Health Science Final Exam

Medicare part D

introduced in 2003 -Covers prescription drugs

Steps Taken to Improve Quality: Clinical practice guidelines

protocols that help to standardize care for certain conditions

Sub acute facilities

provide care for patients who have discharged from the hospital (acute care), but are not ready to discharge home for any number of reasons - Patients spend time recovering and improving in a subacute facility until they are ready to discharge home

Tribal self-governed health systems

Tribes can choose to self-govern a single hospital or clinic, a single program or service line, or the entire health system

What drug prevents HIV infection even if the individual is exposed to the virus?

Truvada

What part does medicare part B NOT cover

Vision, dental or hearing aids

Primary care provider

"Family doctor" - pediatrician, physicians, physicians assistants, nurse practitioners

Skilled nursing facility

"nursing home" - These patients require more care and assistance than any of the previous LTC options provide - Patients tend to be medically complex as many are nearing end of life (This requires skilled staff and physician involvement) - Heavily regulated by government to ensure safety

Medicare part D funding

$40 premium $400 prescription drug deductible

LTC: In home care

*Different from home health care* - keep individuals safe and as independent as possible to avoid placement in an institution - Provide personal care - light assistance with things like bathing, dressing, preparing meals, running errands, home/yard maintenance, etc

In-network provider

- A provider who has agreed to a contract with the insurance company - Insurance company will cover the vast majority of this care

Out-of network provider

- A provider who is not under contracted rates with an insurance company - HMO won't cover, PPO will cover a little

Future of US healthcare system

- A single payer system, is unlikely in the near future because the US lacks the cultural belief that universal access to health care is essential - the dominant payment model will have a great impact - greater emphasis on prevention

What are the benefits of Multihospital Systems

- Ability to reach a variety of markets - Increased access to capital - Stronger negotiation position with Managed Care Organizations - Access to wide variety of expertise across service lines and administration - Lower operation costs

Medicaid expansion

- Affordable Care Act required Medicaid expansion in all states - Expansion would make ANYONE making less than 138% FPL would be eligible for Medicaid

What is the eligibility of Medicare?

- American citizen 65+ years old or legal resident for at least 5 years AND OR your spouse worked and paid taxes for at least 10 years - disabled individuals entitled to social security benefits (worked and paid taxes at least 10 years) - patients with end stage renal disease and ALS

Long term care hospitals

- Average length of stay greater than 25 days but shorter stay than long term care facility - Often transfer from short stay hospitals and receive treatment for complex conditions (ventilator weaning, chronic and severe illness)

Short stay hospitals

- Average length of stay is 25 days or less - most hospitals are short stay

Research and Development Process of Vaccines - Development

- Clinical trials (Phase 1-3) - New drug application submitted to FDA

How does the developmental process work for Orphan drugs?

- Longer patents - tax breaks for research and development expenses - waiver on million of dollars in fees

What can poor access to health care lead to

- Lower life expectancy - frequent hospitalizations - higher treatments costs - more health complications

What is being done to contain the cost of health care?

- Managed Care Organizations - Capitation Models - Price control models (alternatives to the fee for service) such as Bundled payments Diagnosis-related groups - Peer review from insurance companies - Increased cost-sharing (Higher copays and coinsurance, larger deductibles)

Imperfect Market

- in a free market, prices are drive by supply and demand - the us healthcare system is not a true free market --> prices are negotiated by insurance companies so that the beneficiary doesn't have to bear the burden of prices *POV of beneficiary*

What is the INSURANCE components of the US health care system

- Determines the package of health services an individual will receive and specifies how and where health care services can be received - To protect against catastrophic risk - Pay for a beneficiary's medical care

How do individuals get private insurance?

- Employer-sponsored health insurance (49%) - Individually purchased health insurance (6%) - The Affordable Care Act requires employers to provide a health insurance option if they have 50 or more full-time employees

Why is healthcare so expensive in the US?

- Expenditures (E) = Price (P) x Quality (Q) - US expenditures (E) are the highest in the world - US quantity (Q) is around average - This means that high prices (P) are driving cost way up

Indian Health Service

- Federally funded health care services provided to American Indian and Alaskan Native tribes and their descendants - IHS employs health care professionals and owns/operates health care facilities near or on tribal lands - 26 hospitals, 91 health centers/health stations

What is the FINANCING components of the US health care system

- Funds paid to insurance companies to secure access to insurance - To purchase insurance, or to pay for health care services consumed - Financing may be provided completely by the employer, slit between employee and employer, paid completely by the individual, or paid by the government through taxpayer dollars

Defensive medicine

- Greater utilization of testing and diagnostic services - More frequent utilization of invasive, non-conservative care (this leads to higher costs)

What are the determinants of health?

