HA Final Review
Information blocking
A practice by some electronic health record providers and developers that actively blocks transfer of electronic information between institutions with different electronic systems
Financial risk-sharing
A practice that transfers some measure of financial risk form insurers to providers and 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. Deductibles require beneficiaries to meed predetermined, out-of-pocket expenditure levels before an insurer assumes payment responsibility. This by providers bases their reimbursement levels on insurer-determined parameters related to costs, patient treatment outcomes, and other factors for defined population groups
Integratie medicine
A treatment approach that brings conventional medicine and complementary medicine together in a coordinated manner
Maintenance of Certification (MOC)
An American Board of Medical Specialists (ABMS) requirement on ongoing, educational programs and recertification examinations every 10 years in each of the specialities and subspecialties in which a physician is certified. The requirements culminate in an ABMS- sponsored board certification examination 10 years after first receiving certification and every ten years thereafter
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
Extends funding for Medicaid's Children's Insurance Program (CHIP) for two years and establishes a physician payment schedule that predictably specifies the inflation rate for Medicare physician reimbursement. This also promotes paying for value and quality of care rather than quantity through programs streaming physicians participation in quality reporting and payment incentives using the merit based incentive payment system (MIPS) and alternative payment models (APMs)
Disproportionate share hospital (DSH) payment
Federal law requires these Medicaid payments to states for hospitals serving large numbers of Medicaid and low-income, uninsured individuals. The law establishes an annual allotment for each state. These payments provide critical financial supplements to hospitals serving the neediest populations
Descriptive studies
Identify factors and conditions that determine the distribution of health and disease among specific populations using patient records, interview surveys, various databases, and other information sources to provide the details or characteristics of diseases or biologic phenomena and the prevalence or magnitude of their occurrence. These are relatively fast and inexpensive and often raise questions or suggest hypotheses to be tested by analytic studies.
Experience-rated insurance
Insurance plans that use historically documented patterns of healthcare service utilization for defined populations of subscribers to determine premium charges
Health information administrator
Responsible for the activities of the medical records departments of hospitals, skilled nursing facilities, manages care organizations, rehabilitation centers, ambulatory care facilities, and other licensed healthcare entities. They maintain information 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 this is the entry-level credential
Ambulatory Care
Services that do not require an overnight hospital stay
Explicit quality standards
Standards that are professionally developed and agreed on in advance of a quality assessment. These minimize the variation and bias that result when judgements are internalized
Deinstitutionalization
The mental health movement beginning in the 1960s through which severely mentally ill patients previously confined to large state or county psychiatric hospitals were discharged to community boarding or nursing homes. The movement marked a major shift or mental health service provision from primarily inpatient settings to community-based facilities
Employer Mandate
Under the ACA, it requires all businesses with 50 or more full time equivalent employees to provide health insurance to at least 95 percent of their full time employees and dependents up to age 26, or pay a fee by 2016. Employers are subject to a $2,000 fee per full time employee (in excess of 30 employees). The mandate does not apply to businesses with 49 or fewer employees
Individual mandate
Under the ACA, the requirement that all American citizens (with specific exclusions) obtain health insurance coverage or pay a penalty
Diagnosis-Related groups (DRGs)
A case payment system that radically changed hospital reimbursement, shifting hospital reimbursement from the retrospective to a prospective basis. Provided incentives for the hospital to spend only what was needed to achieve optimal patient outcomes. If outcomes could be achieved at a cost lower than the present payment, the hospital retained 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 non-governmental health insurers.
