U.S Health Care Midterm Review

Federally Qualified Health Centers (FQHC)

*Safety net providers* such as community health clinics and public housing centers that *provide health services regardless of the ability to pay* and are funded by the federal government.

What is the role of insurance companies in the U.S. Health Care Industry?

*Sell health coverage plans* directly to patients or indirectly through the employer or governmental intermediates

What are the advantages of horizontal integration?

- Can buy supplies and services at a volume discount - Hire specialized staff at corporate level to increase expertise - Raise capital less expensively - Market hospital services under a single brand name

Who is Abraham Flexner?

- Commissioned by the AMA to study medical schools in US and Canada - Interviewed deans and confirmed his findings with them - Gave made report on medical schools which reduced the number of medical schools

What two committees did the HITECH Act create?

1. HIT Policy Committee 2. HIT Standards Committee Address HIT-related issues ex. certification/adoption, governance, HIE, meaningful use, privacy and security, quality measures, implementation, and a HIT vocabulary standards committee.

What are the two types of providers under the Managed Care Organization (MCO)?

1. Health Maintenance Organization (HMO) 2. Preferred Provider Organization (PPO)

What are the rights and responsibilities of hospital patients in simple language?

1. High quality hospital care 2. Clean and safe environment 3. Involvement in care 4. Protection of privacy 5. Help when leaving the hospital 6. Help with billing claims *How to remember?* *Q*uality *C*leanliness and safety *H*elp w/ discharge and billing *I*nvolvement *P*rivacy Q-CHIP

What influenced the change to a diagnosis-related group (DRG) hospital reimbursement system?

1. Hospitals had *no incentive to keep costs down with costs per day per bed*; the government and insurance companies paying for unnecessary expensive hospital days 2. Unnecessarily long hospital stays could be *dangerous to a patient's health*

What is the Institute for Healthcare Improvement "Triple Aim"?

1. Improved population health 2. Improved patient experience of care 3. Reductions in per-capita costs

What is the "triple aim" of healthcare reform?

1. Improving the quality, safety, and experience of care; 2. Enhancing population health; and 3. Reducing per capita costs of healthcare.

What is the result of medical advances finding more ways to maintain life?

1. Increase in the duration of chronic illness 2. Increase in the number of chronically ill individuals

Who owns an MCO?

1. Insurance companies 2. Hospitals, physicians, or consumer cooperatives

What are some of the new consumer protections that were *prohibited* under the ACA?

1. Insurance companies *denying coverage of children and adults based on existing conditions* 2. Insurances companies *charging higher rates* for adults based on gender or health status 3. Insurance companies from *denying payments for a subscriber's illness b/c of mistakes in application* 4. Insurance companies imposing *lifetime dollar limits on needed benefits* 5. Insurance companies use of *annual dollar limits on amount of insurance coverage a patient can get* 6. Insurance companies *dropping or limiting coverage because of participation in a clinical trial*

What are some of the major issues with the aging population that are not being addressed by Medicare or private insurance plans?

1. Long-term care services 2. Functional limitations of aging

What specific programs did the Affordable Care Act incorporate into Medicaid?

1. Medicaid Money Follows the Person (MFP) 2. Community First Choice Option in Medicaid 3. State Balancing Incentive Program

What are the two elements of MACRA 2015?

1. Merit-Based Incentive Payment System (MIPS) 2. Alternative Payment Models (APMs)

What are the criteria that a clinical practice guideline must meet to be considered for AHRQ approval?

1. Must contain systematically developed recommendations to assist healthcare decision-making 2. Must be produced under a professional organization 3. Must have verifiable, systematic literature search and review 4. Must be current and most recent

What are the four broad goals of the ACA?

1. New consumer protections 2. Improving quality and lowering costs 3. Increasing access 4. Holding insurance companies accountable

What are some examples of the long-term care industry?

1. Nursing homes 2. Home-care services 3. Adult-care facilities 4. Rehabilitation facilities

How did ACA increase access to affordable care?

1. Preexisting condition insurance plan 2. Children stay on parents plan until 26 3. Fund employment plans for coverage for early retirees 4. Increase primary care workforce 5. Insurance companies must justify premium increases 6. Federal matching funds for states covering some extra low-income individuals and families under Medicaid 7. Increased payments to rural healthcare providers 8. Support construction and expand services at community health centers 9. Let states offer home and community based services to disabled people through Medicaid 10. Allowing health insurance across state lines

What are the five elements of a policy brief?