- Heredity - lifestyle - environment (EMPHASIS) - medical care

What are barriers to access?

- High cost of care - inadequate or no insurance coverage - lack of availability of services - lack of culturally competent care

Financial Incentives for Quality

- Hospital Acquired conditions (surgical site infections, falls with injury, etc) - 30 day hospital readmission (financial penalties for patients readmitted to the hospital within 30 days for their last discharge) - capitation and bundled payment models

How does payment work for LTC services

- LTC services are not covered by private insurance or Medicare - Individuals have the option of buying separate long term care insurance (Premiums are very high, so this isn't common) - Medicaid does cover LTC

What is the DELIVERY components of the US health care system

- Medical clinics, surgeons, medical equipment suppliers - To provide health care services - The provision of health care services by various providers (Doctors, hospitals, nurses, dentists, therapists, etc)

What are the different types of medical errors?

- Medication errors (adverse drug events) - Diagnostic errors - surgical errors - systematic errors (falls, pressure ulcers, blood clots, hospital acquired infections)

The single-payer system as a cost-containment strategy

- National regulatory mechanisms to keep costs at a certain percentage of GDP - Budgets established for each sector of health care delivery system and funded by government (this keeps costs from spiraling out of control)

Barriers to reporting to the PSN (public safety network)

- No feedback on incident follow-up - Form too long, lack of time - Incident seemed trivial (of little value or importance) - Not sure who is responsible to make report

Medicare part A funding

- No premiums - Deductible: $1,316 - Copays vary - funded through payroll taxes paid by all working Americans and employers

Direct care for military

- care is provided on military bases for active duty patients and families - for non active duty, care is provided at VA hospitals and clinic - true socialized medicine: care is provided by government

What are steps taken to improve quality?

- clinical practice guidelines - cost efficiency - critical pathways - risk management

LTC: continuum of care

- in home services - institutional long term care (residential care, assisted living, and skilled nursing facilities)

Who is involved in Health Care?

- Providers (nurses) - Educators (Undergrad programs, grad programs) - Insurers (private insurance companies, publicly funded insurers) - suppliers (pharmaceutical and biotechnology companies, equipment providers)

What is the Payment components of the US health care system

- Providers are reimbursed for their delivery of health care services and/or products - This amount may be paid in full by insurance, in full by the patient, or the bill may be split between insurance and patient

Negatives of the single payer system as a cost containment strategy

- Providers not as responsive to patient needs - Little incentive for efficiency amongst providers or hospitals - Once the budget allocation is exhausted, providers must cut back on services

Classify Boone Hospital

- Publicly owned by Boone County - non profit - single hospital - general hospital - short stay hospital - no swing beds - not a critical access hospital

What are issues impacting medicare solvency

- Rising cost of healthcare - aging baby boomer population = more medicare beneficiaries - shrinking number of workers which reduces payroll tax $$

Social and community context

- Social support network (family, friends, neighbors) - culture - discrimination and bias (race, gender, disability)

4 important components to hospital's error-reporting systems

- Supportive environment of reporting - Reports received from a broad range of staff - Timely distirbution of reports - Structured mechanisms to review

Research and Development Process of Vaccines - Discovery

- company identifies a disease and molecular compound - FDA application

Patient Safety Network

- a way to identify and superficially understand a situation that may or may not have led to patient harm - Documentation of patient safety events completed by anyone working in the health care setting - includes: date/time, location, who was involved, event described - Contributing factors: technology, workarounds, staffing - Patient information: ID, degree of harm, outcome, notification of family

Health and healthcare

- access (to what extens? access to generalist? specialist?) - health literacy

Racial and ethnic minorities in the US are more likely to...

- be uninsured - have medical debt - delay seeking care

In what ways does the US outperform comparable nations?