National Center for Complementary and Integrative Health (NCCIH)
A center of the National Institutes of Health devoted to defining, through rigorous scientific investigation, the usefulness and safety of complementary and integrative interventions and providing the public with research-based information to guide health care decision making
Health information Technology for Economic and Clinical Health Act (HITECH Act)
A component of the American Recovery and Reinvestment Act of 2009 dedicated to promoting nationwide adoption and use of electronic health records
Managed behavioral healthcare organization (MBHO)
A corporate entity to which a health plan may outsource the management of mental health services for its subscribers. This assumes the financial risks and benefits of mangling treatment budgets and authorization for access to mental health services
Healthcare effectiveness data and information set (HEIDS)
A data collection and aggregation system that 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. This has evolved through several stages of development and continuously refines its measurement through rigorous reviews and independent audits
Ambulatory surgery center (ASC)
A facility performing surgical and nonsurgical procedures on an ambulatory (outpatient) basis in a hospital or freestanding center's general operating rooms, dedicated ambulatory surgery rooms, and other specialized rooms such as endoscopy units and cardiac catheterization labs
Indemnity insurance
A form of insurance in which the insurance company sets allowable charges for services that it will reimburse after services are delivered and allows providers to bill patient for an 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 coordinate care for the patients they serve under the original Medicare (not Medicare Advantage managed care) program. The ACA enables this to share in savings to the federal government based on performance in improving quality and reducing healthcare costs.
Aging in Place
A healthcare system that brings together a variety of health and other supportive services to enable order, frail adults to live independently inter own residences for as long as safely possible
Capitation
A managed care reimbursement method that prepays providers for services on a per-member per-month basis whether or not services are used. If providers exceed the predetermined amount, they may incur a financial penalty. If providers use fewer resources than predicted, they may retain the excess as profit.
Natural history of disease
A matrix used by epidemiologists and health services planners that places everything known about a particular disease or condition in the sequence of its origin and progression when untreated. The matrix identifies causes and stages of a particular disease or condition and facilities matching of causes and stages with appropriate types of interventions intended to prevent the conditions occurrence or to arrest its progress after onset
Alternative payment model (APM)
A model through which physicians and other healthcare providers accept a measure of financial risk and are reimbursed based upon prudent resource use and the quality of patient outcomes rather than on a piecemeal fee-for-services basis. An example includes bundled payments for care and accountable care organizations
Hospice
A philosophy supporting a coordinated program of care for the terminally ill that focuses on maintaining comfort and quality of life. The most common criterion for admission into this is a diagnosis of a terminal illness with a limited life expectancy of six months or less
Hospitalist
A physician, typically board certified in internal medicine, who specializes in the care of hospital patients. May be an employee of one or more hospitals or an employee of one or more companies that contract with hospitals to provide services.
Carve-out
A process through which insurers outsource subscribers' mental illness care oversight to firms specializing in managing service use for mental health diagnosis
Accreditation
A process whereby a professional organization or non-governmental agency grants recognition to a school, educational program, or healthcare institution for demonstrated ability to meet predetermined criteria for established standards. This contrasts with certification, which is a process through which a state or professional organization attests to an individuals advanced training and performance abilities in a field of healthcare practice.
Assisted living
A program that provides and/or arranges for daily meals, personal and other supportive services, health care, and 24 hour oversight to persons residing in a group residential facility who need assistance with the activities of daily living
Medicare Advantage
A program through which Medicare beneficiaries may have their benefits administered by managed healthcare organizations (MCOs)
Case series
A published summary of a small number of individual cases in the biomedical literature that usually occur for extremely rare conditions or for new illnesses or syndromes and often when the diagnosis is unknown, typically without rigorous analyses. Generally are developed by experts and undergo peer review before they are published
Certification
A regulatory process, much less stringent that licensure, under which a state or professional organization attests to an individuals advanced training and performance abilities in a field of healthcare practice. Specific professions set certification standards for approval by their respective state or professional organizations.
Health services research
A research field combining perspectives and methods of epidemiology, sociology, economics, and clinical medicine. This also uses process and outcome measures reflecting behavioral and economic variables associated with questions of treatment effectiveness and cost-benefit
Academic Health Center
A university affiliated complex of professional, academic, and clinical care facilities such as medicine, nursing, pharmacy, density, and allied health professions that are the principal places of education and training for physicians and other healthcare personnel, the sites for most basic medical research, and the settings for clinical trials. These teaching hospitals are major providers of highly sophisticated patient care required by trauma centers; burn centers; neonatal intensive care centers; and the technologically advanced treatment of cancer, heart disease, and neurological and other acute and chronic conditions. These teaching hospitals also provide much of the primary care for the economically disadvantaged population in their geographical area.
