HC Delivery Ch. 1-7 Review Questions

Why did medicine have a domestic, rather than professional, character in the preindustrial era? How did urbanization change that?

(1) In rural and small-town communities, there was a strong orientation toward self-reliance. (2) The market for physicians' services was limited by economic conditions. 3)Personal health services had to be purchased without the help of government or private insurance. (4) There was often little that a physician could do for a patient that the patient's family could not do. Urbanization also spread family members further and women entered the workforce

According to the Institute of Medicine, what are the four main components of a fully developed electronic health records (EHR) system?

(1) collection and storage of health information; (2) immediate electronic access to person and population level information by authorized users; (3) provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and (4) support of efficient processes for health care delivery.

Discuss how the concepts of premium, covered services, and cost sharing apply to health insurance.

A premium is the amount charged by the insurer, Premiums are determined by the assessment of risk. Services covered by an insurance plan are referred to as benefits. insured pays out-of-pocket expenses referred to as deductibles and copayments/coinsurance. A deductible, paid annually, is the amount the insured must first pay before benefits by the plan are payable. A copayment is a flat amount the insured must pay each time health services are received.

What is alternative medicine?

Alternative medicine refers to the broad domain of all healthcare resources. regarded as nontraditional because the efficacy of many of these treatments has not been scientifically established. include homeopathy, herbal formulas, use of other natural products

What is Medicare Part B? What main benefits are covered under PartB?

B, the Supplementary Medical Insurance (SMI) portion of Medicare, is a voluntary program financed partly by general tax revenues. outpatient services such as physician services; hospital outpatient services (outpatient surgery, diagnostic tests, radiology, etc.); emergency department visits; outpatient rehabilitation services; renal dialysis; prostheses; medical equipment and supplies; annual exams and an array of preventive services. Noncoveredservices include dental care, hearing aids, eyeglasses (except after cataract surgery), and services not related to treatment or injury.

What has been the main cause of the dichotomy in the way physical and mental health issues have traditionally been addressed by the health delivery system?

Diagnosis and categorization of mental distress have not always been as clear-cut. Difficulties in identifying certain behaviors as indicative of mental disorders, the predominance of the medical model that has focused on the physical aspects of health care, while mental health has been relegated to a secondary status.

Which conditions during the World War II and postwar period lent support to employer-based health insurance in the United States?

During the World War II period, Congress implemented wage freezes. became popular to offer group health insurance in lieu of wages. In 1948, the US Supreme Court ruled that employee benefits, including health insurance, were alegitimate part of the union-management negotiations. Employer contributions toward the purchase of health insurance became exempt from taxable income for the employee.

Discuss the roles of efficacy, safety, and cost effectiveness in the context of health technology assessment.

Efficacy refers to effectiveness or health benefits a technology provides. Safety considerations are crucial for protecting patients against harm from technology. Cost effectiveness evaluates the benefits in relation to costs.

What are the main objectives of public health?

Ensuring conditions that promote optimum health for the society as a whole. To counteract any threats that may jeopardize health and safety of the general population.

The Blum model points to four key determinants of health. Discuss their implications for healthcare delivery.

Environment, individual behaviors, a person's hereditary, and medical care. These four elements are interactive. the four must be considered at the same time. healthcare delivery system must go beyond the medical model in order to achieve optimum health. Many costly diseases can be avoided by lifestyle changes, which include healthy diets, exercise, smoking cessation, and abstinence from drugs. One of the problems with the healthcare delivery system is the importance of healthcare expenditures are devoted to the treatment of medical conditions rather than to the prevention and control of factors that produce those medical conditions. Appropriate steps in addressing the key determinants of health can save money as well as suffering.

There are six main types of private health insurance options available to Americans:

Group insurance, Self-insurance, private health insurance, Managed care plans, High-deductible health plans, Medigap.

Distinguish between information technology (IT) and health informatics.

IT deals with the gathering, and transformation of data so it becomes useful information for health care professionals, managers, payers, and patients. health informatics generally applies to specific medical treatments such as cancer treatment, nursing care, imaging and diagnostics, consumer health, public health, clinical research, pharmacy, etc.

What is the difference between experience rating and community rating?

In experience rating, premiums are based on a group's own medical claims experience. Community rating spreads the risk among members of a large community and establishes premiums based on the utilization experience of the whole community.

Describe how health care is rationed in the market justice and social justice systems.