- cancer survival - flu vaccines - mammograms - post-op sepsis - post-op clots - heart attack and ischemic stroke

What is "underinsured"

- deductible is 5% or more of annual household income OR... - out of pocket costs from the previous 12 months are 10% or more of household income for high earners and 5% or more for low earners OR... - those who had a gap in insurance coverage during the previous year - 45% of working-age adults are uninsured or underinsured

What do delays in care lead to

- delayed diagnosis and treatment (disease progression) - longer hospitalizations - more invasive and more costly treatment

Why do practice variations exist?

- financial gain for medical providers - inadequate evidence for the care providers give

Who benefits from long term care (LTC)

- half elderly - children with congenital disorders (cerebral palsy, autism) - individuals with intellectual disability (down syndrome) - severe neurological disorders (multiple sclerosis, stroke, brain injury, etc)

What is the eligibility of medicaid?

- health insurance for low income Americans - legal citizen of Missouri - children of low income families - low income pregnant women - low income blind individuals - disabled individuals and those aged 65+

Neighborhood and built environment

- housing - neighborhood (crime and violence? clean water and air?) - working conditions - food deserts

Root Cause Analysis

- incredibly thorough review of an error that led to significant patient harm - Performed after a sentinel event or after a near miss (retrospective) - Very thorough analysis of all factors that led to medical error Human, procedural and technological factors - Quality improvement committee reviews the event - Includes effectiveness officer, leadership from involved departments, c-suite, possibly individual involved

ACA reform

- landmark legislation undergoes reform frequently - if there is a political will, the ACA will require reform to effectively address shortcomings

What are some realities of medicaid

- medicaid reimburses at a fraction of what Medicare and private insurance reimburses --> this result is that many health care providers don't accept medicaid patients - people come on and off as their incomes fluctuate - paperwork is ongoing

Bundled Payments

- most common: Diagnosis-related groups (DRG) for hospitalizations - insurer pays a lump sum of $$ for the care the patient receives in the hospital --> this amount is based on historical data on costs of patients with same diagnosis and similar co-morbidities --> if the outcome meets quality measures, and the actual cost of care came in lower, the hospital gets to pocket the difference Ex- If the cost of all care for that hospitalization is less than $25,000, the hospital still gets to keep the whole $25,000. On the flip side, if cost of care is greater than $25,000, the hospital doesn't get any additional $$

What is in the ACA? Title 1

- outlawed experience rating - banned lifetime and annual benefit caps - individual insurance mandate - parents can keep children on their insurance until age 26 - employee sponsored insurance mandate

How are prices for pharmaceuticals negotiated?

- pharmacy negotiates price with pharmaceutical company to purchase medications - Insurance company negotiates price with pharmacy to purchase medications

Medicare part C funding

- premiums are generally higher, but there is more individualized coverage - funded through $$ from medicare sent to private insurers and through patient premiums

Medicare part B funding

- premiums based on income (as high as $430 a month or as low as $134) - Deductible: $183 - premiums and copays/coinsurance cover 25% of total Medicare costs. General tax revenue covers the other 75%

What hasn't worked -- Is the "Affordable" care Act affordable?

- prescription drug cost and deductibles continue to rise - deductibles rise which keeps people from being able to see docs - many insurers have left the marketplace due to poor profit

Examples of Outpatient Care

- primary care providers - specialist services - outpatient surgical services - emergency departments - home health care - pharmacies - rehab (PT/OT/Speech Therapy) - dentists - hospice care - adult day care - public health services - community health centers (Boone Family Health Center)

How are social determinants of health being addressed in the US healthcare system?

- reliance on private industry to solve public problems - addressing social determinants through government funded health programs such as medicaid (Oregon, North Carolina, New York, and Rhode Island created programs to address social determinants of health through Medicaid)

What is in the ACA? Title 2

- requires medicaid expansion to cover all Americans making under 138% FPL - each state has its own medicaid program and choice of expansion is left to each state

Education

- safe and quality childcare and early childhood education - language and literacy - high school graduation and enrollment in higher education (non high school graduates are more likely to experience chronic health conditions and premature death)

Limitations to IHS

- service areas are expensive and rural - lack of specialists (coverage of outside specialists isn't guaranteed)

What is in the ACA? Title 3, 4, 5

- slow % of rate increases Medicare pays for its beneficiaries' health care - 13 billion dedicated to public health initiatives and programs - all insurance plans must cover certain evidence-supported preventative procedures at no out of pocket costs - medical loss ratio - quality initiatives

Plans and pricing for the ACA

- subsidies for low income Americans - tiered premium subsidies for those below 400% FPL - reduction in out of pocket costs for those below 250% FPL

How insurance companies benefit from ACA?

