What are the core functions of Public Health?
-Assess public health problems (gathering data) -Creating and advocating for solutions to achieve public health goals -Enforcing policies to make sure necessary services are implemented and there is adequate crisis response
What are the cultural barriers to effective communication in the medical interview?
-Authority (some cultures may be submissive to authority) -Physical contact (some may be that physical contact is inappropriate but others may expect it) -Communication styles -Gender -Sexuality -Family (e.g., elder speaks for the patient)
How do computerized information systems improve healthcare quality?
-Automatic reminders about pts who might be due for follow-up -Reducing drug prescription errors
What are the factors that increase self-awareness?
-Being aware that culture is not overt (often cultural rules are not discussed until broken) -Everyone is ethnocentric -Misinterpreting behaviors can happen -Realize we may not know when we offend others -Recognize your own culture -Be aware of your own stereotypes
What level of access do people with Medicaid have?
-Better access than those without insurance -Worse access than those with private insurance
What are the benefits of a Staff Model of HMOs?
-Better monitoring of utilization of services -Greater control of provider practice patterns
What are the problems with Clinical Practice Guidelines?
-Bias (e.g., most guidelines are funded by pharmaceutical companies) -Based on research on narrowly defined populations (e.g., non-elderly pts with a single condition) -Do not take into account individual patient preferences
How does race and education influenced infant mortality rates?
-Blacks = highest infant mortality rate -Higher education = less infant mortality NOTE: Blacks with highest education still have worse infant mortality than Whites with lowest education
How does race affect breast cancer dx and tx?
-Blacks have LOWER incidence of breast cancer BUT: -Blacks more likely to be diagnosed at advanced stages of breast cancer -Blacks more likely to die from breast cancer
What are the parts of the Three-Function Model of Medical Interviews?
-Building the relationship -Assessing the patient's problems (how does the patient understand the disease? what is their explanatory model for the disease?) -Managing the patient's problems
What are the "Patient" characteristics of a HMO (health maintenance organization)?
-Can only use in-network providers -Gate keeping
What services are offered at retail health clinics?
-Care for acute infection (ear infection, URI, UTI) -Minor wound care -Immunizations -School physicials
What is the problem with the "Bad Apples Theory" of healthcare quality improvement?
-Causes an "escape" mentality rather than a focus on understanding what went wrong (i.e., "it wasn't me!") -Problems are usually not due solely to one person (typically includes poor organization, unclear communication, poor leadership) -Focuses on discipline rather than learning
Who is eligible to enroll in Covered California?
-Citizens or nationals of the US or non-citizens who are lawfully present in US -Cannot be incarcerated -Must be residents of CA
What are the Quit Tam Whistleblower provisions?
-Citizens with evidence of fraud may sue on behalf of government -Whistleblower (aka "relator") gets 15-25% of recovered funds
What are four developments in Process improvement?
-Clinical practice guidelines (CPGs) -Cost efficiency (aka cost effectiveness) -Critical pathways -Risk management
What is the definition of a New Patient for the purpose E/M level coding?
-Coming to practice for first time -Belongs to practice but has not been seen by physician in practice for 3 years -A first visit for any new work-related injury or illness (regardless of when they last saw physician) Everyone else is an Established patient
What are the advantages of a retail health clinic?
-Convenience (no appointment needed) -Low cost -Open 7 days/week -Many insurance plans now accept their services
What are the Patient disadvantages of concierge practice?
-Cost -Sense of obligations
How can changing the principles of coverage eliminate racial and ethnic inequality in healthcare?
-Cover everyone -Coverage that is comprehensive -Asses and reduce the impact of cost-sharing on low-income population -Adequately reimburse services (i.e., government insurance pay the same as private insurance)
What effect did the ACA have on Medicare?
-Covers yearly wellness exams at no cost (before medicare would only cover one wellness exam at 65 yrs old) -Age and gender appropriate screenings are now covered at no cost
What are the goals of Covered California?
-Create new health insurance marketplace for individuals and small businesses -Help individuals compare and choose the right plan for them and if they are eligible for subsidies/assistance
What factors have shaped the formation of the US healthcare system?
-Cultural beliefs and values (self-reliance) -Technology -Social changes (urbanization, immigration) -Economic constraints -Political opportunism
What are examples of painless cost control?
-Cutting prices of drugs, supplies, provider fees (i.e., control price inflation) -Reducing administrative waste -Eliminating medical interventions of no benefit (.e.g, unnecessary testing) -Substituting less costly technologies that are equally effective -Increasing the provision of preventive services that cost less than illness they prevent
How does the ACA help reduce racial disparities?
-Data collection on health inequality -Improve healthcare diversity -Incentives for working in underserved areas -Support for cultural competence training -Increased funding for health disparity research -Insurance coverage expansion -Expanding medicaid -Insurance must cover chronic conditions -Community health center funding
What are the four phases of payment in Medicare Part D?
-Deductible (can't exceed $320) -25% Copayments (until coverage limit) -Coverage Gap/Doughnut hole (until out of pocket threshold) -Catastrophic coverage
What are the limitations of the False Claims Act?
-Does not cover tax issues -Fraud must be large enough for a civil case to be filed -Defendant must have deep pockets for a civil case to be worth effort (otherwise they just declare bankruptcy) -Must have very strong case if government chooses not to join
What are the problems with Pay-for-Performance (P4P)?
-Encourages avoidance of high risk patients (in order to keep performance scores up) -Difficult to assign quality to specific physician when most patients see multiple physicians in one year -Increase disparity (penalizes those who serve vulnerable populations in low SES areas because they are more likely to have poor health)
What are the benefits of EMR?
-Enhancement of overall patient care -More on-formulary medicine prescribed -Few lab tests ordered -Reduces chances of losing charts -Increased noticing of side effects or drug interactions -Better legibility -Environmentally friendly -Growing need for information (quality management, disease surveillance, outcome reporting) -Reduced billing and coding errors
What is the difference between new and established patients for E/M coding?
-Established patients require less work to get higher E/M levels -Only 2 of the three key components of E/M are required for established patients (History, Physical Exam, Medical Decision Making) -> all 3 are required for new patients
What did the 2007 National Healthcare Disparities Report show?
-Ethnic minorities and lower SES face barriers to accessing care and receive lower quality care -Across all core measures, quality and access disparities have grown between 2000 and 2005
What are the six sections of the CPT codes?
-Evaluation and Management (E/M) -Anesthesiology -Surgery -Radiology/Imaging -Pathology/Labs -Medicine
What is "meaningful use" (with respect to EMR)?
-Evidence that the care process leads to improved outcomes -The measure accurately captures whether evidence-based care as been provided -There are few intervening care processes that must occur before improved outcome is realized -Implementing the measure has little or no chance of causing negative consequences
Examples of FCA violations?
-Falsifying test results -Falsifying quality or cost of products -Billing for unnecessary or not performed services -Charging costs to a grant that were not related to the grant
What are the cultural variables in End-of-Life issues?
-Fatalistic beliefs (lacking power to make decisions) -High status family member may be responsible for decisions -Religion and spirituality may guide decisions -Truth telling beliefs (some believe it is wrong to tell person they are dying) -Grief expression (some believe it is wrong to show sadness) -Postmortem testing (some do not believe in autopsy)
What are the methods of hospital/physician payment from least aggregated to most aggregated?
-Fee-for-service -Per diem -DRG (diagnosis-related group) -Capitation -Salary/Global budget
How do concierge practices make their services legal?
