healthcare org ch 5-8 exam 2

HMO Act of 1973

- HMO: health management org - who: federal legislation enacted by the Nixon administration - what: provided loans and grants for the planning, development, and implementation of combined insurance and health care delivery org and required that a comprehensive array of preventive and primary care services be included the HMO arrangement - by linking the payment for services with the quality of care, the HMO Act paved the way for the proliferation (rapid increase of numbers) of managed care principles that become the bedrock of US health insurance reform in the succeeding three decades

diagnosis-related groups (DRG's)

- a case payment system that radically changed hospital reimbursement shifting hospital reimbursement from the retrospective to a prospective basis - provided incentives for the hospitals to spend only what was needed to achieve optimal patient outcomes - if outcomes could be achieved at a cost lower than the preset payment, the hospital received an excess payment for those cases - if the hospital spent more to treat cases than allowed, it absorbed the excess costs - this payment system was widely adopted by nongovernmental health insurers

financial risk sharing

- a concept used by MCOs to transfer some measure of financial risk from insurers to beneficiaries - such transfers of financial risk to beneficiaries commonly take the form of co-payments and deductibles - co-payments require that beneficiaries pay a set fee each time they receive a covered service, such as a co-payment for each physician office visit - a deductive require beneficiaries to meet a predetermined, out-of-pocket expenditure level before the MCO assumes payment responsibility for the balance of charges

national institute for complementary and alternative medicine

- a division of the National Institutes of health devoted to conducting and reporting on research focused on complementary and alternative therapies

Agency for Healthcare Research and quality (AHRQ)

- a federal agency charged with research to develop and disseminate (distinguish) evidenced based practice guidelines - AHRQ is a major collaborating agency in several ACA implementation initiatives

indemnity insurance

- a form of insurance - an insurance company sets allowable charged for services that it will reimburse after services are delivered which allows providers to bill patients for any uncovered excess costs

accountable care organization (ACO)

- a group of providers and suppliers of health care, health-related services, and others involved in caring for Medicare patients that voluntarily work together to co-ordinate care for the patients they serve under the original medicare (not medicare advantage managed care) program - the ACA enables ACOs to share in savings to the federal gvt based on ACO performance to improving quality and reducing health care costs - a group of providers and suppliers that help w medicare patients

capitation

- a managed care reimbursement method that pre-pays physicians for services on a per-member per-month basis whether or not services are used - if a physician exceeds the predetermined capitation amount, he or she may incur a financial penalty - if the physician uses fewer resources than predicted, he or she may retain the excess as profit

self-funded health insurance

- a mechanism through which an employer collects premiums and pools these into a fund or account that it uses to pay medical benefit claims instead of using a commercial carrier - often use the services of actuarial firms to set premium rates and a third-party administrator to administer benefits, pay claims, and collect data on utilization - offer advantages to employers, such as avoiding additional administrative and other charges made by commercial carriers, avoiding premium taxes, and enabling interest accrual on cash reserves in the benefit accounts

health insurance exchange (HIE)

- a network that enables a basic level of interoperability among electronic health record maintained by individual physicians and health care organizations - organized and governed by regional health information organizations (RHIOs)

osteopathic medicine

- a philosophy of medical education with particular focus on the musculoskeletal system - graduates receive a DO rather than MD degree and are considered as rigorously trained and qualified as their MD degree counterparts

hospitalist

- a physician who specializes in the care of hospital patients - board certified in internal medicine - may be an employee of one or more hospitals or an employee of one or more companies that contract with hospitals to provide services

nurse practitioner

- a registered nurse (usually w a master's degree) that specializes in a particular area of nursing practice such as primary care, geriatrics, psychiatry, emergency medicine, or other medical fields - function under the supervision of physicians and provide diagnostic, preventive, and therapeutic health care services and may prescribe medications as allowed by law as delegated by physicians

certification

- a regulatory process, much less stringent than licensure, under which a state or professional org attests to an individual's advanced training and performance abilities in a field of health care practice - specific professions set certification standards for approval by their respective state or professional org

patient-centered medical home (PCMH)