- they supported it from the beginning because more customers - during the first years, insurance companies were spending every cent from premiums - now insurance companies have adjusted to raise premiums and narrow networks

What is in the ACA? Title 6-10

- transparency regarding physician payments for pharma and medical device companies - establish patient centered outcomes research institute to support research on clinical effectiveness of treatments - limits pharmaceutical companies' ability to delay patient expiration - new taxes to help pay for the law

What is the financial impact for uninsured Americans

- twice as likely to have difficulty paying medical bills compared to those with health insurance - medical debt

No Central Agency

-Insurance companies, Medicare, Medicaid, and VA all reimburse for health care services - health care is primarily delivered and paid for by private companies - many countries (Australia, England, Canada) have a central agency - A central agency serves to enforce a budget on health care costs - US health care has both private and public financing

How often do compounds get approved?

1 out of 10,000

Merit-Based Incentive Payment System (MIPS)

1. Health care providers report their quality measures to CMS (Center for Medicare and Medicaid Services) 2. Quality measures depend on profession (Diabetes management, Return to prior level of function, Best practice in care) 3. Financially incentivizes to demonstrate high quality care

5 environmental-focused determinants that impact health identifies by healthy people 2020

1. economic stability 2. education 3. social and community context 4. neighborhood and built environment 5. health and health care

What 2 purposes do PCP's face as gatekeepers

1. offers an expert to refer appropriately so specialists aren't inundated with patients they can't help 2. coordination of care which helps reduce the "silo effect" (one individual is responsible for the whole picture of care)

When was medicare and medicaid passed?

1967

What is Blum's Model

4 Factors that are the major contributors to individual health 1. Environment 2. lifestyle 3. heredity 4. Medical care

How long does the whole research and development process take?

8-15 years

Copayment

A flat amount a "beneficiary" must pay each time they receive health services Ex- You take a trip to Disneyworld in Orlando. There are multiple theme parks, and you must pay the ticket fee for each park you visit. Once you pay that ticket fee, you have full access to rides and entertainment

Medicare part C

A medicare advantage plan offered by private insurance companies. Alternative to part B, but if you don't like part B you can use part C. - outpatient services

Litigation risks

A result is "defensive medicine" where doctors prescribe additional, often unnecessary testing and frequent return visits to protect themselves from a lawsuit

Health

A state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity

Long term care

A variety of individualized, coordinated services that promote independence for people with limited function. Those services are provided over an extended period of time

Medical Care

Access to expert, skilled care with appropriate medical resources/equipment

Punitive culture

All errors are punished by lack of promotion or advancement, or even termination

How quickly can a pregnant woman qualify for Medicaid?

Approval within 2-4 weeks Non-pregnant patient average: 30-45 days

The Affordable Care Act

An expansion of medicaid, most of employers must provide health insurance, have insurance or face surtax, prevents rejection based on pre-existing condition. Also referred to as "Obamacare", signed into law in 2010.

Health Maintenance organization

An insurance plan that allows beneficiaries to see a list of providers (doctors, etc) who have agreed to contracts with the insurer. Insurance won't cover costs for visiting providers outside this group of providers

Preferred Provider Organization

An insurance plan that allows beneficiaries to see providers who have agreed to contracts with the insurer. Insurance will cover a lesser amount of the costs for visiting providers outside this preferred group

Outpatient Services

Any health services that are provided with the patient not staying the night in the facility

Decision support systems

Assist clinicians with decision making - haven't improved in quality as much as many had hoped

Just culture - Coach

At risk behavior Action: risk not recognized or believed Change: remove incentives for at risk behaviors, Creating incentives for healthy behaviors, Increasing situational awareness)

What are the 5 A's of Access

Availability, Accessibility, Accommodation, Affordability, Acceptability

Swing beds in hospitals

Beds classified from acute skilled nursing. 3 day hospitalization required to qualify as a swing bed

Accommodation

Business hours fit patient needs? Long wait times? Walk-ins? - Clinic opens M-F at 6am, closest at 7pm and is open Saturdays from 8am-12pm

Accessibility

Can patients reach providers conveniently? Location and physical space - The clinic is located on the 2nd floor and the elevator is under maintenance and currently unstable

What do newly-developed diabetes medications help do?

