Healthcare Administration Final
Alternative Payment Model (APM)
A Model through which physicians and other healthcare providers accept a measure of financial risk and are reimbursed based upon prudent resource use and quality of patients outcomes rather than on ha piecemeal fee-for-service basis. Examples of APMs include bundled payments for care and accountable care organizations.
Diagnosis-related groups (DRGs)
A case payment system that radically changed hospital reimbursement shifting hospital reimbursement from the retrospective to a prospective basis. This system provided incentives for the hospital to spend only what was needed to achieve optimal patient outcomes.
Managed behavioral healthcare organization (MBHO)
A corporate entity to which a health plan may outsource the management of mental health services for its subscribers. This entity assumes the financial risks and benefits of managing treatment budgets and authorization for access to mental health services.
Indemnity Insurance
A form of insurance in which the insurance company sets allowable charges for services that it will reimburse after services are delivered and allows providers to bill patients for any uncovered excess costs.
aging in place
A healthcare system that brings together a variety of health and other supportive services to enable older, frail adults to live independently in their own residences for as long as is safely possible.
Hospitalist
A physician typically board certified in internal medicine who specializes in the care of hospital patients. may be an employee of one or more hospitals or an employee of one or more companies that contract with hospitals to provide services
Information Blocking
A practice by some electronic health record providers and developers that actively blocks transfer of electronic information between institutions with different electronic systems.
Financial Risk Sharing
A practice that transfers some measure of financial risk from insurers to providers and beneficiaries. Such transfers of financial risk to beneficiaries commonly take the form of copayments and deductibles. Co-payments require that beneficiaries pay a set fee each time they receive a covered service, such as a co-payment for each physician office visit. Deductibles require beneficiaries to meet predetermined, out-of-pocket expenditure levels before an insurer assumes payment responsibility. Financial risk-sharing by providers bases their reimbursement levels on insurer-determined parameters related to costs, patient treatment outcomes, and other factors for defined population groups.
Computerized Physician Order Entry (CPOE)
A process in which a physician enters patient treatment orders into an individual patient's electronic health record.
carve-out
A process through which insurers outsource subscribers' mental illness care oversight to firms specializing in managing service use for mental health diagnoses.
assisted living
A program that provides and/or arranges for daily meals, personal and other supportive services, health care, and 24-hour oversight to persons residing in a group residential facility who need assistance with the activities of daily living.
Medicare Advantage
A program through which Medicare beneficiaries may have their benefits administered by managed healthcare organizations (MCOs).
health services research
A research field combining perspectives and methods of epidemiology, sociology, economics, and clinical medicine. It also uses process and outcome measures reflecting behavioral and economic variables associated with questions of treatment effectiveness and cost-benefit.
Academic Health Center
A university-affiliated complex of professional academic and clinical care facilities such as medicine, nursing, pharmacy, dentistry, and allied health professions that are the principal places of education and training for physicians and other healthcare personnel, the sites for most basic medical research, and the settings for clinical trials.
Maintenance of Certification (MOC)
An American Board of Medical Specialties ( ABMS) requirements of ongoing, educational programs and recertification examination every 10 years in each of the specialties and subspecialties in which a physician is certified. The requirements culminate in an ABMS-sponsored board recertification examination 10 years after first receiving certification and every 10 years afterwards.
Monolithic model of health information exchange
An HIE design in which all member institutions send clinical data to one central repository where all data reside together in one universal and standardized format. In this model, authorized users may access individual, transinstitutional patient records from the central repository
Federated Model of Health Information Exchange
An HIE design in which member institutions maintain their own data at their respective sites in the standardized format used by an HIE
Computerized Decision Support System (CDSS)
An electronic information based system in which individual patient data is matched with a computerized knowledge base such as evidence based clinical practice guidelines, to assist healthcare providers in formulating accurate diagnoses, recommendations, and treatment plans
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.
naturally occurring retirement community (NORC)
Apartment complexes, neighborhoods, or sections of communities where residents have opted to remain in their homes as they age.
Behavioral Scientist
Behavioral science include professionals in social work, health education, community mental health, alcoholism and drug abuse services, and other health and human service areas.
laboratory technologist and technicians
Clinical laboratory personnel who analyze body fluids, tissues, and cells checking for bacteria and other micro organisms: analyze chemical content of body fluids: test drug levels in blood to monitor the effectiveness of treatment: and match blood for transfusion. Technologist have a bachelor's or higher degree: technicians may hold associate's degrees or certificates.
Assessment (as a core function of public health)
Collecting and analyzing data to define population health status and quantify existing or emerging health problems
Electronic Health Record (EHR)
Computerized patient records that essentially replace paper charts.
basic science research
Conducted by biochemists, physiologists, biologists, pharmacologists, and others concerned with sciences that are fundamental to understanding the growth, development, structure, and functions of the human body and its responses to external stimuli.
clinical observation unit (COU)
Dedicated locations adjacent to hospitals EDs or as beds located in other areas of the hospitals, COUs use a period of 6-24 hours to triage, diagnose, treat and monitor patient responses whole common complaints such as chest pain, abdominal pain, cardiac arrhythmia's, and congestive heart failure are assessed.
Empirical Quality Standards
Derived from distributions, averages, ranges, and other measures of data variability, empirical quality standards compare information collected from a number of similar health service providers to identify practices that deviate from norms.
never events
Egregious medical errors occurring in hospitals, the treatment for which the DHHS will not provide reimbursement.
national health care workforce commission (NHCWC)
Established by the ACA, the NHCWC was mandated to evaluate and make recommendations for the nation's healthcare workforce including education and training support for existing and potential new workers at all levels, efficient workforce deployment, professional compensation, and coordination among different types of providers. Congress has withheld funding, so the NHCWC has never commenced work.