-Fees are NOT for medical services (those are paid by insurances) -Fees are for administrative or membership costs
What are the three general types of cost control?
-Financing controls = limit how much people pay health plans (which in turn should limit how much they can pay providers) -Reimbursement controls = limit how much health plans pay providers (which in turn should limit how much health plans need to charge) -Utilization controls = limit the extent of use of services
What are the key tasks of Primary Care?
-First contact care (initial evaluation by physician) -Longitudinality/Continuity (sustaining pt-caregive relationship over time) -Comprehensiveness (able to manage wide range of healthcare needs) -Coordination (referring and then following-up with pt)
How is Medicare Part B financed?
-General federal revenues (taxes) -Monthly premiums (based on income -> higher premiums for higher income family)
What are the benefits of a Network Model of HMOs?
-Good for large geographic areas with many group practices -Large choice of physicians for patients
What are the three areas of CLAS?
-Governance, leadership, and workforce (promote policies that are culturally and linguistically diverse) -Communication and language assistance (use translators and provide materials in languages) -Engagement, continuous improvement, and accountability (focus on improving quality of care to culture and languages in community)
Who are the primary financiers of healthcare in the US?
-Government = largest player (paid via taxes) -Employers = paid via work
What is the Network Model of HMOs?
-HMO contracts with more than one medical group or practice -HMO pays via capitation
What is the Group Model of HMOs?
-HMO contracts with multi-specialty or independent group practice and one or more hospitals -Providers employed by practice (not HMO) -HMO pays via capitation
What is the Staff Model of HMOs?
-HMO employs its own providers, paying a fixed yearly salary -Bonuses given to providers at end of year based on productivity
Access to healthcare in the US is restricted to which people?
-Have health insurance through employer -Covered under government program -Can afford to buy insurance out of pocket -Able to pay for services privately
What provider consumer protections have been added by the ACA?
-Health plans can't retroactively cancel insurance because patient or employer made honest mistake on application -Cannot limit or deny coverage to children under 19 because of pre-existing condition -Lifetime limits and annual limits on coverage are phased out
How does education and gender influence death rates?
-Higher education = lower death rate -Females = lower death rate
How are Vertical Integration HMOs better than Virtual Integration HMOs?
-Higher quality of care (better for chronic illness, preventive care) -Hight pt satisfaction -Physicians more likely to adopt quality improvement practices
Minorities and Low SES are at face what problems?
-Higher rates of death from cancer -Receiving less screening for cardiac risk factors -Receive fewer childhood and adult immunizations -More likely to have unmet healthcare needs -Receive less diabetic service -More likely to be hospitalized due to DM -Receive less life-saving procedures (even when insured) -Receive less appropriate care for conditions -Less likely to have pain treated
What is the IPA Model of HMOs?
-IPA (independent practice association) acts as intermediary between HMO and multiple solo/group practices -HMO pays for services (capitation) -IPA manages administration and contracting functions
What was the Flexner Report of 1910?
-Identified inconsistencies in medical education training -Causes the AMA to require medical schools to be certified in order for graduates to become licensed
What are the benefits of Compliance Programs?
-Implied transparency -Creates an inference of good faith on part of company -Allows for self-auditing, internal control, and identification of errors -Reduced likelihood of FCA cases being pursued by DOJ -Reduced civil penalties (lower fines) when cases are pursued
What changes to the healthcare system can help eliminate racial and ethnic inequality in healthcare?
-Improve cultural and linguistic skills to serve diverse population -Expand cross-cultural education to providers (CLAS) -Expand use of community health workers (people from community who speak language and understand culture) -Expand patient education and health literacy programs
What are the non-financial barriers to healthcare?
-Inability to access care when needed (due to shortage of PCPs) -Language -Literacy -Cultural differences -Gender -Race
What changes to the healthcare infrastructure can be made to help eliminate racial and ethnic inequality?
-Incentives for healthcare providers to work in medically underserved communities (e.g., loan reimbursement) -Expand community health centers -Reinvigorate community health planning -Increase healthcare workforce diversity (small percentage of doctors are minorities compared to national percentage)
What are the Patient advantages of a concierge practice?
-Increased access -More time with doctor -Ease of scheduling (same day appointments) -Thoroughness (due to longer time with provider) -Partner in health (provider advocates for patient at specialist referrals) -Peace of mind
Who is exempt from having insurance under the ACA?
-Indian tribes -Incarcerated people -People not lawfully present in US -People with religious reasons -People who can't afford coverage -People facing a hardship -People who are not required to file taxes
What is the relationship between healthcare cost and healthcare outcomes?
-Initially, increasing cost has more effect on increasing outcomes -Later, increasing costs has diminished/marginal return on outcomes (e.g., putting money toward areas with low health outcomes will make the most improvement)
What are the ethical concerns of concierge medicine?
-Is it ethical to provider higher level of service at additional fee? -Are they just cherry picking healthiest and wealthiest patients? -What if patient's can't afford concierge care? -What happens when all practices convert to concierge model?
What parts of the ACA is working?
-It has decreased number of uninsured people -It has reduced costs/premiums (i.e., less inflation) -Increased competition among insurers (i.e., health insurance industry is growing)
What is "Self-Insurance"?
-Large company acts as its own insurance company -Company sets aside large amount of money to pay for medical insurance liability for employees (thus company doesn't have pay an insurance company)
What do Compliance Programs do?
-Lay out methods of personnel training -Ongoing self-assessment -Allow employees to bring concerns to management without fear or retribution -Identify and correct internal problems
Low English Proficient (LEP) patients are face what problems with healthcare?
-Less likely to have regular source of primary care (or receive preventive medicine) -Less satisfied with care they receive -More likely to report overall problems with care (e.g., medical errors) -Avoid seeking medical help (>20% avoid care altogether)
What are the traditional quality assurance strategies that have not been effective at improving quality?
-Licensing and re-licensing mandates (i.e., requiring practitioners to get a license does not necessarily make them competent) -Peer-review (usually just focuses on bad apples on a case by case basis)
What are the "Patient" characteristics of a POS (point of service)?
-Like HMO -> Gatekeeping (need authorization before seeing specialist) -Like PPO -> Free choice of providers
What are the disadvantages of a retail health clinic?
-Limited in scope of services -May or may not collaborate with PCPs -Many patients are lost to follow-up (no way to ensure they get needed follow-up)
What are the Provider disadvantages of concierge practice?
-Limited range of pathology (skills may get rusty) -Higher patient expectations -On call 24/7 (theoretically) -More responsibility due to close relationship with patient
What are the benefits of patient empowerment (i.e., including patients in decision process)?
-Lowers overall cost (less unnecessary procedures) -Better outcomes (when pts participate in decisions about surgery, surgery rates fall and satisfaction improved)
Why are PAs not used much in concierge practices?
-Loyalty of patients to doctor -Inability of PAs to start own practice -Patients feel they are paying extra so should see physician
What quality improvement strategies are proposed to help eliminate racial and ethnic inequality?
-Make reducing disparity a key goal for Pay-for-Performance and Quality Improvement initiatives -Regularly collect and monitor data on patient race, SES, language, immigration status, place of residence -Publicly report healthcare access and quality measures
What are the Provider advantages of concierge practice?
-Manageable patient load -Increased time with patients -Reasonable work hours -Not beholden to a third party (insurance) -Professional satisfaction -Lifestyle -Income (due to membership fees and lower malpractice insurance)
What were the characteristics of medicine during Pre-Industrial America (1750-1850)?