In the market justice system, healthcare services are rationed through prices and the ability to pay. ex: demand-side rationing, or price-rationing. Under social justice, the government makes attempts, to limit the supply of healthcare services. ex: planned rationing, supply-side rationing, or non-price rationing.

What is Medicare Part A? What benefits does Part A cover?

Part A, the hospital insurance (HI) portion of Medicare, is financed by special payroll taxes collected for Social Security. Part A covers hospital inpatient services, care in a skilled nursing facility (SNF), home health visits, and hospice care

Briefly explain the prescription drug program under Medicare Part D.

Part D is voluntary. It requires payment of a monthly premium for people who want coverage. Coverage is offered through two types of private plans: (a) Stand-alone Prescription Drug Plans that offer only drug coverage are available to those who want to stay in the original Medicare fee-for-service program. (b) Medicare Advantage Prescription Drug Plans are available to those who want to obtain all health care services through managed care organizations participating in Part C.

Why is there a geographic maldistribution of the physician labor force in the United States?

Physicians are more likely to concentrate in metropolitan and suburban areas. because the former generally offer greater prospects for high income, professional interaction, access to modern facilities and technology, continuing education and growth, high standards of living, and social amenities

Discuss the general concept of insurance and its general principles.

Protection against risk. There are four fundamental principles underlying the concept of insurance: (1) Risk is unpredictable for the individual insured. (2) Risk can be predicted with a reasonable degree of accuracy for a group or a population. (3) Insurance provides a mechanism for transferring risk from the individual to the group through the pooling of resources. (4) Actual losses are shared on some equitable basis by all insured members.

What main roles does the government play in the US health services system?

The government determines eligibility criteria it also determines the reimbursement rates In order to render services to Medicaid and Medicare patients, healthcare facilities must be certified. These organizations must comply with the standards of participation formulated by the government. regulates the healthcare industry through licensing of personnel and healthcare establishments. expanding further by mandating that individuals have to get

Discuss the main cultural beliefs and values in American society that have influenced healthcare delivery

The medical model of healthcare delivery is founded on advances in science and technology. the holistic aspects of health and use of alternative therapies have been deemphasized. health care has largely been viewed as an economic good (or service), not as a public resource. we find a clear distinction in the types of services between poor and affluent communities, and between rural and urban locations. Medical practice has emphasized treatment rather than health education. In contrast, commitment of resources to the preservation and enhancement of health and well-being have lagged far behind.

On what basis were the elderly and the poor regarded as vulnerable groups for whom special government-sponsored programs needed to be created?

The poor and the elderly generally could not afford the increasing cost of health care. The health status of these population groups was significantly worse than that of the general population, and they required a higher level of health care services. had higher incidence and prevalence of disease compared to younger groups.

What are the major methods of reimbursement for outpatient services?

a. Fee-for-service reimbursement pays a separate amount for each identifiable and individually distinct unit of service. Charges may be based on a set of bundled services. For example, normal vaginal delivery may have one set fee that includes the procedure and pre- and post-delivery care. Optometrists sometimes advertise package prices that include the charges for eye exams, frames for eyeglasses, and corrective lenses. c. Reimbursement based on a resource-based relative value scale (RBRVS) is used by Medicare to reimburse physicians according to a "relative value" assigned to each physician service. There are three main payment approaches used under the various managed care arrangements: • The preferred-provider approach may be regarded as a variation of the fee-for-service approach. The main distinction is that an MCO establishes fee schedules based on discounts negotiated with providers. • Under capitation, a set monthly fee per enrollee (PMPM rate) is paid to the provider. All services rendered by the provider are covered under the capitated fee. • Salary combined with productivity bonuses is the third method used by some MCOs that employ their own physicians. e. Ambulatory Payment Classification

What are some of the ethical issues surrounding the development and use of medical technology?

a. Self interests of insurers, pharmaceutical industry, and physician advocacy groups may inject conflict of interest when these same groups have major roles in HTA b. HTA funding by sources that have a financial stake in the results can inject biases in the results c. Should society pay for novel treatments that do not affect health and longevity? d. Withholding experimental therapies from people who could benefit e. Ethical conduct in clinical research

Provide a brief description of the roles and responsibilities of health services administrators.

are employed at the top, middle, and entry levels of organizations. Top-level administrators provide leadership and strategic direction, work closely with the governing board, and are responsible for an organization's long-term success. Middle-level administrators may have leadership roles for major service centers or bedepartmental managers. Their jobs involve major planning and coordinating functions, organizing human and physical resources, directing and supervising, operational and financial controls, and decision making.