1. Problem and policy-oriented 2. Analysis-driven 3. Evidence-based 4. Offers viable recommendations 5. Appealing layout *How to remember?* PERAA *P*roblem and Policy *E*vidence-based *R*ecommendations *A*nalysis-driven *A*ppealing layout

What are the five major interest groups that played key roles in debates on tax-funded health services?

1. Providers 2. Insurers 3. Consumers 4. Business 5. Labor

Who are the stakeholders in the U.S. Health Care Industry?

1. Public 2. Employers 3. Providers 4. Hospitals and Other Healthcare Facilities 5. Governments 6. Complementary and Alternative Therapists 7. Health Insurers 8. Long-Term Care Industry 9. Voluntary Facilities and Agencies 10. Health Professions Education and Training Institutions 11. Professional Associations 12. Other Health Industry Organization 13. Research Communities *How to remember?* PEP - HGC - IL - VEPOR

What are the pros of HITECH?

1. Rapid access to patient records 2. Reduces fragmented care 3. Monitor disease progression 4. Tracking of illness 5. Follow advances in medicine/treatment 6. E-prescribing 7. Protects patient data

What was the impact of Managed Care Organizations (MCOs) on the healthcare industry?

1. Restructuring of the health care delivery system 2. Helped with rising health care costs 3. Helped with fragmented health care delivery 4. Increased access

What did the ACA intend to do?

1. Reverse incentives that drive up costs 2. Enact requirements that increase accountability and transparency of quality 3. Increase access by expanding health insurance coverage 4. Consumer protections 5. Enhances access to needed services for the most vulnerable populations How to remember? *RAACV* *R* - Reverse incentives that drive up costs *A* - Accountability and transparency of quality *A* - Access (expanding health insurance) *C* - Consumer protections *V* - Vulnerable population access

What are two important social health issues that the Managed Care Organizations (MCOs) helped solve?

1. Rising health care costs 2. Fragmented health care delivery

What are the five comprehensive primary care functions aligned identified by CPC that align withs ACA goals?

1. Risk-stratified case management to customize care plans according to level of patient needs 2. Access and continuity of care 3. Planned care for chronic conditions and preventive care 4. Patient and caregiver engagement 5. Coordination of care across the medical neighborhood *How to remember?* CAPEC *C*ustomized care plan *A*ccess *P*lanned care for chronic conditions and preventative care *E*ngagement between patient and coordination *C*oordination

What federal requirements must all Federally Qualified Health Centers (FQHC) comply with?

1. Serve medically *underserved population* 2. Provide appropriate and necessary services with *fees adjusted on patient's ability to pay* 3. Demonstrate *sound clinical and financial management* 4. Be *governed by a board*, a majority of which includes health center patients

What are the four main strategies for social and medical interventions?

1. Social or public policy interventions 2. Community-based interventions 3. Health care interventions 4. Individual interventions

Why are patient rights in jeopardy in the hospital setting?

1. The pressure of the daily schedule in the hospital 2. Physicians are likely to spend only a few minutes with each patient

What is the typical path of training physicians in the US?

1. Undergraduate degree (4 years) 2. Medical school accredited by the AAMC (4 years) 3. Residency specialty training accredited by the ACGME (3 - 7 years) 4. Certification by one of the ABMS boards 5. Optional fellowship accredited by ACGME (1 - 4 years) 6. Optional certifications by the ABMS boards in medical subspecialties

What are some of the new consumer protections that were *established* under the ACA?

1. Website for consumers to *compare health coverage options* 2. Ability for consumers to *appeal coverage determinations/claims* to their insurance company and establish an external review process 3. Provide *federal grants* to states to establish or expand independent offices to *help consumers navigate private health insurance system*

What are some examples of complementary and alternative therapies?

1. Yoga 2. Spiritual healing 3. Relaxation techniques 4. Herbal remedies 5. Energy healing

When was Medicaid and Medicare implemented?

1965

What program provided the financial incentives for the meaningful use program?

Center for Medicare and Medicaid (CMS)

What was the largest expansion of health insurance coverage for children in the US since Medicaid began?