-Medicine was a trade (not a profession) -Trained through 2 year apprenticeships -Non-science based medical education (no standardization) -Alms houses and Pest houses (where you go to die) -No insurance
What are the benefits of an IPA Model of HMOs?
-Most successful in terms of enrollment and maintaining members over time -Expanded specialty referral base (large number of providers) -Small physician groups can take advantage of HMO contracts
Where does data for healthcare access come from?
-National Health Interview Survey (NHIS) -Medical Expenditure Panel Survey (MEPS)
How is Medicare Part D for Low-Income Subsidy different from regular Part D?
-No coverage gap -Lower/no premiums, deductibles, copays -May switch plan every month
What are the benefits for ACA for patients?
-No more denial of coverage due to preexisting conditions -No more yearly or lifetime caps on coverage -All preventive care is zero cost (no deductible, no copay, no coinsurance) -All female contraceptives (e.g., barriers, birth control, emergency contraception, sterilization) is zero cost (does NOT include abortion and male sterilization) -Women do not need referral to ob/gyn -Immunizations are fully covered -Screening and counseling is covered (e.g., STDs, obesity, smoking, domestic violence) -Genetic testing for BRCA for women at high risk is covered
What are the tax benefits of employer-based healthcare?
-Non-taxable for employee -Tax deductible for employer
According to "Rays Symposium," how has life expectancy changed in the US?
-Not increasing as much as other countries -Actually declining in some areas (primarily south)
What are the problem with HEDIS?
-Only evaluates healthcare plans (not hospitals or physicians) -Few employers use quality data to select health plans for employees (usually based on cost)
What are the four main ways of financing healthcare?
-Out-of-pocket payments -Individual health insurance -Employed based health insurance -Government financing
What are examples of "regressive" mode of healthcare finance?
-Out-of-pocket payments (since low-income are more likely to get sick, they spend a larger percentage of income on healthcare than wealthy ppl do) -Experience-rated private health insurance and premiums (paying more for increased risk of illness -> low income will pay more because more likely to get sick) -Employment-based health insurance
How does the ACA support primary care practitioners?
-PCPs get 10% bonus for taking on new medicare/medicaid patients -Increased money for community health centers -Removal of PA barriers to care in rural health (i.e., don't need physician being present) -Expanding residency slot for primary care -National Health Service Corps (NHSC) has more money for student loan repayment and scholarships -Max amount of loan repayment increased to 50k from 35k -Teaching is counted toward NHSC requirements for loan repayment -Can reapply for more loan repayment after 2 yrs of service
How is Medicaid financed?
-Partly by state and partly by federal government (federal contribution > state contribution) -Every state must provide basic health services to receive federal funds NO premiums or deductible for patients
How can PAs get into the concierge practice?
-Partner with physician to get own patient pool and then convert practice -Hybrid models = some patients are traditional and some are concierge
What are the "Patient" characteristics of a PPO (preferred provider organization)?
-Patient agrees to use in-network preferred providers -Patients can use out-of-network providers for higher deductible and copay -There is NO gatekeeping (pt can see specialist without PCP referral)
How does the ACA control costs (i.e., finance itself)?
-People with salary > 200k must payer higher for medicare part A taxes -New taxes on businesses that offer high-end insurance plans, make drugs & medical devices and the tanning salons - less reimbursement to Medicare advantage insurance plans -Limit the amount of money from premiums kept by insurance company as profit -Inhibit Medicare reimbursement rates to hospitals from rising quickly -New federal advisory board to monitor increased costs
In California, what additional coverage does Medi-Cal provide over and above the basic Medicaid federal coverage?
-Prescription drugs -Dental -Vision -Hospice -Inpatient psych -Rehab
How has the US tried to contain costs?
-Price Controls (DRGs) -Peer Review Organizations (PROs) aka Quality Improvement Organizations (deny payment if care was not found to be necessary or of quality) -Competition (providers compete for patients who have ability to choose from different providers)
Who is Medicare Part D administered by?
-Private insurers run it -Government subsidizes cost
What are the three models of concierge medicine?
-Privately owned/Privately established -Privately owned/Corporately established (i.e., corporate backing for finances) -Corporately owned (like a chain)
What are the three modes of healthcare financing with respect to income levels?
-Progressive = percentage of income paid is higher for higher income levels (.e.g, 5% for 20K, 8% for 100K) -Regressive = percentage of income paid is lower for higher income levels (e.g., 5% for 20 K, 2% for 100K) -Proportional = percentage of income paid is same across all income levels (e.g., 5% payment regardless of income)
What are the similar themes among all concierge practices?
-Providers care for fewer patients -Patient pays additional fee to be members ofpractice -Higher level of service for patients
What are the "Provider" characteristics of a PPO (preferred provider organization)?
-Providers negotiate with PPO to be in-network -Providers agree to accept discounted fees from plan's members in exchange for "preferred provider" status -Preferred provider status increases patient flow (thus increasing income) -Providers are NOT paid with capitation
What factors do patients perceive as important for quality healthcare?
-Rapport -Short wait times -Short telephone hold times -Emergency care and tx -Helpful staff -Good communication -Facility appearance
What are the problems with Medicaid?
-Reimburses providers less than Medicare or private insurance (makes it difficult to find providers who accept Medicaid) -Health outcomes for Medicaid recipients lag behind others -Does not cover 24-hour custodial services for people unable to care for themselves (forcing them to enter nursing home)
Why did multispecialty group practices not become the dominant organizational structure in the US?
-Resistance to it by professional societies (concerned about lack of physician-patient relationship) -Hospitals became central to medical care (making these practices less unique)
What factors contribute to racial and ethnic health disparities in access and quality?
-SES (many minorities are low SES) -Residential segregation (many minorities live in medically underserved areas) -Occupational risk (minorities work in riskier jobs) -Health risk (minorities are more likely to be chronically ill) -Structural inequality (historic and current racism and discrimination) -Uninsured or underinsured (many doctors won't accept Medicaid due to low-reimbursement) -Cultural and Linguistic barriers
What is "Reinsurance"?
-Safety net for larger companies using self-insurance -Company purchases insurance from insurance company that will will only take effect if money set aside from self-insured company is exhausted
What services are provided by Public Health?
-Sanitation -Seat belt laws -Water safety issues -Immunizations -Pasteurized milk -STD prevention -Fire extinguishers in public buildings
What are the AAFP Guidelines for retail health clinics?
-Scope of practice must be well defined and limited in number of services -Services must be evidence-based and quality improvement oriented -Use a team based approach by connecting with local practices for continuity of care -Must have a protocol for referral of services out of scope of practice -EMR should be sufficient to gather and communicate data to PCP
According to "Rays Symposium", what factors explain the US health disadvantage?
-Smoking -Obesity -Lack of safety practices (e.g., helmet use) -High relative poverty rates and inequality -Spending less on social programs
According to "Unnatural causes in sickness and in wealth," life expectancy can be determined by...
-Social class = most important -Education -Income -Where you live
What are some barriers to "Assessing the Patient's Problems" in the medical interview?
-Some diseases are acceptable while others are not in some cultures (e.g., pts may fear stigma of mental illness) -Cultural beliefs about the reason for the problem (and therefore treatment) may vary across cultures
What happens if you don't enroll for Medicare Part D?
-Subject to life-long penalty -Must enroll during open enrollment: Oct 15 - Dec 7
How do higher copayments affect parents' attempts to help their children's asthma?