What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees?

as a fringe benefit. Health insurance protects employees against the high cost of healthcare services.

What are the major differences of Healthy People 2020 from the previous Healthy People initiatives?

by including multiple new topic areas, such as adolescent health, genomics, global health, health communication and health information technology, and social determinants of health. also establishes four foundational health measures to monitor progress. include general health status, health-related quality of life and well-being, determinants of health, and disparities.

Name the four basic functional components of the US healthcare delivery system. What role does each play in the delivery of health care?

financing, insurance, delivery, and payment. Financing pays for the purchase of health insurance. Insurance protects the buyers of health coverage against risks. Delivery of health care enables people to receive services covered under their health insurance plans. Payments for services delivered to the insured.

Whatare the main characteristics of primary care?

healthcare delivery is organized around primary care. Primary care is the first contact a patient makes with the health delivery system. Referrals for specialized services are made by primary care physicians. One of the main functions of primary care is to coordinate the delivery of health services between the patient and the myriad delivery components of the system. primary care professionals serve the role of patient advisor, advocate, and system gatekeeper. gives advice regarding various diagnoses and therapies, discusses treatment options, and provides continuing care over time.Coordination of an individual's total healthcare needs is meant to ensure continuity and comprehensiveness. Primary care is comprehensive because it addresses any health problem at any given stage of a patient's life cycle

Why is the hospital emergency department sometimes used for nonurgent conditions?

include eerroneous self-perceptions of the severity of ailment or injury, the 24-hour open-door policy, convenience, and unavailability of primary care providers. costs are high and services are not designed for nonurgent care. Inappropriate use of the emergency department wastes precious resources.

Why is the US health care market referred to as "imperfect?"

it does not meet the classical criteria of a free market. (a) The health plans acting as intermediaries for the patients (b) Patients lack the information necessary to make decisions. (c) Prices are often set by the health plans. (d) forcing providers to form alliances and integrated delivery systems (e) Health insurance shields patients against the cost of health care. (f) The utilization of health care is generally determined by need rather than price-based demand.

What role does an IT department play in a modern health care organization?

manage the flow of information and ensure that it is made available in a user-friendly format. play a critical role in decisions to adopt new information technologies that would improve health care delivery and organizational efficiency.

Who are nonphysician primary care providers?

nurse practitioners, physician assistants, and certified nurse midwives. They play a critical role in the provision of health care, particularly primary care to underserved populations.

Discuss the gatekeeping role of primary care.

patients do not visit specialists without a referral from their primary care physicians. protects patients from unnecessary procedures and over treatment. This is because specialists are much greater users of tests and procedures, and such interventions carry a definite risk of iatrogenic complications. Gatekeeping must emphasize the coordinating role of primary care to ensure comprehensiveness and continuity of care.

Who are the major players in the US health services system? What are the positive and negative effects of the often-conflicting self-interests of these players?

physicians, administrators of health service institutions, insurance executives, large employers, and the government. The conflicting self-interests of the various players produce countervailing forces within the system. One positive effect of these opposing forces is that they prevent any single entity from dominating the system. they also make it difficult to achieve system-wide reforms, cost containment

What factors are associated with the development of health services professionals in the United States?

population trends, advances in research and technology, disease and illness trends, and the changing environment of healthcare financing and delivery.

Why is there an imbalance between primary care and specialty care in the United States?

the demographics of the general population. The major driving force behind specialistsis the development of medical technology. Higher reimbursement for specialists, Specialists not only earn higher incomes, but they also have more predictable work hours and enjoy higher prestige

How did the emergence of general hospitals strengthen the professional sovereignty of physicians?

the rise of hospitals was a key precondition for the formation of a sovereign profession. For economic reasons, as hospitals expanded, their survival became increasingly dependent on physicians to keep the beds filled. became important for hospitals to keep the physicians satisfied.

What are the two main objectives of a HC delivery system?

to enable all citizens to receive healthcare services whenever needed, and to provide cost-effective health services that meet certain standards of quality.

In general, who are allied health professionals?

two broad categories: technicians/assistants and therapists/ technologists. complement the physician and nursing work force.

What is the basic philosophy of home health care? Describe the services provided through home health care.

with the philosophy of maintaining people in the least restrictive environment possible. Home health services typically include nursing care, such as changing dressings, monitoring medications, and providing help with bathing; short-term rehabilitation, such as physical therapy, occupational therapy, and speech therapy; homemaker services.