Monolithic model of health information exchange
An HIE design in which all member institutions send clinical data to one central repository where all data reside together in one universal and standardized format. In this model, authorized users may access individual, trans-institutional patient records from the central repository
Federated model of health information exchange
An HIE design in which member institutions maintain their own data as their respective sites in the standardized format used by an HIE. In this model, individual, trans-institutional patient records are assembled in real time by searching all institutions' databases only when requested by authorized users for a particular episode of care
Computerized decision support system (CDSS)
An electronic information based system in which individual patient data is matched with a computerized knowledge base such as evidence based clinical practice guidelines, to assist healthcare providers in formulation accurate diagnoses, recommendations, and treatment plans. May generate "hard stops" to prevent a disallowed practice or severe errors or "soft stops" that warn of less severe errors and allow physicians to choose to ignore or follow the warning
American Board of Medical Specialties (ABMS)
An independent, not-for-profit organization, assists in 24 specialty member boards to develop and utilize professional and educational standards that apply to the certification of physician specialties in the United States and internationally
Long-term care facility (LTCF)
An institution such as a nursing home, skilled nursing facility (SNF), or assisted living facility that provides health care to people who are unable to manage independently in the community. Care may represent custodial or chronic care management or short-term rehabilitative services
Health systems agency (HSA)
An organization created by the National Health Planning and Resources Development Act of 1974 that included broad representation of healthcare providers and consumers on governing boards and committees to deliberate and recommend healthcare resource allocations to their respective federal and state governing bodies
Naturally occurring retirement community (NORC)
Apartment complexes, neighborhoods, or sections of communities where residents have opted to remain in their homes as they age
Laboratory technologists and technicians
Clinical laboratory personnel who analyze body fluids, tissues, and checks checking for bacteria and other micro organisms; analyze chemical content of fluids; test drug levels in blood to monitor the effectiveness of treatment; and match blood for transfusion. Technologists have a bachelor's or higher degree; technicians may hold associates degrees or certificates
Assessment (as a core function of public health)
Collecting and analyzing data to define population health status and quantity existing or emerging health problems
Federally qualified health center (FQHC)
Community-based primary care center staffed by a multidisciplinary team of health care and related support personnel, with fees adjusted based on ability to pay. These also provide services to link patients with other community resources. Funded by the Health Resources and Services Administration to serve the neediest populations, these must meet specific operating parameters and may be organized as part of a local health department, a larger human services organization, or a stand-alone, not-for-profit agency
Electronic health record (EHR)
Computerized patient records that essentially replace paper charts
Basic science research
Conducted by biochemists, physiologists, biologists, pharmacologists, and others concerned with sciences that are fundamental to understanding the growth, development, structure, and functions of the human body and its responses to external stimuli. Much of this is conducted at the cellular level
Horizontal Integration
Consolidation of two or more hospitals or other entities under one owner through merger or acquisition
Clinical Observation Unit (COU)
Dedicated locations adjacent to hospital EDs to as beds located in other areas of the hospital, COU's use a period of 6-24 hours to triage, diagnose, treat and monitor patient responses while common complaint such as chest pain, abdominal pain, cardiac arrhythmias, and congestive heart failure are assessed
Empirical quality standards
Derived from distributions, averages, ranges, and other measures of data variability, these compare information collected from a number of similar health service providers to identify practices that deviate from norms.