-Switch to less expensive drugs -Give children less of the drug than prescribed -Put off doctor visits -Less likely to go to ER for asthma attacks
What are Quality Report Cards? How are they supposed to improve healthcare quality?
-Systematic measurements of quality of care released to the public -Empowers consumer/employer to select high quality caregivers (in reality, doesn't really do this) -Motivates improvements in practices/hospitals with poor grades
What are the examples of "proportional" mode of healthcare finance?
-Taxes/Government revenue that finance healthcare (on average, everyone pays same percentage income for taxes for healthcare)
How does defensive medicine drive up costs?
-Tests and services are performed even though not medically justified in order to avoid lawsuit -Unrestricted malpractice claims drive up provider's insurance premiums
What are the types of proposals for Malpractice Reform?
-Tort reform -Alternative dispute resolution -Use of practice guidelines to determine if negligence happened -No-fault reform -Enterprise liability
What was the traditional healthcare structure? and who was the major power in this healthcare structure?
-Traditional structure = fee-for-service (physicians were not employees of hospital) -Traditional major power = physicians (physicians admitted patients to hospitals, and hospitals had no income without patients)
What does it mean when that the US has been a "paradox of excess and deprivation"?
-US is least universal access but most costly healthcare in world -Some people receive too little care (lack of insurance, insurance won't cover enough costs, physicians won't accept insurance) -Some people receive too much care (20-30% receive more care than needed increasing costs)
Why do Latinos delay seeking healthcare or not go to the doctor?
-Undocumented (so can't qualify for Medicaid) -Fear of exposing status as undocumented (even though ACA doesn't collect that information) -Language barrier -Part-time/self-employed so don't have employer covered insurance -Cultural uneasiness with Western medicine (prefer natural remedies) -Tradition of privacy and individual pride -Doctors appear untrustworthy due to lack of relationship -Lack of comfort discussing sex or mental health
What are the characteristics of a Free Market?
-Unrestrained competition among providers -Pts have information about availability of services -Pts directly bear costs of services received -Pts make decision about purchases of services
The medical profession grew in Post-Industrial America (1850-1900) due to...
-Urbanization (pts could come to doctors instead of house calls) -New scientific discoveries -Medical schools paired up with universities -Flexner Report medical reform -Growth of hospitals
Who are retail health clinics staffed by?
-Usually one NP (may be doctor or PA) -Usually only the provider is present (possibly also one med tech)
How does an imperfect market system drive up costs?
-Utilization of healthcare is driven by need and not demand -Quantity of healthcare produced is higher than in true markets -Prices are higher than the true cost of production
What are the barriers to the "Building the Relationship" in the medical interview?
-Verbal (use professional interpreter for this) -Personal space issues (too close) -Gestures with different meanings across cultures -Eye contact has different meanings across cultures
Why AA Fmale has higher mortality rate in Breast CA
-disparities in access to healthcare -the quality of care received -less start tx within 30 days -differences in adherence to mammography recommendations, -more likely to have poor prognosis forms of breast cancer
For the ROS: 1) is it ok to write "All other systems reviewed and are negative"? 2) is it ok to write "ROS negative"
1 = yes 2 = no
What are the components of high-quality care according to the text?
1. Access to care (reduced access -> worse health outcomes) 2. Adequate scientific knowledge/guidelines (lack of scientific studies about a treatment -> unexpected side effects) 3. Competent healthcare providers (lacking knowledge about current science -> medical negligence) 4. Separation of financial and clinical decision (fee-for-service -> increased use of unnecessary, dangerous care; capitation -> decreased use of needed care) 5. Organization of healthcare institutions to maximize quality (e.g., enough nursing staff, monitoring whether reports were received)
What are the 10 categories of essential health that must be covered to some degree under the ACA?
1. Ambulatory services 2. Emergency services 3. Hospitalization 4. Maternity and new born care (e.g., breast pumps) 5. Mental health and substance abuse 6. Prescription drugs 7. Rehabs 8. Labs 9. Preventive service and chronic disease management 10. Pediatric services (including oral and vision)
What benefits are offered under Covered California?
1. Ambulatory services 2. Emergency services 3. Hospitalization 4. Maternity and new born care (e.g., breast pumps) 5. Mental health and substance abuse 6. Prescription drugs 7. Rehabs 8. Labs 9. Preventive service and chronic disease management 10. Pediatric services (including oral and vision)
What are the 2 types of three-tiered capitation IPA structures?
1. CapCap Associates model = insurance pays IPA capitation payment, and IPA pays individual physician capitation payment 2. CapFee Associated model = insurance pays IPA capitation payment, and IPA pays individual physicians fee-for-service payments
What methods have been used to mitigate the financial risk that physicians' take when being paid with capitations?
1. Carve-outs = re-instating fee-for-service payments for certain services (e.g., pap smears not covered by capitation payment) 2. Risk-adjusted capitation = higher monthly capitation payments for patients who are more likely to require more time (e.g., elderly, chronic illness)
What are the four types of Cost Sharing?
1. Deductibles 2. Copayments 3. Coinsurance 4. Stop-loss Provision
What are the characteristics of of the Regionalized Model of healthcare organization?
1. Different staff and facilities are assigned to distinct healthcare tiers (primary, secondary, or tertiary) 2. Flow of patients across tiers occur in orderly, regulated fashion (primary -> secondary -> tertiary) 3. Emphasis on primary care 4. Most physicians work in primary care, each serving a small population 5. Tertiary care facilities serve a very large population Example: UK healthcare
What are the negative characteristics of the Malpractice System?
1. Fear of lawsuit generates an "I didn't do it" response rather than focusing on ways of improvement 2. Increase in waste (lots of frivolous suits taking up time and money and motivating unnecessary procedures) 3. Validates a questionable assumption that trial by jury is the best method of determining whether there was negligence 4. Inequality (low SES patients are less likely to receive help from lawyer for filing lawsuits)
What are the goals of the Malpractice System?
1. Financially compensate people who in the course of seeking medical care have suffered medical injury 2. Prevent physicians from negligently causing harm to patients
What are the major tensions in healthcare that need to balanced?
1. Health of individual vs Health of population 2. Tertiary care vs. Primary care 3. Acute care vs. Chronic/preventive care 4. Cost unawareness vs. Cost awareness 5. Unlimited expectation of care vs. Affordability of care 6. Individual physician vs. Healthcare team 7. Professional management by individual practitioners vs. Corporate management by administrators 8. Market competition vs. Government regulation 9. Inequity in distribution vs. Fair distribution
What are the proposals for improving healthcare quality?
1. Identifying and sanctioning "bad apples" 2. Clinical practice guidelines 3. Measuring practice patterns (evaluating process and outcomes over a long list of pts instead of specific cases) 4. Continuous quality improvement (forming interdisciplinary team to gather data and search for ways of internal improvement) 5. Computerized information systems 6. Public reporting of quality (i.e., healthcare report cards) 7. Pay for reporting (hospitals that don't publicly report certain quality measures receive less medicare payments) 8. Pay for performance (P4P) 9. Financial neutral clinical decision making
What are the four main healthcare reform components of the ACA?
1. Individual mandate after 2014 (almost everyone must have insurance) 2. Employer mandate after 2014 (employers of > 50 employees must have employees covered) 3. Medicaid expansion after 2014 4. Insurance market regulation after 2010 (e.g., eliminating caps, letting depends up to 26 stay on parents insurance, eliminating pre-existing conditions)
What are the four principles of insurance?