Children's Health Insurance Program (CHIP)

What was the Supreme Court's ruling on Congress' authority to impose financial penalties for noncompliance?

Constitutional The mandate is not a legal command to buy insurance. Rather, it just makes going without insurance just another thing the government taxes.

What is the role of the public in the U.S. Health Care Industry?

Consumers of medical care

What is the consumer interest group?

Consumers of the health care service

What is the role of the pharmaceutical companies interest group?

Controlling prices on prescription drugs

Telemedicine

Remote consultation by patients with physicians or other health professionals via telephone, closed-circuit television, or the Internet.

Supply-Side Rationing

Restricting the availability of expensive medical technology and specialty care.

Medicaid Money Follows the Person (MFP)

Sets demonstration projects in motion by *providing grants to states for additional federal matching funds for Medicaid beneficiaries* making the transition from an institution back to their homes or to other community settings

What is the role of the American Medical Association (AMA) in Obama's health care reform?

Supported the Obama plan for expanding healthcare access to all Americans

What is true integration?

The *elimination of unnecessary duplication*, creating systems that bring previously separate entities together in a streamlined manner, and a *comprehensive management system* for these previously independent entities to act cohesively.

What is one of the most important outcomes of Flexner's report?

The *stimulation of financial support for medical education* from foundations and wealthy individuals, especially university-based schools

What is the largest medical lobby?

The American Medical Association (AMA)

What legislation is related to rural health networks?

The Balanced Budget Act of 1997

Which act created the Children's Health Insurance Program (CHIP)?

The Balanced Budget Act of 1997

Is the U.S. health care system based on market justice or social justice?

The U.S. health care system is a mix of market and social justice. *Market Justice* → private, employer-based health insurance *Social Justice* → publicly financed Medicaid and Medicare

How will the aging population affect health care?

The growing number of older adults face serious *gaps in financial coverage* for long-term care needs.

What was the Supreme Court's ruling on Congress' authority to make a state's existing Medicaid contingent with ACA's provisions?

Unconstitutional. It is unconstitutionally coercive so they prohibited the federal government from making states' existing Medicaid funding contingent on participation in the expansion. But it made no changes to the preexisting Medicaid law and the federal government's authority to require states' compliance with existing Medicaid program rules.

How has the insurance industry played a major role in the development of the ACA?

Under the ACA, between 2014 and 2018, *the insurance industry will contribute annual fees to the federal government* totaling $47.5 billion as a percent of premiums to *help offset the ACA costs*. In subsequent years, the industry will pay fees based upon rates o premium increase. This fee levy recognizes that *the ACA will add millions of new insurance company customers*.

What population did the Children's Health Insurance Program (CHIP) target?

Uninsured children whose family income was too high to qualify for Medicaid and too low to afford private health insurance

What is alternative medicine?

Used in place of conventional medicine

What is complementary medicine?

Using alternative medicine with traditional medicine

What is the mission of Office of the National Coordinator for Health IT (ONC)?

Using information and technology to: - Improve health and health care - Reduce costs

Was the Balanced Budget Act of 1997 effective?

Yes. Between 1998 and 2002, there were *declines in Medicare spending growth*.

What is the role of hospitals and other healthcare facilities in the U.S. Health Care Industry?

Shapes provider activity

Which distribution principle uses supply-side rationing?

Social Justice

What types of physician information can the public view?

1. Education 2. Training 3. Licensure 4. Membership in professional societies 5. State disciplinary actions 6. Serious misdemeanor convictions

What are the primary financiers of managed care?

1. Employers 2. Government

What are the three main supports offered by CPC?

1. Enhanced payment 2. Data feedback 3. Learning activities and technical assistance

What are the two primary purposes of the Health Insurance Portability and Accountability Act (HIPAA)?

1. Ensure workers could *maintain uninterrupted health insurance coverage* if they lost or changed jobs by enabling them to continue coverage through their prior employer's group health plan 2. *Ensuring the privacy of personal health information*

How does the ACA hold health insurance companies accountable?

1. Ensures premiums spent on health care and benefits/quality improvements 2. Eliminates additional medicare costs and provides bonus payments to Medicare Advantage plans that provide high quality care

What are the four main categories of the determinants of health?