Bundled payment for care initiative (BPCI)
Developed by the CMS Center for Medicare and Medicaid Innovation (CMMI) that was created by the ACA; Recognize that separate Medicare fee-for-service payments for individual services provided during a beneficiary's single illness result in fragmented care with minimal coordination across providers and settings, rewarding service quality. They are testing whether, as prior research has shown, payments for bundled "episodes of care" an align incentives for hospitals, post-acute care providers, physicians, and other healthcare personnel to collaborate across many settings to achieve improved patient outcomes at lower cost
Never events
Egregious medical errors occurring in hospitals, such as wrong-sided surgery, the treatment for which the DHHS will not provide reimbursement
Emergency Medical Treatment and Labor Act (EMTALA)
Enacted in the 1995 federal budget because of concerns about inappropriate patient transfers between hospitals prompted by payment considerations. This requires hospitals to treat everyone who presents in their emergency departments regardless of ability to pay. Stiff financial penalties and risk of Medicare decertification by hospitals inappropriately transferring patients, accompanies the EMTALA legal provisions
Children's Health Insurance Program (CHIP)
Establish by the balanced budget act of 1997, this targets uninsured, eligible children for Medicaid enrollment. It has successfully enrolled millions of children in Medicaid and has been re-funded continuously since its inception, including for two additional years through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
National Prevention, Health Promotion, and Public Health Council
Established by the ACA and chaired by the U.S. Surgeon General, an organization charged with developing and leading a national prevention strategy and making recommendations to the President and Congress for federal policy changes that support public health goals. The council provides leadership to and coordination of public health activities of 17 federal departments, agencies and offices and receives input from a 22 nonfederal member, presidentially appointed Prevention Advisory Group
National Health Care Workforce Commission (NHCWC)
Established by the ACA, this was mandated to evaluate and make recommendations for the nation healthcare workforce including education and training support for existing and potential new workers at all levels, efficient workforce deployment, professional compensation, and coordination among different types of providers. Congress has withheld funding, so the _________ has never commenced work.
HMO Act of 1973
Federal legislation enacted by the Nixon administration that provided loans and grants for the planning, development, ad implementation of combined insurance and healthcare delivery organizations and required that a comprehensive array of preventive and primary care services be included in this arrangement. By linking the payment for services with the quality of care, this paved the way for the proliferation on managed care principles that became the foundation of U.S. health insurance reform in the succeeding three decades.
High-deductible health plan (HDHP)
First dubbed "consumer-driven health plan", the plans are now known as ... The goals of this are to entice employees with lower premium costs in exchange for agreeing to make out-of-pocket up front payments for health services. This intends to encourage cost-consciousness about the use if healthcare services. Today, these are the second most common type of plan offered by employers with 24 percent of U.S. workers selecting this option
Graduate medical education consortia
Formal associations of medical schools, teaching hospitals, and other organizations involved in the training of medical residents. The consortia 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
Assurance (as a core function of public health)
Governmental public health agency responsibility to ensure that basic components of the healthcare delivery system are in place
Medicate Modernization and Prescription Drug Act of 2003 (MMA)
In addition to adding prescription drug coverage for Medicare beneficiaries, the Act established Medicare Advantage plans with new parameters to replace the Medicare + Choice option created by the Balanced Budget Act of 1997
Behavioral sceintist
Include professionals in social work, health education, community mental health, alcoholism and drug abuse services, and other health and human service areas. Bachelor's or master's level degree professionals in these fields counsel and support individuals and families in addressing the personal, economic, and social problems associated with illness, addictions, employment challenges, and disabilities
Informed consent
Legally recognized patient right, formalized in a document for a patient's signature, to ensure patients' understanding of the risks and benefits of a medical intervention
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, telemedicine, disease registries, risk satisfaction, proactive patient outreach, and performance feedback to providers. Programs may also use clinical specialists who provide monitoring and support to patients with disease management issues
Block grants
Mechanism to shift the federal government's direct support and administration of healthcare programs to state and local governments
Ecological models
Models that identify causes of public health problems rooted in the physical and/or social environment and behavior related to an individual. These take into account the vast number of determinants that affect the health status of groups of people and facilitate decisions about the most expeditious path to developing effective interventions.