1. Individual risk is unpredictable 2. Risk can be predictable with some accuracy in a large group 3. Insurance can shift risk from the individual to the group through pooling resources 4. Losses are shared by all members
According to "Rays Symposium," what are the nine areas of US health disadvantage?
1. Infant mortality 2. Injuries/homicide 3. Adolescent pregnancy 4. HIV and STDs 5. Drug-related deaths 6. Obesity and DM 7. Cardiovascular disease 8. Chronic lung disease 9. Disability
What methods are used for Rationing?
1. Medical effectiveness (e.g., who would benefit more from the supply?) - usually done for microallocation (choosing between 2 patients) 2. Cost effectiveness (e.g., which pts benefit the most per cost of supply?) - usually done for macroallocation (distribution across society)
How is US healthcare different from other countries?
1. No central governing agency 2. Technology driven 3. Focus on acute care 4. High cost (more of GDP than any other country) 5. Unequal access 6. Average outcomes (e.g., infant mortality, life expectancy) 7. Imperfect market conditions 8. Defensive medicine 9. Government is subsidiary to private sector 10. Market justice conflicts with Social justice 11. Multiple players in balance of power 12. Quest for integration and accountability 13. Access is selectively based on insurance coverage
What are the six core dimensions of high quality care according to the Institute of Internal Medicine?
1. Safe = avoiding iatrogenic injuries 2. Effective = providing services base on scientific knowledge to avoid under- and over-use 3. Patient-centered = being respectful to pt and having their values guide clinical decision 4. Timely = reducing delays for treatment 5. Efficient = avoiding waste of equipment, supplies, time 6. Equitable = care does not vary based on personal characteristics
What are the four models of HMOs?
1. Staff Model 2. Group Model 3. Network Model 4. IPA (independent practice association) Model
What are the characteristics of the Dispersed Model of healthcare organization?
1. Staff and facilities may act at multiple points along healthcare tiers (e.g., one hospital may have primary care and tertiary care; an internist may be specialized and act as PCP) 2. Free-flowing movement of patients across tiers (e.g., patient may jump straight to tertiary tier without going to primary care first) 3. Emphasis on tertiary care (hospitals compete to have most specialized equipment) Example: US healthcare
What are the 3 components of medical care according to Avedis Donabedian?
1. Structure = stable characteristics (e.g., tools, physical setting) 2. Process = way in which care is carried out (e.g., ordering tests, prescribing meds) 3. Outcomes = effects of utilizing structure and process (e.g., infection rates, patient satisfaction, mortality rate)
What are rising healthcare costs due to?
1. Third party payments (insurance pays for most of the services used, not the consumer) 2. Imperfect market system 3. Growth of technology (new technology needs to be used to pay for itself) 4. Increase in elderly population (who consume 3.5x more healthcare than non-elderly) 5. Medical model of healthcare delivery (emphasis on acute care and not prevention) 6. Multiplayer system and administrative costs (accounts for 25% of all costs) 7. Defensive medicine 8. Waste and abuse (fraud - providing services not necessary) 9. Practice variations (different practice patterns in different geographic areas causes inefficient delivery of services)
Medicare is also known as Title...
18
Medicaid is also known as Title...
19
When did Medicare and Medicaid come to be?
1965
In what year did / does the Affordable Care Act (ACA) prohibit health insurers from denying coverage to children based on preexisting conditions?
2010
The individual and employer mandates, as part of the Affordable Care Act (ACA), were/will be implemented in which year?
2014
How many times has the issue of national health insurance been the subject of intense legislative attention in American history?
6
What does Medicare Part B cover?
80% coverage of: -Medical expenses -Physician services -PT, OT, Speech therapy -Diagnostic tests -Preventive care NOT covered: -Vision -Hearing aids -Dental
How much will the ACA cost?
938 billion dollars over 10 years BUT with the added new taxes and fees, it should actually reduce federal deficit by 124 billion dollars
What is a Bundled Payment?
A set price meant to cover every element of clinical care and support for a specific procedure or condition
What is the definition of healthcare Access?
Ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner
What is AIM? What and who does it cover?
Access for Infants and Mothers Medical costs through pregnancy and 60 days after birth for mid-income women that: -Don't qualify for Medi-Cal/Medicare -Don't have insurance -Have a copay > $500
For which age group is U.S. life expectancy better than other countries?
Ages > 75
What is AIIHI? What and who does it cover?
American Indian and Infant Health Initiative Provides home visits and connects people to social services if: -high risk family in one of 5 CA counties with greastest disparity in maternal/infant health
What is a Deductible?
Amount the insured pays out of pocket (in addition to premium) before benefits are paid by plan -Once deductible is met, insurance being paying their portion of costs
What was the HMO act of 1973?
Any employer with > 25 employees must offer HMO as option within health insurance plan to employees
Who does the False Claims Act law apply to?
Any federally funded contracts or program (except Tax fraud) Examples: -DOD -Medicare and federal healthcare programs
What is the definition of Financing?
Any mechanism that gives people the ability to pay for healthcare services
What is ALW? What and who does it cover?
Assisted Living Waiver Pays for assisted living (as alternative to nursing home) if: -Live in sacramento, LA, or san joaquin -Enrolled in Medi-Cal -Need level of care provided by a nursing facility
What is Cost Efficiency?
Attempt to determine optimal quality by demarcating line between under- and over-use (such that benefits received are greater than costs incurred)
How has the ACA affected Medicare Part D?
Attempting to eliminate the Coverage Gap/Doughnut whole by 2020 (government providing subsidies gradually to lower pt payment to 25% - same as copayment)
What is Cost Shifting?
Attempts by hospitals/physicians to make up for lost revenue by: -Increasing utilization of services -Charging higher prices in areas free of controls by insurance/medicare (can make cost containment difficult)
What is culture?
Beliefs and behaviors that are learned and shared by members of a group
People, including the insured, spouse, and children, covered by a policy are known as...
Beneficiaries
What are the benefits and costs of the Dispersed Model of healthcare organization?
Benefits: -More flexibility and convenience for pts -More direct access for pts -More autonomy for pts Costs: -Increased cost of healthcare -Lack of quality healthcare (due to disorganization)
What are the benefits and costs of working in a rural underserved area?
Benefits: -More responsibility -More challenging cases -Less day-to-day supervision Costs: -Less pay -Longer hours -More medicaid patients
What was the first hospital insurance in the US?
Blue Cross - 1929 great depression and economic instability caused Baylor University to to set up insurance
What was the first physician insurance in the US?
Blue Shield - 1939 by the California Medical Association
How is healthcare quality and healthcare access related to cost?
Both require increased overall cost
Who is eligible for the Low-Income Subsidy for Medicare Part D?
Both: a) Income below 150% of federal poverty level b) Assets < certain amount (depending on single or married)
What is BCCTP? What and who does it cover?
Breast and Cervical Cancer Treatment Program Provides breast/cervical cancer tx to low income CA residents if: -Screened by either Every Woman Counts or Family PACT -Age < 65 -Income below 200% of poverty level -No health insurance
What models of healthcare do Britain, Canada, and Germany use?
Britain = National health system (government finance and providers) Canada = National health insurance (government financed, private providers) Germany = Socialized health insurance (government mandated employer contributions, private providers)
Which billing code system is used for medical, surgical, and diagnostic procedures?
CPT (current procedural terminology)
Which state Medicaid program serves the most people and spends the most money?
California
What is CCS? What and who does it cover?
