Intro to HCA -test 2- U1-7
Know the five principle responsibilities of a hospital governing board
EECGG Establish mission and vision Establish policies and procedures CEO-hire/fire Guarantee fiscal viability Guarantee quality of care
EBITDA
Earnings before interest, taxes, depreciation, and amortization
Medicare beneficiaries
Eligible individuals age 65 & older• Eligible individuals under age 65 & permanently disabled• Eligible individuals under age 65 with end stage renal disease (ESRD, permanent kidney failure) or amyotrophic lateral sclerosis ("Lou Gehrig's/ALS" disease)
Medicaid beneficiaries
Eligible individuals are low income:• Pregnant women & children• Families with dependent children• Blind, disabled, or elderly with federal Supplemental Security Income (SSI)
EMTALA
Emergency Medical Treatment and Active Labor Act
ER
Emergency Room
the difference between Medicare and Medicaid
Medicare- Federally-funded program• Overseen by Secretary of Health & Human Services (HHS)• CMS (Centers for Medicare and Medicaid Services) responsible for day-to-day administration of the program Medicaid- Funded jointly by Federal and State Governments• Day-to-day administration performed at state level• CMS (Centers for Medicare and Medicaid Services) establishes certain guidelines & parameters that each state program must abide by
liabilities
Money (capital) borrowed from either banks in the form of a line of credit or from investors in the form of bonds.
Understand the current and future funding challenges for Medicare and Medicaid, including what the "drivers" behind those challenge
More people accessing benefits• Fewer people contributing taxes• Longer life expectancy• Increasing healthcare costs
NICU
Newborn Intensive Care Unity
PPACA
Patient Protection and Affordable Care Act
PICU
Pediatric Intensive Care Unit
PPO
Preferred Provider Organization
Understand the levels of care within the acute care segment
Primary-the first step, The ER, primary care physicians Secondary- overnight visits Tertiary- ICU, life or death Quaternary- research and teaching
Understand who the major payers are in the healthcare industry
Private/self-pay Government- federal (Medicare-old or disabled) & state(Medicaid-poor) Traditional Health insurance and managed care companies
Anti-Kickback Statute (AKS) / Legislation of 1972
Prohibits asking for or receiving anything of value to induce or reward referrals of federal healthcare program business (namely CMS and may include health services, drugs, and supplies).
Ethics in Patient Referrals Act or Physician Self-referral ("Stark") Legislation
Prohibits physicians from referring CMS patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician's immediate family has a financial relationship-unless an exception applies.
PPS
Prospective Payment System
For Profit and Not-for-Profit healthcare organizations Similarities
Provide charity (free) care Many are very profitable; some are not profitable • Utilize collection efforts, including legal action, to collect payment • Provide treatment to low income government program patients (Medicaid) • Abide by all legal and regulatory requirements of hospitals
Understand the distinguishing characteristics of the Public and Private healthcare Sectors
Public health comprises health policies and administration, health education, and behavior and epidemiology. Private is about the non-government sections of healthcare- How lovely and cute is home. Acute-care hospitals, ambulatory surgery centers, physicians' clinics, inpatient or outpatient rehabilitation centers, long-term care facilities, and Hospice and Palliative care organizations. Hospitals, long-term care facilities, ambulatory surgery centers, clinics, inpatient and outpatient care, and hospice.
Emergency Medical Treatment and Active Labor Act (EMTALA)
Requires hospitals that have emergency departments to: 1. Provide a medical screening exam (MSE) by a qualified medical professional 2. If the patient has an emergency medical condition, to provide stabilizing medical treatment to any person who presents at the hospital regardless of the patient's ability to pay.
how insurance works
Equitable transfer of risk of a loss from one entity to another in exchange for payment
individual advocacy groups that represent For Profit
FAH
False Claims Act (FCA)
FCA protects the Federal Government from being overcharged or sold substandard good or services.
FAH
Federation of American Hospitals
FFS
Fee for Service
Understand the concept of "governance" as it relates to healthcare organizations
Governance means to lead over or control. Hospitals have governing boards that are in charge of leading the hospitals.
GPO
Group Purchasing Organization
Health Insurance Portability and Accountability Act (HIPAA)
HIPPA was preceded by a law passed in 1986 called the consolidated omnibus budget reconciliation act or COBRA. COBRA allows employees to continue group health insurance coverage after employment terminated. HIPAA eliminated or reduced insurance waiting periods for new employees. HIPAA defines standards for electronic healthcare data transactions so it can easily be shared. HIPAA requires protection of health information.