- a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes, including appropriately arranging patients' care with other qualified professionals for preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues

academic health center

- a university-affiliated complex of professional academic and clinical care facilities such as medicine, nursing, pharmacy, dentistry, and allied health professions that are the principal places of education and training for physicians and other health care personal - academic center teaching hospitals are major providers of highly sophisticated patient care required by trauma centers, burn centers, neonatal intensive care centers and tech advanced treatment of cancer

accreditation council for graduate medical education (ACGME)

- an independent not-for-profit professional org that accredits 3-7 year program of advanced education and clinical practice required by physicians to provide direct patient care and a recognized speciality

american board of medical specialities (ABMS)

- an independent, non-for-profit-org - ABMS assists its 24 speciality member board to develop and utilize professional and education standards that apply to the certification of physician specialties around the world

managed care backlash

- beginning in the late 1990s, organized medicine, other health care providers, and consumers railed against MCO policies on choice of providers, referrals, and other practices that were viewed as unduly restrictive - public concerns driving sentiments toward more gvt regulation of the managed care industry included the belief that managed care was hurting the quality of patient care and that the managed care industry was not doing as good a job for patients as other sectors of the health care industry - since 1998, all 50 state legislatures enacted over 900 laws and regulations addressing both consumer and provider protections relative to managed care policies

registration

- begun as a method to facilitate contacts among professionals and potential employers - is the least restrictive form of health professional regulation - most programs are voluntary and range from listings of individuals offering a specific service to professional or occupational groups requiring educational qualifications and testing

laboratory technologists and technicians

- clinical laboratory personnel who analyze body fluids, tissues, and cells checking for bacteria and other micro-organisms - analyze chemical content of body fluids, test drug levels in blood to monitor the effectiveness of treatment, and match blood for transfusions - technologists typically have a bachelor's or higher degree - technicians typically hold associate's degree or certificates

federally qualified health center (FQHC)

- community-based primary care center staffed by a multidisciplinary team of healthcare and related support personnel, with fees adjusted based on ability to pay - provide services to link patients with other community resources - funded by the Health Resources and Services Administration to serve the neediest populations - FQHCs must meet specific operating parameters - may be organized as part of a local health department, a larger human services organization, or as a stand-alone, not-for-profit agency - community based health center that adjusts to the patients pay. usually placed in a poor area

voluntary ambulatory health agency

- community-based, not-for-profit org governed by a volunteer board of directors that may provide direct medical care, education, advocacy, or a combination of these services - many voluntary agencies were established by interest groups to address unmet health or health related of specific population groups - sources of financial support may include gvt grants, fees for services, third party reimbursement, and private contributions - a community based ambulatory center that people volunteer for

independent payment advisory board (IPAB)

- created by the ACA, the mission of the IPAB is to recommend policies to Congress to curb Medicare spending including suggestions to improve coordination of care, eliminate waste, encourage best practices, and prioritize primary care - beginning in 2015 and every other year thereafter, the IPAB is also charged with submitting recommendations to the President and Congress to slow overall growth in national health care expenditures

bundled payment for care initiatives (BPCI)

- developed by the CMS Center for Medicare & Medicaid Innovation (CMMI) that was created by the ACA - BPCI recognized that separate Medicare fee-for-service payments for individual services provided during a beneficiary's single illness often result in fragmented care with minimal co-ordination across providers and settings and results in rewarding service quantity rather than quality - designed to test whether, as prior research has shown, payments for bundled "episodes of care" can align incentives for hospitals, post-acute care providers, physicians, and other health care personnel to work closely together across many settings to achieve improved patient outcomes at a lower cost

consumer-driven health plan (CDHP)

- developed in a reaction to the managed care backlash, the goals of CDHPs were to have employees take more responsibility for health care decisions and exercise more cost consciousness - typically consist of either a health reimbursement arrangement (HRA) or a health savings account (HSA) - HSAs outpaced HRAs by 2:1

emergency medical treatment and labor act (EMTALA)