California Children's Services Provides health services for children with certain diseases if: -Age < 21 -Family income < 40K -Out of pocket expense > 20% family income -Adopted with known health problem
What is DHCS?
California department of healthcare services (administers Medi-Cal)
What is Covered California?
California's marketplace for health plans being offered under the ACA
Paying the physician/hospital one lump sum for each patient's care during a month or year is what method of payment?
Capitation
What is high-quality healthcare?
Care that assists: -people to stay healthy -cure acute illness -allow chronically ill people to live as long and fulfilling a life as possible"
What are Community Health Centers?
Centers that provide medical services to a specific community or region as part of a health safety net Health safety net = group of providers who provide medical care to underserved
What is CHDPP? What and who does it cover?
Child Health and Disability Prevention Program Preventive health program providing assessment and referral for low income youth
How has the ACA affected coverage of children under a parent's plan?
Children can be on parents plan up to 26 years old (used to be 19 years old)
What is Underwriting?
Classification and rating of risk that allows insurance to evaluate and select/reject persons for a policy
What are retail health clinics?
Clinics located in a retail store (e.g., Target, CVS, Walmart)
What are Promotoras?
Community outreach health workers in Hispanic communities who raise awareness of health and education issues
What is a Compliance Program?
Comprehensive strategy to ensure a company consistently complies with all applicable laws and regulations (e.g., avoid accidental billing) E.g. HIPAA, sexual harassment, discrimination, billing
What is Vertical Integration of HMO healthcare?
Consolidation of all levels of healthcare (all types of care, all facilities, all staff) under one organization and ownership Kaiser Permanente HMO - owns hospitals, employs physicians, administers health insurance
What is covered under Medicare Part D? What is not covered?
Covered: -2 drugs from each class -Biologicals -Insulin -Some vaccines NOT covered: -OTC meds -Vitamins and minerals -Fertility or ED drugs -Hair growth drugs -Barbituates (with some exceptions) -Benzos (with some exceptions)
What effect did the ACA have on Medicaid?
Created Medicaid Expansion (individual states decided on whether or not to accept this expansion) Before Expansion = only certain poor individuals (e.g., pregnant, with kids, etc.) could have medicaid After Expansion = anyone below 138% of federal poverty can have medicaid
What is CLAS?
Culturally and Linguistically Appropriate Services -15 standards that help organizations advance health equity, improve quality, and eliminate disparities
Paying the physician/hospital a lump sum for all services delivered based on a patient's diagnosis is what method of payment?
DRG (diagnosis related group)
How has the ACA affected hospital readmissions and hospital-induced harm?
Decreased both
What is Denti-Cal? What and who does it cover?
Dental coverage (performed by MD, DO, or DDS) to low income youth (age < 21)
What are DRGs? What was their purpose?
Diagnosis Related Groups = Medicare pays predetermined amount for a specific diagnosis based on average of how much treatment for this condition should cost Tried to contain costs by converting medicare reimbursement from a retrospective system (paying afterwards for fee-for-service) to prospective system - authorized in 1983
What is the Acuity Caveat?
Documentation for the E/M level coding that stated "Unable to obtain history due to..." -Mental status -Urgency of condition -Inability to communicate
What is the most important facto determining whether or not government decides to pursue a FCA?
Does the company have a compliance program
What is Cal MediConnect? What and who does it cover?
Dual eligible care (both medicare and medical) demonstration in a few CA counties -Qualified people are automatically enrolled on first day of birth month and randomly assigned to a plan -Can opt out of demonstration and switch plans at any time
Which billing code system is used for provider services?
E/M (evaluation and management) -> part of CPT
How is EHR different from EMR?
EHR = electronic personal health record that pt can access in a "patient portal" to input history and refill requests EMR = electronic medical records that providers use
How can the Physical Exam be scored for E/M coding?
Either via: -12 organ systems -9 body areas (Most commonly used is organ systems)
What is the most common source of healthcare for those without financing ability?
Emergency Department
How is healthcare in the US primarily financed?
Employer-based insurance
What is the Cultural Blind Spot Syndrome?
Erroneous belief that no barriers exist if both patient and provider are of the same race
What words should be used when listing the possible diagnoses for an established problem? for a problem that is not established?
Established: improved, well-controlled, resolved, worsening, failing to change as expected Not established: possible, probable, rule out
What is Accountability?
Ethically providing quality healthcare in an efficient manner (using resources sensibly)
What is medical negligence?
Failure to meet standard of practice of an average qualified physician practicing in same specialty
True of False - CPT will be replaced by ICD-10?
False
True of False - Department of Health and Human Services will grant an extension for ICD-10 implementation beyond the October 1 2015 compliance ate?
False
True of False - The increased number of ICD-10 codes will make the new coding system harder to use.
False
True of False - All ICD-10 coding must be performed electronically.
False (hard copy coding books will still be available)
True of False - ICD-10 was developed without clinical input.
False (many medical societies contributed)
True of False - ICD-10 is already out of date.
False - it has been updated annually since original development many years ago in order to keep pace with medical/technological advances
What is Family PACT? What and who does it cover?
Family Planning, Access, Care, and Treatment Family planning, pregnancy, and reproductive health education for: -All men and women able to conceive -Poor with no medical insurance or haven't met deductible -Insurance that doesn't cover family planning/birth control -Anyone who wants to keep family planning services confidential
Who is Medicare Part A administered by?
Federal government CMS (centers for medicare and medicaid services)
What is the FQHC program?
Federally Qualified Health Centers -Medicare and Medicaid can reimburse higher for rural, underserved areas if clinic is non-profit
Paying the physician/hospital for each individual service or supply (e.g., office visit, ECG, catheter) is what method of payment?
Fee-for-service
How are Community Health Centers financed?
Fee-for-service (but at reduced price)
What challenges do females face more so than males?
Females are: -More likely to be talked down to by physicians -More likely to be told that is "all in their head" -Less likely to be counseled on cardiac prevention -Less likely to receive tests and prophylaxis for cardiac issues -More likely to have chronic conditions -More likely not to fill prescriptions due to cost -More likely to be on Medicaid -Have difficult times findings places that do abortions -Receive inappropraite care (e.g., hysterectomies)
What is Up Coding?
Fraud in which there is too much thorough documentation without medical necessity (i.e., giving an E/M level of 5 without needing to)
Which of the following national health insurance plans is financed by money being collected through taxes or premiums by a public or quasipublic fund that reimburses health care providers?
Government-financed health insurance
Which report card program is most influential?
HEDIS = healthcare effectiveness data and information set (contains data of 71 performance indicators for healthcare plans) (developed by NCQA = national committee for quality assurance)
Which is the most tightly integrated MCO (managed care organization)?
HMO
What's the relationship between amount of treatment and health outcomes (per state)?
High treatment states have worse health outcomes than low treatment states
Why does higher status lead to better health outcomes?
Higher status/income -> More control over life -> Less chronic stress -> Less cortisol -> Less illness
What is Excess Death?
Higher than expected rate of death in a given population (premature death)
How do you determine Complication Risk rating for the Medical Decision Making component of E/M ratings?
Highest level of risk based on these components: -Specific presenting problem -Comorbidities or risk factors that increase complication risk -Specific diagnostic procedure -Specific type of management
What is a Pharmacy Benefit Manager?
Hired by insurance company to: -Negotiate drug prices between manufactures and insurance company -Develop formularies (what drugs covered) -Establish pharmacy networks -Process drug claims
Which billing code system is used for diagnoses?