HIPAA
Health Insurance Portability and Accountability Act
HMO
Health Maintenance Organization
HFMA
Healthcare Financial Management Association
examples of multi-hospital systems
Hospital Corporation of America (HCA) - Nashville, Tennessee Intermountain Healthcare, Inc. (IHC) - Salt Lake City, Utah
Understand the organizational structure of a hospital; including the difference between the "hospital staff" and the "medical staff"
Hospital staff is janitors, lunch ladies, nurses, receptionists etc., employed by the hospital Medical staff is doctors and physicians, often not employed by hospitals, were credentialed and privileged to work at hospital by governing board
Understand the structure of the Private healthcare sector
How Lovely And Cute Is Home Hospitals Long term care ambulatory surgery centers clinics inpatient and outpatient hospice
IRB
Institutional Review Board
ICU
Intensive Care Unit
ISO
International Organization for Standardization
the economic effects of medical malpractice on the healthcare industry
It increases the cost of healthcare. It is expensive.
Structure of the Healthcare Industry
It is divided into two sectors- the private and the public sector. Public health is made up of- health policies and administration, health education and behavior and epidemiology. Private is about the non-government sections of healthcare- How lovely and cute is home. Acute-care hospitals, ambulatory surgery centers, physicians clinics, inpatient or outpatient rehabilitation centers, long term care facilities, and Hospice and Palliative care organizations. Hospitals, long term care facilities, ambulatory surgery centers, clinics, inpatient and outpatient care, hospice.
how Medicaid is administered and how it is funded
Jointly funded between Federal & State- 40 expanded states 90fed/10sta expanded. Nonexpanded- 55fed/45 state run by the state
The Patient Protection and Affordable Care Act ("Obamacare", ACA, PPACA)
Key provisions- Medical expansion, individual mandate, employer mandate, insurance exchanges, qualifying health plans/ essential health benefits objectives- Overall goal to decrease the number of uninsured Americans. Reduce steadily increasing healthcare spending.
Be familiar with the "U.S. Healthcare Industry Diagram" and be able to identify the diagram's main components
1. Government - US Department of Health and Human Services and individual state departments of health 2. Patients- categorized by payer - employer insured, individual market insured, CMS Medicare, CMS/state Medicaid & uninsured 3. Healthcare providers - acute care, post-acute care, outpatient care, long-term care, and home health 4. Peripheral entities -insurance industry, 3rd party organizations, suppliers, and manufacturers.
For Profit and Not-for-Profit healthcare organizations Differences
48% Not-for-Profit - A corporation that has a charitable purpose is tax-exempt, & has no owners, organizational premise, is more likely to be charitable, and more likely to be in education and teaching, AHA, stakeholders 21% For-Profit- A corporation that is owned by shareholders/investors who supply capital & expect to earn a return on their investment, business premise, FAH
Understand the concept of a fiduciary relationship
A fiduciary is a relationship of trust between two parties where one party is responsible for certain assets of the other party. Someone who has special responsibilities in connection with the administration, investment, monitoring, and distribution of tangible assets/property
co- payment
A fixed amount, such as $25, that a member must pay out-of-pocket for a medical service or prescription
equity
A stock/share representing an ownership interest; amount of funds contributed by the owner
Professional organizations
ACHE, HFMA, ANA, AORN, HIMSS
individual advocacy groups that represent Not-for-Profit hospitals
AHA
ACO
Accountable Care Organization
ADLs
Activities of Daily Living
Understand the concept of Activities of Daily Living within the long-term care segment
Activities of daily living- brushing your teeth, putting on socks, cleaning, shampooing your hair, clipping your nails, going to the bathroom, eating...