Control blood sugar, but also protect against the common conditions that develop with diabetes including heart disease

Steps Taken to Improve Quality: Critical Pathways

Coordinate collaboration in a patient's care across multiple health care disciplines

Which aspect(s) of the iron triangle is impacted by the ACA? Limit pharmaceutical companies' ability to delay patent expiration

Cost

Which aspect(s) of the iron triangle is impacted by the ACA? Medical loss ratio

Cost

Which aspect(s) of the iron triangle is impacted by the ACA? Slow % of rate increases Medicare pays for its beneficiaries' health care

Cost

Which aspect(s) of the iron triangle is impacted by the ACA? Subsidies to offset premium prices for low-income Americans (<400% FPL) and reduced out of pocket costs for low-income Americans (<250%FPL)

Cost

How/why did outpatient care expand

Costs for inpatient services began to spiral out of control in the 80s, so changes in payment were made in 80s, 90s and with the ACA. This shifted more payment to outpatient facilities compared to inpatient which resulted in an increase in outpatient services

Medicare part A

Covers: inpatient services - hospital stays - psychiatric hospitals - impatient rehabilitation - skilled nursing facility - home health - hospice

Medicare part B

Covers: outpatient services - doctor's appointments - hospital emergency debt - urgent care - outpatient surgery - ambulance - MRI, X-ray

What are the 4 basic components of the US health care delivery system

Delivery Financing Insurance Payment

Lifestyle

Diet, physical activity, smoking, alcohol, risk factors

Clinical information systems

Electronic health records

Economic stability

Employment/income Are you full time? part time? benefits? Does your income bring you stability?

Availability

Enough providers in the area or in the network? Are necessary services provided -- interpreter, transportation? - there are only 3 specialists in a large urban area

Administrative costs

Enrollment, contract negotiations, claims processing, utilization monitoring, appeals of claims, marketing and promotion

ACA Title 1

Established health insurance for individuals who don't qualify for Medicare or Medicaid and don't have employer-sponsored health insurance, the marketplace provides an insurance option

Health care for prison population

For many prisoners, no access to care prior to or after their incarceration - poor care

Has Increased Access to Health Insurance Impacted Health?

For this group (age 49-64, previously uninsured), getting insurance reduced their rate of death

Fraud

Fraud occurs when insurance companies are billed by providers (or people claiming to be providers) for services that were not provided

Telemedicine/telehealth

Health care assessment and consultation occurs from distance via telecommunications

"Volume and Intensity" of Services

Health care providers are paid for each individual service they provide and the cost is negotiated between the insurer and each provider

Capitation

Health care providers are paid monthly by the insurance company per patient under their care (like a membership fee) - provider receives the same "per patient" payment regardless of whether they didn't see the patient at all that month of if they saw them 10 times - the provider incentivized to keep the patient healthy because the provider's schedule opens up to accept more patients - model transfers risk from the insurer to the provider

Fee for service

Health care providers are reimbursed for all goods and services they provide - most widely used model in US Ex- Cox daughter was born

What are social determinants of health responsible for?

Health inequities - the unfair and avoidable differences in health status seen within and between countries

What is the key provision if ACA

Health insurance marketplace and subsides

What are the top 3 causes of death

Heart Disease, Cancer, and Medical errors

What is the leading race without a primary care provider?

Hispanic

Critical Access Hospitals

Hospitals serving rural communities - No more than 25 acute care and/or swing beds - 24 hour emergency care - Can have up to 10 bed psychiatric unit - Can have up to 10 bed rehabilitation unit

Just culture - Console

Human error Action: slip, lapse, mistake Change: process, procedures, training, design

Purchased care for Military personnel

If patients cannot receive care through military health system, hospital, or clinic, they may receive from a private sector provider - this care will be covered through their military health insurance (TRICARE)

Veterans' access to private sector care

If veterans face long wait times for care or if they live more than 40 miles from the VA facility, they can receive care in the private sector

CHIP - Children's Health Insurance Plan

Implemented nationwide in 1997 to address issue of uninsured children in US. Fills the gap so children whose parents make too much to qualify them for Medicaid, but not enough to afford insurance, are covered through CHIP

Partial Access

Individuals must be able to pay for health services before they are provided those services - health care is treated as a commodity in the US

Inpatient care

Inpatient health care services provided to patients while they are lodging in the health care facility

Affordability

Insurance? out- of-pocket costs?

