Chapter 13

What are the difference between allopathic and non-allopathic health care providers?

-Allopathic providers- Produce effects different from those of diseases (MD) -Osteopathic providers- More holistic; focus on relationship between body structure and function (DO) -Non-allopathic providers- Independent providers who provide non-traditional forms of health care

What is the difference between complimentary and alternative medicine? Give examples of each

-Complementary Medicine- Using a non-mainstream approach together with conventional medicine (acupuncture with medicine to help lessen pain) -Alternative Medicine- Using a non-mainstream approach in place of conventional medicine (using a special diet to treat cancer instead of chemotherapy)

Explain how each of the following types of reimbursement works: fee-for-services, packaged pricing, resource-based relative value scale, capitation, and prospective reimbursement

-Fee-for-service: A method of paying for health care in which after the service is rendered, a fee is paid - Packaged Pricing: Several related health services are included in one price - Resource-based relative value scale: Reimbursement to physicians according to the relative value of the service provided - Capitation: A method of paying for covered health care services on a per-person premium basis for a specific time period prior to the service being rendered - Prospective Reimbursement: Uses pre-established criteria to determine in advance the amount of reimbursement

What are the advantages and disadvantages of managed care?

-Healthcare costs are usually contained -Established fee schedules are used -Authorized services are usually paid for -Most preventative medical treatment is covered -Patient's out-of-pocket expenses tend to be less than with traditional insurance

What is the difference between independent and limited (restricted) care providers?

-Independent care providers- Specialized education and legal authority to treat any health problem or disease -Limited care provider-Advanced training in a health care specialty

What is the difference between LPNs and RNs?

-Licensed Practical Nurse (LPN)- Those prepared in 1- to 2-year programs to provide non-technical bedside nursing care under the supervision of physicians or registered nurses -Registered Nurses (RN)- One who has successfully completed an accredited academic program and a state licensing examination

What are 3 major problems facing the health care system in the US?

1. Cost containment 2. Access 3. Quality

What are the domains of practice noted in the spectrum of health care?

1. Public health practice-Incorporates interventions aimed at disease prevention and health promotion, specific protection, and a good share of case findings 2. Medical practice- Those services usually provided by or under the supervision of a physician or other traditional health care provider 3. Long-term practice- Restorative care and long-term care for chronic conditions 4. End-of-life practice-Services provided shortly before death

In what type of facility are most health care workers employed?

39% work in hospitals, 26% work in outpatient health care settings, 20% in nursing/residential care, and 8% in home health services

Explain the following insurance policy provisions: a $500 deductible, 20/80 co-insurance, a $4,500 fixed indemnity for a basic surgical procedure, an exclusion of the pre-existing condition of lung cancer, and a $10 copayment

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Zubik v. Burwell

A case before the United States Supreme Court on whether religious institutions (other than churches) should be exempt from the contraceptive mandate, a regulation adopted by the US Department of Health and Human Services (HHS) under the Affordable Care Act (ACA) that requires non-church employers to cover certain contraceptives for their female employees

What is a physician assistant?

A health care professional who practices medicine with physician supervision

Exclusion

A health condition written into the health insurance policy indicating what is not covered by the policy

What is meant by third-party payment?

A health insurance term indicating that bills will be paid by the insurer and not the patient or the health care provider; the standard method of payment in the U.S.

Pre-existing condition

A medical condition that had been diagnosed or treated usually within the 6 months before the date a health insurance policy goes into effect

Copayment

A negotiated set amount that a patient pays upfront for a certain service

What are advanced practice registered nurses (APRNs)?

A nurse who has obtained a master's or doctoral degrees

Premium

A set amount of money for regular, periodic payments

Policy

A written agreement between a private insurance company and an individual or group of individuals to pay for certain health care costs during a certain time period in return for regular, periodic payments

What is covered in each of the 4 parts of Medicaid- Parts A, B, C, and D?

A- hospital insurance B- medical insurance C- managed care plans D- prescription drug plans *A & B are guaranteed, C is not available everywhere and D is optional

What is the Children's Health Insurance Program (CHIP)?

CHIP: A title insurance program under the Social Security Act that provides health insurance to uninsured children

What kind of education do limited (restricted) care providers have?