Understand the types of acute care and long-term care providers
Acute care segment- Hospitals, ambulatory surgery centers, clinics, and medical groups- Long-term care- Patients homes, assisted living facilities, nursing homes, skilled nursing facilities-
Understand the distinguishing characteristics acute care and long-term care
Acute care segment- Hospitals, ambulatory surgery centers, clinics, and medical groups- the purpose is to diagnose treat, and cure Long-term care- Patients homes, assisted living facilities, nursing homes, skilled nursing facilities- the purpose is basic and instrumental ADLs activities of Daily living
the drivers of high-cost healthcare
Administrative costs, Drug costs, Defensive medicine, Expensive mix of treatments , wages and work rules, and Branding. ADD EWB
capital
An expense (purchase) that is over $3,000 and will be used on more than one patient.
asset
An item that either possesses or creates an economic benefit for the organization.
what constitutes a multi-hospital system
Any combination of two or more acute-care facilities under one ownership entity. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more, and at least 25%, of their owned or leased non-hospital pre-acute or post-acute care health care organizations
Medical Staff Credentialing and Privileges
Applies to Physicians preformed by hospital governing board or Board of trustees Mandatory Criteria used medical staff bylaws
Accreditation
Applies to facilities preformed by The Joint Commission (TJC) DNV- Healthcare, Healthcare Facilities accreditation program HFAP voluntary criteria used the Joint commision standards, ISO standards, CMS conditions of participation DNV
CMS Certification
Applies to facilities and medical professionals Preformed by state health department or accreditation organization with deemed status Mandatory to treat and bill Medicare and Medicaid patients Criteria used CMS conditions of participation or accreditation organization's standards
Physician Board Certification
Applies to physicians Preformed by American board of medical specialties ABMS Voluntary Criteria used specialty board utilizing ABMS approved examinations
the main aspects of the Patient Protection and Affordable Care Act, including their effect on the healthcare industry
Medicaid Expansion • Individual Mandate • Employer Mandate• Insurance Exchanges (along with subsidies) • Qualifying Health Plans/Essential Health Benefits Objectives:• Overall goal to decrease the number of uninsured Americans• Reduce steadily increasing healthcare spending
MD
Medical Doctor
Know what bylaws are and how they apply to a governing body
bylaws are rules that the hospital follows
the history of Medicare and Medicaid
The Medicare & Medicaid Programs• Established through 1965 Medicare amendments to the Social Security Act (Title XVIII).
net income
The amount of money that is left over after all expenses are deducted
deductible
The amount of out-of-pocket costs that must be paid by the member before any portion is paid by the health plan
expense
The cost of doing business. Or the dollar amount of resources used in providing services.
Understand the current state of the healthcare industry, including some of the more prevalent challenges
The current state of the healthcare industry is not great. There is a lot of money being spent and wasted, malpractice and medical errors occur. there is a lack of communication and obesity and diabetes are on the rise which complicates a lot of treatment and diagnosis. People are forgetting the simple things like policy's, handwashing and communicating.
contractual allowances
The differences offered to insurance companies, and the difference between what is charged and Medicare's or Medicaid's fixed fee schedule that must be deducted from Gross Revenue.
net revenue
The dollar amount of revenue after deductions from gross revenue; the amount of cash a healthcare organization can expect to collect
Understand the relationship between a governing board, management, and the Medical Staff
The governing board is at the top then the management or ceo is in charge of the day-to-day stuff and the medical staff follows the governing board and the ceo
premium
The money paid to a health plan for coverage by the insurer
Understand the different types of medical schools and the "types" of physicians they "Produce"
Traditional medical schools produce MDs medical doctors Osteopathic medical schools produce DOs or Doctors of osteopathy Podiatric medical schools produce DPMs or podiatrists Chiropractic medical schools produce chiropractors
the various types of health insurance and how they work
Traditional- Insurance company pays a set amount of money in the event of a loss or claim• Beneficiaries can go to any licensed provider (greatest flexibility, but expensive) Managed Care- in addition to paying for claims, managed care utilizes methods to reduce the number of visits, reduce costs, and improve quality, three types-HMO, PPO, POS
HHS
US Department of Health and Human Services
FDA
US Food and Drug Administration
Tort
a civil wrong committed against a person or property.