Third-Party insurers and payers

Insurers are the intermediary between those who finance, deliver and receive health care service - these insurance companies don't have much incentive to advocate for patients on the quality of care or price

What technology has the highest rates?

MRI, CT, Knee Replacement surgery (2nd to Germany)

What durgs target proteins on cells in the lungs to help improve lung function and prolong life for cystic fibrosis? and how accurate are they?

Kalydeco Orkambi Trikafta - Works on 90% of patients

The amount spent on Research and development compared to drug sales

Less on research and development compared to sales

Hospital consumer assessment of healthcare providers and systems (HCAHPS)

Measures patients' perceptions of the quality of care they received in hospital - publicly reported

Why do pharmaceutical companies argue such high prices

Lots of money is required to fund research and big development

What technology was invented in the US?

MRI, CT scan, PET scan, CRISPT gene editing, etc

North Carolina's medicaid model

Medicaid in NC switched from Fee for service to value based reimbursement model

What will North Carolina do with the savings

Medicaid will provide resources to address housing stability, food insecurity, interpersonal violence and transportation insecurity

How does Medicare interact with critical access hospitals

Medicare pays critical access hospitals more for the same services compared to hospitals without the critical access designation - this is because the hospitals in small rural communities are less profitable, but serve a very important function

Multiple payer system

Medicare, medicaid, united health care, blue cross blue shield, aetna, humana, etc...

What percent makes up Medicare, Medicaid, VHA, IHS

Medicare: 15% Medicaid: 20% Veterans Health Ad.: 1% Indian Health service: small %

Proportion of Americans who believe they would receive better care if they were a dfiferent race?

Most to least Black, non hispanic Hispanic Asian All Americans White

Increased access through medicaid expansion

National uninsured rate for poor adults without dependent children (currently not eligible for Medicaid in MO), dropped from 45.4% to 16.5% in 2015

Effectiveness of IHS

Native American Health disparities - higher rates of suicide, diabetes, alcoholism, liver disease, etc

Does the US set limits on pharmaceutical prices or negotiate with manufacturers?

No

Medicare out of pocket costs

No out of pocket maximum so the costs get quite high - 80/20 coinsurance with no limit

Does the US have supply side rationing?

No restrictions on certain procedures or tests as long as they are deemed acceptable practice

How does lack of insurance affect access

No usual source of care

Tertiary prevention

Prevent complications from chronic conditions and prevent further illness, injury, or disability

What drugs are used to activate a patient's immune system to fight cancer?

Opdivo Yervoy Keytruda

What type of medicare is most at risk and why?

Part A because it is financed through payroll taxes -- will run out in 2026

Single Hospital

Part of a lrger health system with a lot of outpatient clinics, but only one hospital

Jenae is a health sciences student at Mizzou. She works as a patient transporter at a local hospital. Her job, in part, is to make sure patients and their families safely leave the hospital after being discharged. This often means Jenae goes to patient rooms with a wheelchair and helps the patients into the chair, pushes them to the exit and helps them get into their vehicles so family can drive them home. One afternoon, Jenae walked into a patient's room to transport them to the hospital exit. The patient had yellow "fall risk" bracelet meaning their condition/symptoms put the patient at increased risk of falling. As Jenae helped the patient from bed into the wheelchair, she noticed that the patient was, indeed, quite unsteady. There were 3 gloves and IV tubing on the floor and the floor was slick from the IV fluid. It looked like a nurse or doctor had been in a hurry and hasn't cleaned everything up after taking the patient's IV out. This made transferring from the bed to the wheelchair even more difficult. Jenae recognizes this situation could have led to a fall that hurt the patient, herself or both. What tool does she have at her disposal to communicate this issue so it doesn't happen again?

Patient safety network

Steps Taken to Improve Quality: Cost efficiency

Payment models incentivize efficient care that leads to improved patient outcomes

Research and Development Process of Vaccines - Delivery

Phase 4 (on the market -- available to patient)

Funding for CHIP

Premiums paid by families are based on income. Can be as high as $316/month or as low as $0

How do PCP's work as coordinators?