1. Environment 2. Behavior and lifestyle 3. Heredity 4. Medical care

What are some of the ACA provisions that support the PCMH?

1. Expanded Medicaid eligibility 2. Medicare and Medicaid payment increases for primary care and designated preventive services 3. Funding to place primary care providers in shortage areas 4. Center for Medicare and Medicaid Innovation testing new payment and delivery models, e.g., Comprehensive Primary Care (CPC) *How to remember?* E - P - T *E*ligibility for Medicaid *P*rimary care emphasis (payment increases + funding for shortage areas) *T*esting new payment and delivery models

What are the cons of HITECH?

1. Expensive infrastructure to establish and maintain 2. No clear evidence that it improves quality and reduces health care cots 3. Health info. technology software may become incompatible with existing systems

What is the purpose of MACRA 2015?

1. Extend funding for Medicaid Children's Health Insurance Program (CHIP) for four years 2. Implementing the "Doc fix" to establish a schedule that predictably specifies the inflation rate for Medicare reimbursementants

What program set the requirements for the meaningful use program?

Office of the National Coordinator for Health IT (ONC)

Agency for Healthcare Research and Quality (AHRQ)

A federal agency directed to fund outcomes and health services research to start developing practice guidelines

Medicaid

A federal and state assistance program that pays for health care services for people who cannot afford them.

Medicare

A federal program of health insurance for persons 65 years of age and older

What is a big struggle in health care for rural communities?

- Rural health systems struggle with *shortages of various services*. - *Increasing costs* and *declining populations*

What were some of the issues with the U.S. health care system before the ACA?

1. Focus on acute care instead of primary preventive care 2. Rewarding providers for the volume of services delivered rather than with financial incentives to maintain or improve health status

What are the different types of hospitals?

1. General 2. Specialty 3. Teaching 4. Rural 5. Profit vs. Not-for-profit 6. Independent vs. Multi-facility

Health Insurance Portability and Accountability Act (HIPAA)

- *Protects health insurance coverage* for workers and their families when they change or lose their jobs - Requires the establishment of *national standards for electronic health care transactions* and national identifiers for providers, health insurance plans, and employers

How does the diagnosis-related group (DRG) hospital reimbursement system work?

- *The patient's diagnosis predetermines how much the hospital will be paid*, and the hospital knows that amount in advance. - The payment is a set amount based on the average cost of treating a particular illness at a certain level of severity. If the patient requires less care or fewer days in the hospital than the DRG average, the hospital is paid the average cost regardless, and the hospital makes money. If the patient requires a longer stay or more care than the DRG average, the hospital loses money.

What is the role of voluntary facilities and agencies?

- A safety net to replace the services of government or other organizations eliminated by budgetary reductions - *Provide health counseling, health care, and research support*

Managed Care Organization (MCO)

- An organization that *functions like an insurance company* - Promises to provide health care services contracted under the health plan to the enrollees of the plan

What is the role of insurance company interest groups in Obama's health care reform?

- Appeared to support the general idea while vigorously *opposing the idea of a public option that would limit their profits* - Spent millions of dollars in lobbying efforts and *misinforming the public about the healthcare reform*

What did the HITECH Act do?

- Created the *Medicare and Medicaid Electronic Health Record Incentive Program* - Allowed the *Center for Medicare and Medicaid (CMS)* to incentivize eligible professionals and hospitals to adopt, upgrade, implement or demonstrate *meaningful use of certified EHR technology* to improve patient care.

What is the Patient's Bill of Rights?

- Developed by the American Hospital Association (AHA) in 1972 - Includes the rights and responsibilities of patients while in the hospital

What is the role of the Federally Qualified Health Centers (FQHC)?

- Established in *urban and rural communities* - Focus on the needs of the *underserved*, comprehensive primary care, professional staffing, community involvement, and partnerships between the public and private sectors - Specialized care programs for migrant farm workers, homeless, residents of public housing

How are patients in Federally Qualified Health Centers (FQHC) get charged?

- Fees are based on income - Services are offered without charge for the neediest patients - No patient may be denied services due to inability to pay

What is the purpose of rural health networks?

- Formed by federal and state governments to address the *shortage of various services* in rural communities - Provide *local access to primary, acute, and emergency care* - Provide *links to more distant regional specialists and tertiary care services*

What is the role of public health interest groups?