- enacted in 1995 federal budget bc of concerns about inappropriate patient transfers between hospitals prompted by payment considerations - require hospitals to treat everyone who presents in their emergency departments, regardless of ability to pay - stiff financial penalties, and as risk of Medicare decertification by hospitals inappropriately transferring patients, accompanies the EMTALA legal provisions

urgent care center

- facilities that provide walk-in, extended-hour access for acute illness and injury care that is either beyond the scope or the availability of the typical primary care practice or retail clinic - may provide other health services such as occupational medicine, travel medicine, sports and school physicals

graduate medical education consortia

- formal association of medical schools, teaching hospitals, and other orgs involved in the training of medical residents - provide centralized coordination and direction that encourages the members to function collectively with major aims to improve the structure and governance of residency programs, to increase residents' ambulatory care training experiences, and to address imbalances in physician specialty and location

preferred provider organizations (PPO)

- formed by physicians and hospitals to serve the needs of private, third-party payers and self insured firms, PPOs guarantee a certain volume of business to hospitals and physicians in return for a negotiated discount in fees - PPOs offer attractive feature to both physicians and hospitals - physicians are not required to share in financial risk as a condition of participation, and PPOs use negotiated discount fees, requirements that members receive care exclusively from contracted providers (or incur financial penalty), requirements for preauthorization of hospital admission, and second opinions for major procedures - currently, PPOs are the most popular managed care plans, encompassing 56% of employer-covered workers in 2012

therapeutic science practitioner

- include physical therapists, occupational therapists, speech language pathology and audiology therapists, radiation therapists, and respiratory therapists, representing some of the allied health disciplines in this category - depending on their field, therapeutic science practitioners' required credentials range from bachelor's degree to doctoral level educational preparation

behavioral scientists

- include professional in social work, health education, community mental health, alcoholism and drug abuse services, and other health and human service

community-rated insurance

- insurance plans in which all individuals in a defined group pay premiums without regard to age, gender, occupation, or health status - community ratings helped ensure nondiscrimination against groups with varying risk characteristics to provide coverage at reasonable rates for the community as a whole

experienced-rated insurance

- insurance plans that use historically documented patterns of health care service utilization for defined populations of subscribers to determine premium chargers

value-based purchasing (VBP)

- mandated by the ACA - medicare program through which participating hospitals may earn incentive payments based on clinical outcomes and patient satisfaction or incur reduction in medicare payments based on compliance with medicare determined criteria for "clinical processes of care" and "patient experience of care measures"

retail clinic

- operated at retail sites such as pharmacies and supermarkets under consumer-friendly names - example: "minuteclinic" and "takecare" "CVS" - staffed by nurse practitioners or physician assistants - a physician is not required on site - clinics have physician consultation available by phone

international medical graduates (IMGs)

- physicians trained in medical schools outside the US who fill the annual shortfall in US medical school graduates required to staff hospitals - responsibility for evaluating credentials of IMGs entering the US residency programs lie with the Educational Commission for Foreign Medical Graduates

healthcare effectiveness data and information set (HEDIS)

- provides a standardized method for MCOs to collect, calculate, and report information about their performance to allow employers, other purchasers, and consumers to compare different health insurance plans - HEDIS has evolved through several stages of development and continuously refines its measurements through rigorous reviews and independent audits

physician assistant (PA)