Limited (restricted) care providers have advanced training and usually a doctoral degree in a health care specialty

Describe some of the major changes that have taken place in health care delivery over the years

Health care in the United States has evolved from home and folk remedies to the services of the independent doctor who often visited the sick in their homes to a highly complex almost $3 trillion plus industry. Also, doctors are more specialized and new procedures have been developed

Briefly explain the differences among health maintenance organizations (HMOs), preferred provider organizations (PPOs), and a point-of-service (POS) option

Health maintenance organizations (HMOs): Groups that supply prepaid comprehensive health care with an emphasis on prevention Preferred provider organizations (PPOs): An organization that buys fixed-rate health services from providers and sells them to consumers Point-of-service (POS): An option of an HMO plan that enables enrollees to be at least partially reimbursed for selecting a health care provider outside of the plan

What is meant by the consumer-directed health plans? Give some examples

Health plan options that combine more consumer responsibility for decisions with a tax-sheltered account to pay for out-of-pocket costs for health care and a high-deductible health insurance policy Ex: Health Savings Account

King v. Burwell

King v. Burwell centered on whether plaintiffs' arguments that middle- and low-income adults who purchased health insurance through the federally run Healthcare.gov marketplace were entitled to subsidies based on the language of the law that says tax credits are only to be distributed for marketplaces established by the state

What is meant by a long-term care facility? Give 2 examples

Long-term care facility- Includes not only the traditional institutional residential care, but also special units within these residential facilities Ex: Nursing homes, group homes, transitional care, day care, home health care

What is the difference between Medicare and Medicaid?

Medicare- Federal health insurance program for those 65+ Medicaid- Health insurance program for low-income, no age requirement

What relationship does Medigap insurance have to Medicare?

Medigap fills in the gaps left from Medicare

Why have some questioned whether the US really has a health care system?

Other developed countries have national health insurance run or organized by the government and paid for mostly by taxes. Also, in these countries, almost all citizens are entitled to receive free health care services (routine and basic health care). Health care in the United States is delivered by an array of providers and paid for in a variety of ways, which is why some questioned whether the United States really has a health care system

What are the advantages of outpatient care facilities?

Outpatient care facility- Facility where a patient receives ambulatory care without being admitted as an impatient Advantages of outpatient care facilities: low investment and more profit for the facility providers compared with inpatient facility, convenient for patients and facility providers, low cost and efficient facility for the patients, patient stress levels will decrease because of less time in hospital environment, and scheduling for outpatient is more easy and predictable

What role do public health professionals play in health care delivery?

Public health professionals work in public health organizations that are available to everyone and provide primary service to the economically disadvantaged

What is meant by spectrum of health care?

Refers to the various types of care; four levels of practice have emerged: population-based public health practice, medical practice, long-term practice, and end-of-life practice

Burwell v. Hobby Lobby Stores

Ruling allows closely held for-profit corporations to be exempt from a regulation its owners religiously object to, if there is a less restrictive means of furthering the law's interest, according to the provisions of the Religious Freedom Restoration Act (RFRA)

How is the quality of health care services measured?

The Agency for Health care Research and Quality (AHRQ) and the National Health care Quality Report (NHQR) measure quality

National Federation of Independent Business v. Sebelius (2012)

The Patient Protection and Affordable Care Act's expansion of Medicaid is unconstitutional as-written—it is unduly coercive to force the states to choose between participating in the expansion or forgoing all Medicaid funds. In addition, the individual health insurance mandateis constitutional, by virtue of the Taxing and Spending Clause (though not by the Commerce Clause)

Deductible

The amount of expenses that the beneficiary must incur before the insurance company begins to pay for covered services

On what basic concept is insurance based?

The concept of insurance has everyone in the group, no matter what their individual risk, helping to pay for the collective risk of the group

Why has the cost of health care in the US continued to grow faster than the cost of inflation?

The cost of health care in the US has continued to grow faster than the cost of inflation because there is: Ever-newer technology being developed, ever-increasing demands for the best care, growing medical liabilities, new diagnostic procedures, increased length of lifespans, development of new drugs, and newly identified diseases, which all put great demands on the system

What is the major result of the Affordable Care Act passed in 2010?

The major result of the passing of the Affordable Care Act was that many Americans now had access to Health Insurance. They now felt more secure and in a better position to take care of themselves

Fixed Indemnity

The maximum amount an insurer will pay for a certain service

Why has the number of home health care agencies increased in recent years?

The number of home health care agencies has increased in recent years because of restructuring of health care system, technological advances that enable people to be treated outside of hospitals, and cost containment pressures that have shortened hospital stays

Co-insurance

The portion of the insurance company's improved amounts for covered services that a beneficiary is responsible for paying

What is The Joint Commission? What does it do?

The predominant organization responsible for accrediting health care facilities; certifies more than 20,000 health care organizations and programs in the United States & other countries

Is there a demand for health care workers in the US today? If so, why?

There is a demand for health care workers in the US today because of the geographic maldistribution of health care workers (greatest needs in inner-cities and rural areas)