Health information exchange (HIE)
Networks that enable exchange among basic levels on interoperability of patient information among electric health records maintained by individual physicians and healthcare organizations. These are organized and governed by regional health information organizations (RHIOs)
International medical graduates (IMGs)
Physicians trained in medical schools outside the United States who fill the annual shortfall in U.S. medical school graduates required to staff hospitals. Responsibility for evaluating credentials of this entering the United States residency programs lies with the Educational Commission for Foreign Medical Graduates
Clinical Research
Primarily focuses on steps in the process of medical care such as the early detection, diagnosis, and treatment of disease or injury; the maintenance of optimal, physical, mental, and social functioning; the limitation and rehabilitation of disability; and the palliative care of those who are irreversibly ill. Conducted by a variety of professionals in a medicine, nursing, and allied health, often in collaboration with basic scientists.
Computerized physician order entry (CPOE)
Process in which a physician enters patient treatment orders into an individual patients electronic health record
Institutional review board (IRB)
Professionally constituted expert groups of individuals who judge the merit of research studies and ensure appropriate and ethical participant safeguards are provided to protect research subjects safety. A primary function of this is to ensure fully informed consent and research subjects understanding of risks and benefits of participation.
Comparative effectiveness research
Research designed to inform healthcare decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. Evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care
Continuing care retirement community (CCRC)
Residences on a retirement campus, typically in apartment complexes designed for functional older adults. Unlink ordinary retirement communities that offer only specialized housing, this offers a comprehensive program of social services, meals, and access to contractual medical services in addition to housing
Implicit quality standards
Standards that rely on the internalized judgements of expert individuals conducting a quality assessment and as such are subject to variation and bias
Evidence-based clinical practice guidelines
Systematically developed protocols based on extensive research that are considered the most objective and least biased clinical practice guidelines. They serves as a means to assist in preventing the use of unnecessary treatment modalities and in avoiding negligent events, with patient safety and the delivery of high quality care as foremost priorities.
Analytic Studies
Test hypothesis and try to explain biologic phenomena by seeking statistical associations between factors that may contribute to a subsequent occurrence and the initial occurrence itself
Hill-Burton Act
The 1946 federal law that provided funding to construct new and expand existing U.S. hospitals
Health insurance marketplace (HIM)
The ACA required states to establish health benefit exchanges (now known as health insurance marketplaces, or HIMs) to facilitate individuals and small employers choice among health plans. With participation by insurance companies in each state, This created a competitive health insurance market by providing web-based, easily understandable, comparative information for consumers on plan choices and standardized rules regarding health plan offers and pricing
Balances Budget Act of 1997 (BBA)
The Act contained significant changes to Medicare and Medicaid. It extended healthcare coverage to uninsured children with a major funding allocation to a new Children's Health Insurance Program (CHIP). The Act also proposed to reduce growth in Medicare and Medicaid spending by $125.e billion in five years. It increased beneficiary premiums for Medicare Part B and required new prospective payment systems for hospital outpatient services, skilled nursing facilities, home health agencies, and rehabilitation hospitals. One of its most significant effects was opening the Medicare program to private insurers through the Medicare + Choice Program, by allowing financial risk sharing for the Medicare program with the private sector through managed care plans
Focused Practice in Hospital Medicine
The American Board of Internal Medicine educational program through which physicians already certified in the internal medicine specialty obtain certification as hospitalists
Medicare
The XVII amendment to the Social Security Act of 1935, this guarantees a minimum level of health insurance benefits to all Americans beginning to at age 65 (and other special needs groups without regard to age). This has four parts: A, B, C, and D, which cover (A) physician and outpatient services, (B) hospital care, (C) participation in manages care plans, and (D) prescription drugs. Most parts require beneficiary cost-sharing. These funds derive largely from payroll taxes levied on all American workers that are matched by their employers in equal amounts.