ICD 9/10 (international classification of diseases)
What are the Whistleblower Protections?
If an employee is fired, demoted, or harassed for filing a FCA, then law says: -Employee must be reinstated -Employee receives back pay x 2 (with interest) -Employee is compensated for damages including litigation costs and reasonable attorney fees
The human experience of sickness, which is influenced by culture is known as...
Illness
What does the Health Information Technology for Economic and Clinical Health Act (HITECH) say?
Imposes penalties for not having "meaningful use" of EMR
What part of the ACA still has not been begun yet?
In 2017 - option for state waiver to design alternative coverage programs
What is IHI? How does it affect healthcare quality?
Institute for Healthcare Improvement Independent, non-profit organization that helps put healthcare quality improvement ideas into action
What is Tricare? What and who does it cover?
Insurance as part of MHSS (Military Health Services System) For active duty, retirees, and dependents/survivors of military Tricare Prime = HMO Tricare Extra = PPO Tricare Standard = Fee-for-service
What is "Group Insurance"?
Insurance offered through a group organization (school, job) that anticipates risk based on the group's average characteristics -Costs and risks are distributed equally among all insured members in the group
The person being protected by the insurance is known as...
Insured
The insurance company that assumed the risk is known as...
Insurer
What is Virtual Integration of HMO healthcare?
Integration of all levels of healthcare through contractual relationships (rather than unitary ownership) -HMO makes contracts with hospitals and physicians (but hospitals not owned by HMO)
What is JCAHO? How does it affect healthcare quality?
Joint Commission Clinics/hospitals must be joint commission certified in order to receive money from medicare/medicaid
Which racial/ethnic group is least likely to visit the doctor?
Latinos (about 50% never visit a doctor during a year)
What are the "Patient" characteristics of a EPO (exclusive provider organization)?
Like a HMO -Restricted to in-network providers (cannot go out-of-network) -Gatekeeping is present (must get referral from PCP before seeing specialist)
What is the Rationing of healthcare?
Limitation of resources, including money, going to medical care, such that not all beneficial care is provided to all patients, but rather that it is fairly distributed instead (distributing limited resources in a fair manner, causing not everyone to receive all beneficial services) Examples: -A man not getting a heart transplant because there aren't enough hearts available
What did the Whitehall studies in the 1970's show?
Lower grade of employment = higher incidence of disease (even in the UK where there is universal healthcare)
How is the History E/M level determined?
Lowest E/M score from these subcomponents: -C/C (can be written down by nurse, medical assistant) -HPI (8 elements must be documented by provider) -ROS (14 possible organ systems) -PFSH (only relevant past family and social history)
How is the final E/M level determined?
Lowest score of the 2 (for established patients) or 3 (for new patients) components: -History -Physical exam -Medical decision making
What is Enterprise Liability? What are the benefits?
Making institutions responsible for compensating medical injuries on no-fault basis -Same as "no fault reform" -Incentive for hospitals and HMOs to improve quality of care
What is the purpose of GEMs in ICD-10?
Mapping/coverting of ICD-9 codes to ICD-10 codes that can be used by all providers (NOT to do any actual coding - just convert existing codes to ICD-10)
What is Market Justice? Social Justice?
Market justice = market forces in free economy determine distribution of healthcare and people's ability and willingness to pay Social justice = well-being of larger community is more important than individual, so absence of medical services due to low SES is unjust
What is Stop-Loss Provision?
Maximum amount of money an insurance company will provide in a given year (after which insured is responsible for remaining payments) Note: This has been eliminated by ACA
What was the first multispecialty group practice?
Mayo Clinic
What is the largest source of health insurance coverage in California?
Medi-Cal
How is the Medical Decision Making E/M level determined?
Meeting or exceeding level of at least 2 of the 3 subcomponents: -Number of possible diagnoses -Amount and complexity of data -Risk of significant complications
Which SES class has contributed most to the increased ER visits over the past decade?
Middle class (most of whom have insurance) -> PCPs just can't see them soon enough so they go to ER
How is health inequality related to economic inequality?
More economic inequality = more health ineuality ("Economic policy is health policy")
What is NCQA? How does it affect healthcare quality?
National Committee for Quality Assurance (includes HEDIS) Allows for standardized comparisons of quality outcome measures across hospitals/clinics
How should you Manage a Patient's Problems in a medical interview?
Negotiation 1. Tell pt what they want to know before what they need to know 2. Acknowledge/respect role of family in decision making 3. Inquire about use of alternative/complimentary tx 4. Pt education materials that matches health literacy and language 5. Confirm pt's understanding
What does the Massachusetts individual mandate plan have in common with the previously failed Nixon employer mandate proposal?
Neither eliminates existing government insurance programs.
Does having insurance guarantee access to healthcare?
No -Insurance may not pay well, so providers may not accept it
Do "rule out" diagnoses get coded in the ICD 9/10?
No - only diagnose what you know (e.g., back pain if can't be sure it is strain)
Which is usually non-profit? Which is usually for-profit? -Vertical Integration HMOs -Virtual Integration HMOs
Non-profit = vertical integration For-profit = virtual integration
What is OSHA? How does it affect healthcare quality?
Occupational safety and health administration Regulates work environment for health/safety issues
What is the compliance date for implementation of ICD-10
October 1 2015
What is the governmental process in the False Claim Act?
Once an act is submitted: -Quit tam suit remains under seal for 60 days so DOJ can investigate and decide if suit is worth pursuing -If DOJ decides not to purse the case, whistleblower can still pursue on their own (but they will cover costs on own)
What is a Copayment?
Out of pocket amount of money paid by insured each time services are received (even after deductible is met)
Historically in the United States, health care financing began with which method?
Out-of-pocket
What are Critical Pathways?
Outcome-based and patient-centered care management tools that facilitate coordination of care among multiple clinical departments (i.e., for a specific diagnosis, a timeline identifies planned medical intervention and expected pt outcomes)
What is the formula for healthcare expenditure?
P x Q = E p = price q = quantity e = expenditure
What are E codes?
Part of ICD 9/10 volume 2 Used when there is an external cause for the problem (e.g., shark attack on beach)
What are V codes?
Part of the ICD 9/10 volume 2 Defines circumstances other than disease or injury for an patient encounter (e.g., pregnancy, immunization, annual exam, sports exam)
What is Capitation?
Paying the physician/hospital one lump sum per time period for each patient covered (regardless of whether or not patient was actually seen during that time period)
What is an Entitlement Program? What is the best known example?
People contribute through taxes and are entitled to benefits at certain point, regardless of income or assets Medicare
Paying the hospital a lump sum for all services delivered during day is what method of payment?
Per diem
What is Coinsurance?
Percentage of costs the insurance company and insured each pay (usually 80/20)
What is "Individual Private Health Insurance Plan"?
Person purchases his/her own individual insurance (not through a group plan) -ACA has drastically increased the number of people with this type of insurance
What is Pay-for-Performance (P4P)?
Physician/Hospitals receive more money if quality measure exceed certain benchmarks (i.e., how well one group performs versus peers)
What is Tort Reform? What are the benefits?
Placing limits/caps on malpractice awards paid to patients and lawyers -Slows the growth of physicians' malpractice premiums
What is a multispecialty group practice?
Practice owned by physicians and containing physicians working in various specialties (different specialties all under one roof working together on a single patient)
What is PCIP? What are the eligibility criteria?
Pre-existing Condition Insurance Plan (established by ACA) Eligibility: -Have pre-existing condition or been denied coverage due to health condition -Have no health coverage for at least 6 months -Citizen, national, or legal resident of US
What is PE? What and who does it cover?