- Health promotion and disease prevention - Advocate and education on federal, state, and local decisions

Why was the Two-Midnight Rule implemented?

- Hospitals were billing Medicare for Medicare Part A, inpatient care that should be billed under Medicare Part B, outpatient care - Payment rates higher for inpatient care than outpatient care

What is a diagnosis-related group (DRG)?

- How Medicare and some health insurance companies *categorize hospitalization costs and determine how much to pay for a patient's hospital stay*. - Rather than paying the hospital for what it spent caring for a hospitalized patient, Medicare pays the hospital a fixed amount based on the patient's DRG or diagnosis.

What is the role of health professions education and training institutions?

- Impact nature, quality, and healthcare costs - Instill values, attitudes, and ethics that govern practice

What happened before physician report cards?

- In the 1970s, the AMA code of ethics prohibited information that would point out differences between doctors - Protection of physician performance from public scrutiny

What influenced the evolution of clinical practice guidelines?

- In the late 1970s and early 1980s, publication showed *wide variation in the applications of medical procedures* in different regions of the US - This increased the use of questionable, inappropriate, and unnecessary services that may have increase costs fo health care - Physicians were *unaware of the relative effectiveness of various procedures* - *Patients were not benefiting* from much of the care they received

How did the Balanced Budget Act of 1997 affect rural health networks?

- Included *Rural Hospital Flexibility Program* - Replaced the essential access community hospital/rural primary care hospital with a *critical access hospital (CAH) model* - Provided *Medicare reimbursement for telemedicine*

What is the role of research communities?

- Influence in healthcare research, policy development, and practice by conducting research - Shares findings and supports investigations to affect policy decision making

How did the Rural Hospital Flexibility Program change rural health networks?

- It replaced the essential access community hospital/rural primary care hospital model with a *critical access hospital (CAH) model* - Added *more flexibility* to previous models - *Improves access to hospitals and other services* for rural residents

Readmissions Reduction Program

- Mandated by the ACA, a Medicare program through which *payments to hospitals are reduced based on the readmission of patients with specified diagnoses within 30 days of a prior hospitalization*. - Penalty determinations are based on three prior years' hospital discharge data.

What is the role of employers in the U.S. Health Care Industry?

- Offer health insurance with varying deductibles and co-pays for their employees - Pay for costs and determine what costs should be

What were some of the goals of the Balanced Budget Act of 1997?

- Produce a *balanced budget* - Respond meaningfully to *national health issues from consumer* - Respond meaningfully to *cost-containment* perspectives Specifics: - *Reduce growth in Medicare spending* through savings of $115 billion over five years and targeted hospitals for more than one-third of savings

What is the role of complementary and alternative therapists in the U.S. Health Care Industry?

- Provides *unconventional health therapies* not usually taught in medical schools - Contributes to amount, frequency, and cost of healthcare

Community First Choice Option in Medicaid

- Provides states with an increased federal matching rate to support *community attendant services for individuals who require an institutional level of care* - Allows States to *provide home and community-based attendant services* and supports to eligible Medicaid enrollees under their State Plan

What is the role of the consumer interest group in Obama's health care reform?

- Put pressure on politicians about *rising costs* and *lack of security in healthcare coverage* - Concerns about cost, quality, and access

Describe the Merit-Based Incentive Payment System (MIPS).

- Quality, resource, improvement, meaningful EHR use reporting - Score determines if eligible professional gets payment adjustment

What is the doctrine of informed consent?

- Refers to *full disclosure of facts that the patient needs to make an informed decision* before invasive treatment - Patients have a right to their own body and *autonomy*, including *being able to reject a physician's professional recommendation*

What is the Flexner Report?

- Report by Abraham Flexner by the Carnegie Commission to evaluate medical schools - *Outlined the inadequacies of medical schools* that did not use the German model that promoted medical education on the principles of scientific discovery - Caused schools that did not use this scientific model to close from lack of funding

What is the role of professional associations?

- Represent healthcare professionals or institutions - Influence legislative proposals, regulation, quality issues and politics

What is the role of providers in the U.S. Health Care Industry?

- Responsible for the actual process and outcomes of the service - Responsible for quality and cost of the healthcare system

Describe the initial legislation for rural health networks.