Primary care provider diagnoses a patient with diabetes and then refer the patient to various clinics for the rest

What provider is the "gatekeepers" of health care

Primary care providers - patients begin at primary care and then they are referred to other services as needed

Specialty Hospitals

Provides inpatient care for a specific condition Ex: rehabilitation hospital, children's hospitals, psychiatric hospitals

Quality reporting

Public information on how hospitals perform on a number of quality measures such as 30 day readmission rate and 30 day mortality rates for certain diagnoses

Which aspect(s) of the iron triangle is impacted by the ACA? Established patient-centered outcomes research institute

Quality

Which aspect(s) of the iron triangle is impacted by the ACA? All insurance plans must cover certain evidence-supported preventative procedures at no out-of-pocket costs to the patient

Quality (preventative care), cost (to system and individual), Access (no out of pocket costs leads to improved access to these services)

Which aspect(s) of the iron triangle is impacted by the ACA? Hospital-acquired conditions, 30-day hospital readmission programs, bundled payment program

Quality, cost

Phase III

Randomized control trials testing a larger group of human volunteers with the disease and comorbidities

Phase II

Randomized control trials testing small group of healthy human volunteers who have the disease

Just culture - Punish

Reckless Behavior Action: Conscious disregard of unreasonable risk Change: Remedial action, punitive action

How do HMOs and PPOs entice beneficiaries to recieve care

Reduce out-of-pocket costs when utilizing in-network care - reduced copay, co-insurance, smaller in-network providers

An ER physician, Dr. Rem, misdiagnosed a patient and sent them home with instructions to see their primary care physician in the next few days to discuss their symptoms. The patient was actually having a heart attack and died after going home. The hospital investigated the situation in an effort to make sure something like this never happened again. Which of the following did they likely perform to learn more about the incident so it could be prevented in the future?

Root cause analysis

Multiple Payers

Since there are many different insurance companies/Medicare/Medicaid, each company wants to be billed a specific way --> result is high administrative costs (the provider gets a variety of costs from different payers) - in a single-payer system, a single government agency receives and pays every bill from every health care product and service *POV of provider*

Steps Taken to Improve Quality: Risk management

Steps taken by hospitals and health systems to help prevent adverse events related to patient care

Quest for Quality

The US health system is strongly incentivizing quality - pay for outcomes instead of pay for services

High Technology

The US healthcare system leads the world in innovation and new medical technology

What are the social determinants of health shaped by?

The distribution of money, power, and resources at global, national, and local levels

Out of Pocket Maximum

The maximum amount "out of pocket" a beneficiary will pay for health care services Ex- Someone with a chronic illness who frequently sees the doctor and undergoes expensive procedures is trying to budget their health care expenses for the upcoming year.

What are the social determinants of health?

The conditions in which people are born, grow, live, work, and age

What is the main reason people are uninsured?

The cost is too high - Over 10% of Americans are uninsured

Initial funding of Medicaid

The federal government paid 100% of the cost of the newly enrolled Medicaid beneficiaries until 2020. At that time, fed pays 90% and states pay 10% of the cost of expansion

Acceptibility

The fit between patient and provider attitudes and the practice characteristics - The patient is only comfortable receiving treatment from a female. The patient calls to confirm that a female provider is available.

Deductible

The total amount of $$ an "insurance beneficiary" must pay for health services in a calendar year before any insurance coverage kicks in Ex- Your parents have agreed to help pay for the cost of college but they want to make sure you're serious about your studies. They will pay for 80% of your tuition, rent and groceries after you have paid the first $3000

Why are costs of health care so high?

There are numerous explanations that all play a role - Third party payment - Imperfect market - Multiplayer system - Medical model of health care delivery - Practice variations - Increase in elderly population - Defensive medicine - Growth of technology - Fraud and abuse

Finances and long term care

There are significant costs associated with long term care services. Some services are covered by insurance, but many are not - Financial hardship on individuals and their families - Estimated that over half of long term care is provided informally and unpaid by family members

How are medicare B and D primarily funded?

Through general tax revenue

Capacity

Total number of beds in a hospital

Multihospital system

Two or more hospitals are owned, or managed by a central organization - ex. University of Missouri System, Houston Methodist

Market Justice

US HAS THIS - distribution of health care goods and services is determiend by who can pay for them - if you pay, you have access

Imperfect market

US healthcare system is not a perfect market where prices are driven by supply and demand - Consumers don't bear the entire price (3rd party payers), pricing and necessity of services are opaque, difficult to commoditize health

Practice variations

Variations in practice patterns (and resultant costs) exist across the US

Value based payment model

a concept by which purchasers of health care and payers hold the health care delivery system at large accountable for both quality and cost of care.