Presumptive Eligibility for Pregnant Women Grants immediate, temporary Medi-Cal coverage for ambulatory prenatal care and meds for low income women with pending Medi-Cal application Does NOT cover: -Emergency care -Labor and delivery -Inpatient care
What is primary, secondary, and tertiary care?
Primary = care of common health problems and preventive measures (PCPs) Secondary = more specialized clinical problems and hospital care (internal medicine, OB/GYN, psych) Tertiary = management of rare and complex disorders (cardiac surgery, pediatric hematology)
What is Risk Management?
Proactive efforts to prevent adverse events related to clinical care (i.e., avoiding medical mistakes)
What is the principle standard of CLAS?
Provide quality care and services that are: -Effective -Equitable -Understandable -Respectful -Responsive to diverse cultural health beliefs and practices -Responsive to preferred language, health literacy, and other communication needs
Who are hospital commercials intended for?
Providers (not patients) -> the commercials are intended to make providers want to send their patients to that hospital
What is a culturally competent provider?
Providers who can provide patient-centered care by: -Adjusting attitudes and behaviors to needs of different patients -Accounting for impact of emotional, cultural, and social issues on the medical ailment
What is No-Fault Reform? What are the benefits?
Providing compensation to patients suffering from medical injury regardless of whether injury is due to negligence or not -Compensates more patients -Removal of legal costs -Physicians more willing to discuss causes and learn from medical errors
What is the history behind the False Claims Act?
Rampant fraud in 1980's which government had little resources to fight, so they reinstated Civil War law
What is "painful" cost control?
Rationing of beneficial care in order to save money (i.e., saving money requires lower health outcomes)
What is Gate Keeping?
Requirement of a referral from a PCP in order to receive specialty services
Which type of care is the US really good at?
Rescue care (e.g., cardiac surgery) Also: -Low mortality for cancers (except lung cancer) -Low suicide rates -Good control of HTN and cholesterol
What is the RHC program?
Rural Healthcare Program of 1977 -Medicare and Medicaid can reimburse higher for rural, underserved areas if they employ a PA or NP
Paying the physician/hospital one lump sum for all patients within a certain time period (e.g., a year) is what method of payment?
Salary - physicians Global budget - hospitals
What are the "Provider" characteristics of a EPO (exclusive provider organization)?
Same as a PPO -Providers negotiate with PPO to be in-network -Providers agree to accept discounted fees from plan's members in exchange for "exclusive provider" status -Exclusive provider status increases patient flow (thus increasing income)
What is "painless" cost control?
Saving money by being more efficient with the money spent (i.e., saving money without lowering health outcomes)
What are the components of Medical Necessity?
Services and corresponding E/M levels that are: -Consistent with symptoms or diagnosis of injury -Necessary and consistent with generally accepted professional standards (not experimental or investigational) -Not furnished primarily for convenience -Furnished at the most appropriate level that can be provided safely and effectively
According to "Unnatural causes in sickness and in wealth," most improvements in health over the past century has been due to...
Social reform (NOT medical advances)
What are Clinical Practice Guidelines?
Specific recommendations/protocols for managing a clinical problem, based on scientific evidence (usually created by a medical society)
What is SCHIP? What and who does it cover?
State Children's Health Insurance Program (Title 21) Expands insurance to children who aren't eligible for Medicaid if: -Age < 19 -Family income below 200% of federal poverty levels There are premiums and deductibles but it is on slide scale based on family income
Who administers Medicaid?
States
What is Continuous Quality Improvement (CQI)?
The process of identifying institutional problems and forming interdisciplinary teams that gather data and propose solutions (e.g., noting that infection rates varying by physician was due variability in whether or not physicians prescribed prophylactic tx)
What is Cost Sharing?
The sharing (between insured and insurer) of the cost of the risk that the insurance company takes on
Which agency controls Public Health?
There is no single agency responsible -> divided among many agencies across all levels of government
What does the False Claims Act of 1986 say?
Those who knowingly submit or cause another to submit false claims for government funds are liable for both: 1) 3 times the government damages 2) Civil penalties of $5,500-$11,000 per false claim
True of False - Non-covered entities not covered by HIPAA (worker's compensation, auto insurance) that use ICD-9 need to implement ICD-10.
True
True of False - Practices may continue to create short super bills with ICD-10.
True
True of False - State medicaid programs are required to update their systems to ICD-10.
True
True of False - ICD-10 will still have nonspecific codes.
True - these are to be used when documentation does not support a higher level of specifity (e.g. cannot go above and beyond "ear pain" based on exam and history)
Which individuals are most likely to still be uninsured after 2014?
Undocumented immigrants (not covered by ACA)
Who is Covered California's primary targeted population?
Uninsured consumers This is mostly: -Latinos -Adult students -People with limited English
What is Alternative Dispute Resolution? What are the benefits?
Use mediation and arbitration instead of jury trials in malpractice suits -Reduced legal costs -Dispute will be based more on science than emotional jury
What is VHA? What and who does it cover?
Veterans Health Administration Federally funded VSINs (veteran integrated services networks) that provide care on priority basis to veterans with service-connected illness/disability
Who has higher enrollment: Vertical Integration HMOs or Virtual Integration HMOs?
Virtual integration
What are some unique characteristics of the US culture to be aware of during the medical interview?
We believe that: -Status is based on accomplishments (others may believe it is based on gender/family status) -Internal locus of control (others may be in fate) -Emphasis is on individual (others may emphasize groups) -Patients should receive both good and bad news (others may believe that patients should not receive bad news)
What is Public Health?
What society does collectively to assure the conditions for people to be healthy
When can an E/M level be based on face-to-face time?
When counseling and care coordination dominate visit >50% of the visit is discussion of: -Diagnostic results, impression, recommendation -Prognosis -Risk/benefits of management -Treatment/follow-up options -Importance of compliance -Risk factor reduction -Patient/family education
When does healthcare inequality become concerning for policymakers?
When it cannot be explained by justifiable differences (e.g., patient preference, clinical need)
For how many days does follow-up care after a procedure not get charged?
Within 10 days of procedure - no charge (not including complications)
What is WIC?
Women Infants and Children Provides to low income pregnant and post-partum women and children < 5 years old at nutritional risk: -Food -Healthcare referrals -Nutrition education
What was the 1st broad coverage health insurance in the US?
Worker's compensation (a trial for government sponsored healthcare)
What was the underlying cause of employer-based healthcare in the US?
World War II wage freeze -> used benefits to recruit workforce
According to the Affordable Care Act (ACA), the individual mandate will require virtually all US citizens and legal residents to purchase health insurance. Those who fail to purchase insurance will be:
charged a tax penalty.
The concept of national health insurance rests on the belief that
everyone should contribute to finance health care and everyone should benefit.
Who is eligible expanded Medi-Cal under Covered California and the ACA?
households at or below 138% of federal poverty
Who is eligible for premium assistance or cost-sharing reductions under Covered California and the ACA?
households at or below 400% of federal poverty
Which of the following is a common feature between the individual insurance mandate model and the single-payer, government-financed approach to universal health care coverage?
severing of the connection between employment and health insurance
The primary distinction among national health insurance approaches is: Answer
the mode of financing
Which employers are eligible for Covered California?
those with 50 or fewer employees
Most of the wasteful spending in healthcare is due to...
unnecessary and inefficiently delivered services by providers