what constitutes a vertically integrated healthcare network
a group of hospitals, as well as physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community. Their own insurance
Understand how a physician becomes educated, licensed, board-certified, credentialed and privileged at a hospital; including the distinct difference between each
medical school> Internship/ residency (obtain medical license)>optional fellowship> board certification To be Credentialed- applies> hospital staff review> medical staff review> credentialing committee review> CEO or executive staff review> the board reviews> Grants privileges
capitalization
moving an expense from the income statement to the balance sheet
the sources of funding for hospitals and healthcare organizations
rendering services to patients, gift shop sales, research grants, donations, and earnings on investments
CEO
Chief Executive Officer
CFO
Chief Financial Officer
CNO
Chief Nursing Officer
COO
Chief Operating Officer
CBO
Congressional Budget Office
deduction from gross revenue
Contractual allowances Bad debt Charity care
how Medicare is structured, including its various "parts" and how each "part" is funded
Part A- payroll tax> HI fund> hospitals, skilled nursing facilities and home health Part B- premiums and income tax> SMI fund> physicians, outpatient, home health, mammography Part C- medical advantage AB and often D, offered by private healthcare, fixed payment, premium, pa Part D-premiums and income tax>SMI> drugs
DRG
Diagnosis-related Group
DCM
Doctor of Chiropractic Medicine
DO
Doctor of Osteopathy
DPM
Doctor of Podiatric Medicine
OIG
Office of Inspector General
OR
Operating Room
shareholders
Owners in investor-owned corporations
Know the difference between a professional organization and advocacy organization
Advocacy organizations are groups that speak for the interests of another group, and their legal and political representation through lobbying and legislation (AMA, AHA, FAH) Professional organizations are there to advance the professional careers of their members (ACHE, HFMA, AORN, HIMSS, ANA)
Understand the advocacy organizations within the healthcare industry
Advocacy organizations-The American Medical Association (AMA), The American Hospital Association Not-For-Profit (AHA), The Federation of American Hospitals For-Profit (FAH)
Be able to identify which organizations (and their acronyms) covered in class are considered professional and which are considered advocacy
Advocacy organizations-The American Medical Association (AMA), The American Hospital Association Not-For-Profit (AHA), The Federation of American Hospitals For-Profit (FAH) Professional organizations- American College of Healthcare Executive (ACHE), Healthcare Financial Management Association (HFMA), Association of Operating room nurses (AORN), Healthcare information and management systems society (HIMSS), American Nursing Association (ANA)
ASC
Ambulatory Surgery Center
ABMS
American Board of Medical Specialties
ACHE
American College of Healthcare Executives
ACS
American College of Surgeons
AHCA
American Health Care Association
AHA
American Hospital Association
AMA
American Medical Association
ANA
American Nursing Association
Understand the main governmental organizations that comprise the Public Healthcare Sector
Center for Disease control (CDC), Food and Drug Administration (FDA), Center for Medicare and Medicaid services (CMS), Office of Inspector General (OIG)
CDC
Centers for Disease Control and Prevention
CMS
Centers for Medicare and Medicaid Services
CRNA
Certified Registered Nurse Anesthetist
CCU
Critical Care Unit
the reasons why hospitals and healthcare providers integrate
Cuts costs because you can share equipment, reduce admin costs and realize purchasing economics. Marketing benefits. Lowers transaction cost. Offers Stability. Reduces uncertainty about the quality of care and other aspects. Many argue integration leads to lower costs through economies of scale (debatable) • Achieve improved quality through better clinical coordination • Achieve leverage with insurance companies • Improve market share via controlling patient referrals • Better access to capital (financing)
examples of vertically integrated healthcare Networks
Sentara- when multi-hospital systems also dip into other areas like long term care and peripheral entities. Sentara has its own network of physicians.
Understand what organization oversees and grants physician board certification
The American Board of Medical specialties ABMS
TJC
The Joint Commission
Gross Revenue
The total dollar amount of all billed charges generated from providing healthcare services.
Licensure
This applies to facilities and medical professionals Preformed by state licensing board Mandatory Criteria used- state law stipulating minimum requirements for licensure and provider licensure info
depreciation
an accounting procedure for spreading the cost of a capital item over its estimated useful life (recorded on an income statement
Understand how a governing board functions, including the difference between "governance" and "management"
governance is ultimate authority and management is more advice.
Understand what types of individuals become physicians and what they value
highly motivated people, value helping others and the lifestyle.
stakeholders
the people whose interests are affected by an organization's activities
how a healthcare organization (hospital) measures their financial well-being utilizing the Income Statement
the take revenues(money coming in) minus expenses (money going out) to find the profitability or the profit/loss.
how Medicare payments to hospitals have evolved since its inception and how Medicare currently pays hospitals
they used to pay all costs and now they pay a set cost using DRGs
what can potentially qualify as medical malpractice
unintentional torts/ negligence = medical malpractice