- Rural hospital initiatives have been supported by federal legislation since 1991 - Provided funding to promote the *essential access community hospital* and the *rural primary care hospital* - Allowed physician assistants, nurse practitioners, and clinical nurse specialises to provide primary or inpatient care without a physician

What is the role of the government in the U.S. Health Care Industry?

- Subsidized health care for the elderly, disabled, and poor - Serve not only as payers but also as *regulators and providers* - Taxing authorities that generate the funds to support the system

What are clinical practice guidelines?

- Systematically *developed protocols used to assist practitioner and patient decision about appropriate health care* by defining the roles of specific diagnostic and treatment modalities in patient diagnoses and management - *Based on scientific evidence*

What is the purpose of the HITECH and ARRA Act?

- To promote the development of a nationwide network of electronic health records (EHRs) - To improve quality and reduce costs of health care - To promote continuity of care

What do rural health networks do?

1. *Advocate* at local and state levels on rural health care issues 2. Cooperate in joint community *outreach activities* 3. Seek opportunities to *negotiate MCOs to provide services to enrolled populations*

What are the five core principles of the PCMH?

1. *Inclusion:* Support patients learning to manage and organize their care based upon preferences. Ensures patients, families, and caregivers are included in the development of care plans 2. *Comprehensive:* Offers holistic care 3. *Coordinated:* Ensures that care is organized across all elements of the healthcare system 4. *Accessible:* Delivers accessible service with shorter waiting times, enhanced in-person hours, etc. 5. *Committed to Quality and Safety:* Demonstrates commitment to quality improvement, use of data and health info technology to assist patients to make informed decisions *How to remember?* ICCAQ *I*nclusion *C*omprehensive *C*oordinates *A*ccessible *Q*uality

What were the effects of the Balanced Budget Act of 1997?

1. *Increased cost sharing among Medicare beneficiaries* 2. Extended the prospective payment system introduced with *DRGS (diagnosis related groups)* to other organizations 3. *Opened the Medicare program to private insurers* through the Medicare + Choice Program 4. Created the State Children's Health Insurance Program or the *Children's Health Insurance Program (CHIP)*

What are the responsibilities of patients in the hospital?

1. Cooperate with *reasonable requests* for personal information 2. Inform hospital if they do not understand instructions

What does the Federally Qualified Health Center (FQHC) model emphasize?

1. Coordination and comprehensive care 2. Reductions in health disparities for underserved

What are the components of a policy analysis framework?

1. Delineation and overview of the policy under analysis 2. Historical Analysis 3. Social analysis 4. Economic analysis 5. Political Analysis 6. Policy/Program Evaluation 7. Current proposals for policy reform *How to remember?* *O*verview *S*ocial *H*istorical *E*conomical *P*olitical *P*olicy/Program Evaluation *P*roposal OSHE PPP (Triple P)

What are the judicial challenges of the ACA?

1. Did Congress have the authority to impose the individual coverage mandate with personal financial penalties for noncompliance? 2. Did Congress have the authority to make all of a state's existing Medicaid funding contingent on compliance with ACA's Medicaid expansion provisions?

Two-Midnight Rule

A CMS policy that defines hospital stays of less than two-midnights duration as outpatient visits billable under Medicare part B, rather than more highly reimbursed in patient care under Medicare Part A.

What is a policy brief?

A concise summary of a particular issue, which communicates information to policy-makers and advocates for a certain course of action

Social Justice

A distribution principle, according to which health care is most equitably distributed by a *government-run national health care program*.

Market Justice

A distributional principle according to which health care is most equitably distributed through the *market forces of supply and demand*, rather than government interventions.

What is a policy framework?

A document that sets out a set of procedures or goals, which might be used in negotiation or decision-making to guide a more detailed set of policies, or to guide ongoing maintenance of an organization's policies.

American Federation of Labor and Congress of Industrial Organization (AFL-CIO)

A labor union that had tremendous influence on national health policy

Physician Quality Reporting System (PQRS)

A quality reporting program in which physicians or other eligible professionals collect and report their practice data

Patient-Centered Medical Home (PCMH)

A team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes.

What is the Physician Compare website?