Meaningful use
The criterion defined by the ONC in collaboration with the Centers for Medicare and Medicaid Services that entails meeting a set of time-delineated requirements for eligible professionals and hospitals to qualify for incentive payments under the HITECH Act. In 2015 this criterion was redefined under the Medicare Access and CHIP Reauthorization Act
Agency for Healthcare Research and Quality (AHRQ)
The federal agency charged with research to develop and disseminate evidence-based-practice guidelines. This National Guideline Clearinghouse maintains an online database organized by searchable topics for more than 2000 evidence-based clinical practice guidelines that have met the evaluation criteria
Department of Health and Human Services (DHHS)
The federal governments principal agency concerned with health protection and promotion and provision of health and other human services to vulnerable populations. In addition to administering the Medicare and Medicaid programs, this includes 11 operating divisions
Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS)
The first national, standardized, publicly reported survey of patients perspectives of hospital care created by the Department of Health and Human Services. Results are publicly reported in the CMS "hospital compare" website
Accreditation Council for Graduate Medical Education (ACGME)
The independent, not-for-profit professional organization that accredits 3-7 year programs of advanced education and clinical practice required by physicians to provide direct patient care in a recognized medical specialty
Flexner Report
The landmark report resulting from a comprehensive review of the quality of education in U.S. and Canadian medical schools, funded by the Carnegie Foundation. Issued in 1910, the report was a searing indictment of most medical schools of the time. The report gave increased 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
Expert Opinion
The lowest or least rigorous form of evidence, but also the most commonly practiced; usually expresses the opinion of a medical specialist in an area of interest to a particular patient; it can occur formally, with a referral to a specialist by a patients primary care physician, or informally when physicians discuss a case or medical issue with a colleague via phone, email, or face-to-face in an informal setting
Continuing life care community (CLCC)
The most expensive go CCRC options. This offers unlimited assisted living, medical treatment, and skilled nursing care without any additional charges as residents needs change over time
National Committee for Quality Assurance (NCQA)
The most influential managed care quality assurance organization formed in 1979. This is the primary functions are accreditation for MCO's, PPO's, managed behavioral healthcare organizations, new health plans, and disease-management programs; certifying organizations that verify provider credentials and consultation on physician organizations; and utilization management for organizations, patient-centered medical homes, and disease-management organizations and programs
Licensure
The most restrictive form of health professional regulation administered by individual states. It defines a professionals scope of practice and educational and testing requirements to engage legally in the practice of a profession
Alternative Medicine
The practice of using non-mainstream treatment approaches in place of conventional medicine
Disability-adjusted life years (DALYs)
The total number of years of life lost to illness, disability, or premature death within a given population
Medicaid
Title XIX amendment to the Social Security Act of 1935, this is a joint federal/state program providing insurance coverage for a prescribed scope of basic healthcare services to Americans who qualify based on income parameters, established on a state-by-state basis. This is principally funded from federal grant funds with matching dollars to the states and state general funds. Unlike Medicare, which reimburses providers through intermediaries such as Blue Cross. This directly reimburses providers. Rate-setting formulas, procedures, and policies vary widely among states
Complementary medicine
Treatment that is not mainstream medicine but is used together with mainstream medicine. An example of this would be using acupuncture to treat allergies in addition to obtaining conventional allergy medication prescribed by an allergist.
Merit-based incentive payment system (MIPS)
Under the MACRA, combines three previous quality reporting programs into one reporting system, scoring eligible professionals (EPs) on quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. The composite MIPS performance score determines whether EPs will receive an annual upward, downward, or no payment adjustment.
Co-morbidity
When two disorders or illnesses occur in the same person, simultaneously, or one after another
Community-rated insurance
insurance plans in which all individuals in a defined group pay premiums without regard to age, gender, occupation, or health status. Help ensure nondiscrimination against groups with varying risk characteristics to provide coverage at reasonable rates for the community as a whole
Experimental studies
the investigator actively intervenes by manipulating one variable to see what happens with the other. Although they are the best test of cause and effect, such studies are technically difficult to carry out and often raise ethical issues. Control populations are used to ensure that other non-experimental variables are not affecting the outcome