- provides health care services under the supervision of a physician - most hold master's degree - trained to provide diagnostic, preventive, and therapeutic health care services as delegated by physicians - take medical histories, order and interpret laboratory tests and x-rays, make diagnoses, and prescribe medications as allowed by law - many PAs are employed in specialities such as internal medicine, pediatrics, family medicine, orthopedics, emergency medicine, and surgery

health information administrator

- responsible for the activities of the medical records department of hospitals, skilled nursing facilities, managed care org, rehabilitation centers, ambulatory care facilities, and other licensed health care entities - they maintain info systems to permit patient data to be received, recorded, stored, and retrieved to assist in diagnosis and treatment and supply research data for tracking disease patterns, evaluating the quality of patient care, verifying insurance claims, and maintaining patient record confidentiality - a bachelor's degree in health information administration is the entry-level credential

ambulatory care

- services that do not require an overnight hospital stay --ambulatory=ambulance (quick) - can be hospital based or non-hospital based aka freestanding

evidence-based clinical practice guidelines

- systematically developed protocols based on extensive research that are used to assist practitioner and patients decisions about appropriate health care decisions - guidelines define parameters for specific diagnostic and treatment modalities in patient diagnosis and management

physician compare

- the CMS website, mandated by the ACA, to provide basic contact, practice characteristics, and clinical quality data on Medicare participating physicians and other healthcare professionals

balanced budget act of 1997 (BBA)

- the act was characterized as containing "some of the most sweeping and significant changes to Medicare and Medicaid since their inception (making of) in 1965" - took important incremental steps by extending health care coverage to uninsured children through a $16 million allocation for a new State Children's Health Insurance Program (SCHIP) - proposed to reduce growth in Medicare and Medicaid spending by $125.2 billion in 5 years - increased beneficiary premiums for Medicare Part B and required new prospective payment systems for hospitals outpatient services, skilled nursing facilities, home health agencies, and rehabilitation hospitals - reduced allowance for the medical education expenses of teaching hospitals and funded incentive to hospitals for voluntarily reducing the number of medical residents - first time allowing financial risk-sharing for the Medicare program with the private sector through managed care plans - *cut back on a lot of hospitals because there was too many and they were giving too much money to the hospitals*

flexner report

- the landmark report resulting from a comprehensive review of the quality of education in the US and canadian medical schools - funded by the carnegie foundation - issued in 1910 - report was a searing indictment of most medical schools of the time - as a result some of the university of toronto and especially John Hopkins received praise - the report gave increase leverage to medical education reforms and stimulated financial support from foundations and wealthy individuals which enabled university-affiliated medical schools to gain significant influence over the direction of medical education

national committee on quality assurance (NCQA)

- the most influential managed care quality assurance organization formed in 1979 by the merger of two managed care trade org, the American Managed Care and Review ASsociation and the Group Health Association of America, under the title of the American Association of Health plans - primary functions are accreditations for MCOs, PPOs, managed behavioral health care org, new health plans, and disease management programs; certifying orgs that verify provider credentials and consultation on physician org, utilization management org, patient-centered medical homes, and disease management org and programs

licensure

- the most restrictive form of health professional regulation - administered by individual states - it defines a professional's scope of practice and educational and testing requirements to legally engage in the practice of a profession `

diagnosis-related group (DRG)

- the new payment system provides financial incentives intended to decrease the duration of inpatient stay and to increase device deliver efficiency - helped w ambulatory care

medicaid

- title XIX amendment to the social security act of 1935 - a joint federal/state program that provides insurance coverage for a prescribed scope of basic health care services to americans who qualify based on income parameters, established on a state-by-state basis - unlike Medicare, Medicaid is not an "entitlement" program funded by payroll taxes - funded by personal income and corporate and excise taxes, with funds transferred from more economically affluent individuals to those in need - directly reimburses services providers - rate-setting formulas, procedures, and policies vary widely among states and as such - mediaid has been described as "50 different programs)

medicare

- title XVIII amendment to the social security act of 1935 - guarantees a minimum level of health insurance benefits to all americans beginning at age 65 - funds from payroll taxes

individual mandate

- under the ACA, the requirement that all American citizens (with specific exclusions) obtain health insurance coverage or pay a penalty

disease management programs

MCO programs that attempt to control costs and improve care quality for individuals with chronic and costly conditions through methods such as the use of evidence-based clinical guidelines, patient self-management education, disease registries, risk stratification, proactive patient outreach, and performance feedback to providers - programs may also use clinical specialists who provide monitoring and support to patient with disease management issues