A website that helps patients find and compare physicians and other clinicians enrolled in Medicare so that they can make informed decisions about their health care

How did the Rural Hospital Flexibility Program or CAH program specifically change hospitals?

Added more flexibility to hospitals: - Increased the number of allowed occupied inpatient beds - Increased the max. length of stay before required discharge or transfer - Allowed swing bed program (provides acute hospital care even though it is no longer required)

Vertical Integration

Aggregation of a variety of business entities related to each other

Horizontal Integration

Aggregations of businesses that produce the same good or services

What did the Medicare and Medicaid Electronic Health Record Incentive Program do?

Allowed the *Center for Medicare and Medicaid (CMS)* to incentivize eligible professionals and hospitals to adopt, upgrade, implement or demonstrate *meaningful use of certified EHR technology to improve patient care*.

What is an example of a public health interest group?

American Public Health Association

American Board of Medical Specialties (ABMS)

An independent, not-for-profit organization. It assists its 24 specialty member boards *to develop and utilize professional and educational standards* that apply to the *certification of physician specialists* in the United States and internationally.

What is a second opinion in healthcare?

An opinion from another party (besides the physician) to satisfy concerns about the necessity for various tests and other procedures

Describe the Alternative Payment Models (APMs).

Annual lump sum payment based on 5% of previous year's estimated expenditures

What is the role of the business and labor interest group?

Businesses work with labor unions Ex. Healthcare benefits, wage increases

How do most physicians keep their certifications?

By participating in the ABMS Program for Maintenance of Certification (MOC)

What is the role of pharmaceutical firms in the U.S. Health Care Industry?

Develop and market medications prescribed by doctors to treat patients

What are EHRs?

Electronic Health Records - Computerized patient records that replace paper charts

Electronic Prescribing Incentive Program

Eligible professionals who are successful e-prescribers receive an incentive payment

State Balancing Incentive Program

Enhances federal matching funds to states to increase the proportion of Medicaid *long-term services* and *support dollars allocated toward home- and community-based services*

What is accreditation?

Ensuring *programs* have necessary resources, personnel, and curriculum to produce well-qualified trainees (refers to the institution)

What is the issue with the Two-Midnight Rule?

Hospitals receive less money under this rule because more of their patients are now designated as outpatients.

In rural communities, what determines the survival of a hospital?

How quickly and effectively the hospital could *replace its inpatient services with ambulatory care and long-term care services*

When did the government become the dominant authority in the U.S. Health Care Industry?

In 1965, when Medicare and Medicaid were introduced.

When did physician performance first become available to the public?

In 1986, the Health Care Financing Administration (now renamed CMS) released hospital specific mortality rates for Medicare patients

American Recovery and Reinvestment Act (ARRA)

Included the enactment of the Health Information Technology for Economic and Clinical Health Act, also known as the HITECH Act

What is certification?

Includes board examination and indicates that a *physician* has demonstrated necessary knowledge and skills to practice medicine safely and effectively (refers to the physician

Medicare Part A

Inpatient coverage, home health, hospice.

What is the major stakeholder in the U.S. Health Care Industry?

Insurance companies

What action of the insurance companies resulted in the focus on cost containment and the plight of the uninsured and underinsured?

Insurance companies trying to *eliminate high-risk consumers* and *premium increases*

What is the role of the DHHS Office of Civil Rights?

It has the responsibility for enforcing the Privacy and Security Rules with voluntary compliance activites and civil money penalites

What are the essential access community hospitals and the rural primary care hospitals?

Limited-service hospital models developed as alternatives for hospitals that were too small and geographically isolated to be full-service acute-care facilities.

What are interest groups in health care?

Lobbying centers for or against implementation and passing of tax-funded health service proposals

What are Federally Qualified Health Centers (FQHC) organized under?

Local Health Departments (LHDs)

What is the predominant form of U.S. health insurance?

Managed Care Organization (MCO) Insurance Plans

Are second opinions required in health plans?

Many insurers now require a confirming second opinion before agreeing to pay for certain surgical or other procedures. Medicare and many private health plans cover most of the costs of second opinions.

Which distribution principle uses demand-side rationing?

Market Justice

What is the major public source of financing for nursing home care?

Medicaid

What types of physician information can the public not view?

Medical malpractice and hospital disciplinary information

What is MACRA 2015?