Orphan drugs

a drug that is intended to treat diseases so rare that companies are unwilling to develop them under usual marketing conditions

Off label use

a drug will prove effective for a disease that differs from the one involved in original testing and FDA approval

Risk pooling

a group formed by insurance companies to provide catastrophic coverage by sharing costs and potential exposure - Everyone pays in ($250 monthly), that money is collected by the insurance company, and any time someone in that pool needs health care, the insurance company takes the money out of the pool and pay those out

Access

an individual's responsibility to obtain needed health care services - Can individuals receive care that they need? - Is that care affordable? - Is that care convenient? - Is that care acceptable? - Is that care high quality?

Average Length of Stay (ALOS)

average number of days a patient stays at a hospital - As cost and efficiency have become a focus in health care, ALOS has steadily declined (7.6 days in 1980, 5.4 days in 2013) - Higher ALOS may indicate the hospital is treating more complex patients

What does the cost barrier lead to

delays in care

What will private health insurance look like in the future?

costs, premiums, cost sharing, deductibles, co-pays, will all go up in price

What kind of care does the medical model emphasize

curative care over preventative care

Secondary prevention

early detection and treatment of disease through screening

Blame-free culture

employees are never reprimanded for errors

Social Justice

health care is a social good rather than an economic good and is available to all citizens regardless of ability to pay

Continuum of Services

health care services can be split into 3 categories - curative (medications, treatments, surgeries) - Restorative (physical/occupational) - preventative (health screenings, mammograms)

Residential care facility

independent living with supports in place for safety including monitoring, oversight, assistance with medications

Heredity

individuals have a genetic predisposition to certain diseases and conditions

Who provides home health care

licensed nurses, therapists

Does the ACA identify with market justice or social justice

market justice

Who provides in home care

non health professional workers

General hospital

offers wide variety of services

What does the imperfect market result in

price of health care goods and services is much higher than the cost to produce/provide those services

How are programs to address social determinants of health funded?

primarily with public funds, but private funding also utilized

How much does the US spend on pharmaceuticals per American?

over $1,000 which is 50% higher than the 2nd highest paying country: Sweden

Public Hospital

owned by federal, state or local governments (all public hospitals are nonprofit)

Private hospital

owned by private organizations or private investors

For profit hospitals

pay taxes and profits go to ownership

Occupancy rate

percentage of beds utilized - Hospitals will operate on a budget where they require a certain occupancy rate to break even - Avg. occupancy rate for US hospitals in 2019 was about 65%

Assisted living facility

personal care, 24 hr supervision, nursing and rehabilitation services, recreational activities, social services

Environment model

physical environment or socioeconomic status

Adjusted community rating

premium price is adjusted based on age, gender, geography, smoking/alcohol, and a few other factors, but NOT past medical history

Community rating

same premium price for each beneficiary regardless of any personal or group factors

Administrative information systems

scheduling, billing

Electronic Medical Record

single practice's version of the medical chart. EHR contains infor and notes on the patient from across multiple providers (primary care, specialist, surgeon, etc)

Primary prevention

steps taken to reduce the probability that disease will develop in the future - exercise, good diet, avoid smoking

Political environment around the ACA

strong opposition from conservatives, particularly freedom caucus

Experience Rating

takes previous health history into consideration (Outlawed by the Affordable Care Act)

Phase I

tested on animals and/or petri dish

What country utilizes the highest technology tests and treatments?

the US

Coinsurance

the amount you pay for covered health care after you meet your deductible

Military health system

the federal government funds health care for active duty military personnel. reserve members and retirees. Dependents and spouses are eligible as well

Premium

the monthly charge to maintain health insurance coverage. Payment goes to the health insurance company Ex- like your Netflix subscription -$$ you pay each month for a product or service

Power Balancing

there are many stakeholders in the US health care system - patients, health care providers, employers, insurance companies, government

Non profit hospitals

these hospitals do not pay local, state, or federal taxes or sales tax and are expected to provide services to the community as a result - Providing "charity care" for those who can't pay; educating health professional students; research; 24 hour emergency care; other requirement are very vague which can cause problems - Hospitals do profit but profits must be "reinvested" in the hospital

Means tested

welfare policy eligibility based on income level and net worth