Medicare Access and CHIP Reauthorization Act of 2015

Medicare Part D

Medicare prescription drug reimbursement plans

Medicare Part B

Outpatient care. Extends Medicare to supplemental treatments, and physicians

What does Medicaid eligibility require?

Persons "spend down" their personal resources to meet financial eligibility

Which interest group developed the most powerful lobbies?

Physicians

What issue do physicians have as stakeholders in the U.S. Health Care Industry?

Physicians must find a balance between having a *gatekeeper role* for the insurance companies and being an *advocate* for the patient. The doctor-patient relationship > monetary reward.

What are some examples of providers in the U.S. Health Care Industry?

Physicians, dentists, nurses, nurse practitioners, physician assistants, pharmacists, podiatrists, chiropractors, and a large array of allied health provider

Privacy Rule of HIPAA

Prevents health care plans or providers from disclosing health information about individuals to others, including their employer

Security Rule of HIPAA

Prevents health care plans or providers from disclosing health information that is held or transferred in *electronic form*

Demand-Side Rationing

Prices and ability to pay ration the quantity and type of health care services people consume

Meaningful Use Program (MUP)

Provided incentives to eligible professionals and eligible hospitals to demonstrate "meaningful use" of the EHR technology to improve patient care

What are the advantages of vertical integration?

Provides a *one stop shop* for sponsoring organizations, patients, physicians, other providers, and payers

What is the ABMS Program for Maintenance of Certification (MOC)?

Provides periodic (about 10 years) professional knowledge self-assessment and/or practice improvement activities in the speciality or subspecialties in which one or more certification is held

What is the role of the long-term care industry?

Providing long-term care to the *aging population* and *rehabilitation facilities*

What was the pharmaceutical companies role in crafting the 2003 Medicare Part D presctiption drug benefit olan?

The pharmaceutical industry made it so that Medicare and the federal government were prohibited from negotiating prices with drug companies

What are the personal rights of hospitalized patients?

The right to know: - What is being done to them and why - What the procedure entails - How the procedure can be expected to benefit them - Risks or consequences associated with the procedure - Probability to risks and consequences

What does the increase in complementary and alternative therapies indicate suggest about the health care system?

There is a substantial level of dissatisfaction with traditional scientific medicine.

HIT Standards Committee

This group *provides recommendations* to the National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information.

HIT Policy Committee

This group *provides recommendations* to the ONC on policy framework for the development and adoption of a nationwide HIT infrastructure that permits electronic exchange of health information.

How do pharmaceutical firms receive reimbursement?

Through insurance or governmental drug-benefit plans

What is the role of the Office of the National Coordinator for Health IT (ONC)?

To coordinate nationwide efforts to implement and use the most advanced health information technology and electronic exchange of health information

What was the goal of the Rural Hospital Flexibility Program or CAH program?

To enable small rural hospitals to *maximize reimbursement* and *meet community needs* with responsiveness and flexibility

What is the purpose of the Readmissions Reduction Program?

To encourage hospitals to improve the quality and continuity of care beyond the acute episode that resulted in the initial hospitalization

What is the purpose of the Department of Health and Human Services (DHHS)?

To establish *national standards* for regulations *protecting the privacy and security of certain health information*

What is the purpose of the ABMS Program for Maintenance of Certification (MOC)?

To help *ensure physicians keep their medical knowledge up-to-date* and adopt quality-improvement processes in their practices as they progress through their medical careers

What is the primary goal of employers in the U.S. Health Care Industry?

To make money

What is the primary responsibility of insurance companies in the U.S. Health Care Industry?

To maximize stockholder wealth

What is the primary responsibility of pharmaceutical firms in the U.S. Health Care Industry?

To maximize stockholder wealth

What is the goal of the Managed Care Organization (MCO)?

To provide appropriate, cost-effective medical treatment

What is the purpose of the diagnosis-related group (DRG) hospital reimbursement system?

To provide hospitals with a financial incentive to discharge patients as soon as possible.

What is the mission of the American Board of Medical Specialties (ABMS)?

To serve the public and the medical profession by improving the quality of healthcare through *setting professional standards for lifelong certification* in partnership with Member Boards

What is evidence-based clinical practice?

Treatment protocols *based on scientific evidence* from rigorous systematic review of published medical literature