HMO Act of 1973
Federal legislation enacted by the Nixon administration that provided loans and grants for the planning, development, and implementation of combined insurance and healthcare delivery organizations and required that a comprehensive array of preventive and primary care services be included in the HMO arrangement.
High Deductible Health Plan (HDHP)
First dubbed " consumer-driven health plan," the plans are now known as high deductible health plans (HDHPs), HDHP's goals are to entice employees with lower premium costs exchanges for agreeing to make out-of-pocket up-front payments for health services. The HDHP intends to encourage cost-consciousness about the use of healthcare services. Toda, HDHPs are the second most common type of plan offered by employers with 24% of U.S. workers selecting this option.
Graduate Medical Education Consortia
Formal associations of medical schools, teaching hospitals, and other organizations involved in the training of medical residents.
assurance (as a core function of public health)
Governmental public health agency responsibility to ensure that basic components of the healthcare delivery system are in place.
Community-rated insurance
Insurance plans in which all individuals in a defined group pay premiums without regard to age, gender, occupation, or health status. Community rating helped ensure nondiscrimination against groups with varying risk characteristics to provide coverage at reasonable rates for the community as a whole.
Experience-rated insurance
Insurance plans that use historically documented patterns of healthcare service utilization for defined populations of subscribers to determine premium charges.
disease management programs
MCO programs that attempt to control costs and improve care quality for individuals with chronic and costly conditions through methods such as the use of evidence-based clinical guidelines, patient self-management education, disease registries, risk stratification, proactive patient outreach, and performance feedback to providers.
Continuing Life Care Community (CLCC)
Most expensive of CCRC options. CLCCs offer unlimited assisted living, medical treatment, and skilled nursing care without any additional charges as residents' needs change over time.
international medical graduates (IMG's)
Physicians trained in medical schools outside the United States who fill the annual shortfall in U.S. medical school graduates required to staff hospitals. Responsibility for evaluating credentials of IMGs entering the United States' residency programs lies with the Educational Commission for Foreign Medical Graduates.
comparative effectiveness research
Research designed to inform healthcare decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. Evidence is generated from research studies that compare drugs, medical devices, tests, surgeries, or ways to deliver health care.
Health information administrator
Responsible for the activities of the medical records departments of hospitals, skilled nursing facilities, managed care organizations, rehabilitation centers, ambulatory care facilities, and other licensed health care entities. They maintain information systems to permit patients data to be received, recorded , stored, and retrieved to assist in diagnosis and treatment and supply research data for tracking disease patterns, evaluating the quality of patient care, verifying insurance claims, and maintaining patient record confidentiality. A bachelor's degree in health information administration is the entry-level credential.
ambulatory care
Services that do not require an overnight hospital stay.
Explicit Quality Standards
Standards that are professionally developed and agreed on in advance of a quality assessment. Explicit standards minimize the variation and bias that result when judgments are internalized.
Implicit Quality Standards
Standards that rely on the internalized judgments of expert individuals conducting a quality assessment and as such are subject to variation and bias.
evidence based clinical practice guidelines
Systematically developed protocols based on extensive research that are used to assist practitioner and patient decisions about appropriate healthcare decisions.
Analytic studies
Test hypotheses and try to explain biologic phenomena by seeking statistical associations between factors that may contribute to a subsequent occurrence and the initial occurrence itself.
health insurance marketplace (HIM)
The ACA requires states to establish health benefit exchanges ( now known as health insurance marketplaces, or HIMs) to facilities individuals' and small employers' choices among health plans. With participation by insurance companies in each state, HIMs creates a competitive health insurance market by providing web-based, easily understandable, comparative information for consumers on plan choices and standardized rules regarding health plans offers and pricing.
Focused Practice in Hospital Medicine (FPHM)
The American Board of Internal Medicine educational program through which physicians already certified in the internal medicine specialty obtain certification as hospitalists.
balanced budget act of 1997
The act contain significant changes to Medicare and Medicaid extended health care coverage to uninsured children with major funding allocation to new children's health insurance program (CHIPS) the act also proposed to reduce growth and Medicare and Medicaid spending 125.2 billion in five years it increased beneficiary premiums for Medicare part B and required new prospective payment systems for hospitals outpatient services, skilled nursing facilities, home health agencies, and rehabilitation hospitals.
meaningful use
The criterion defined by the ONC in collaboration with the Centers for Medicare and Medicaid Services that entails meeting a set of time-delineated requirements for eligible professionals and hospitals to qualify for incentive payments under the HITECH Act.
Agency for Healthcare Research and Quality (AHRQ)
The federal agency responsible for tracking and improving the quality, safety, efficiency, and effectiveness of health care for Americans.
National Committee for Quality Assurance (NCQA)
The most influential managed care quality assurance organization, formed in 1979, NCQA primary functions are accreditation for MCOs, PPOs, managed behavioral healthcare organizations, new health plans, and disease-man -management programs; certifying organizations that verify providers credentials and consultation on physician organizations; and utilization management for organizations, patient-centered medical homes, and disease-management organizations and programs.
alternative medicine
The practice of using non-mainstream treatment approaches in place of conventional medicine
Medicaid
Title XIX (Social Security Act, 1935) medicaid is a joint federal/state program providing insurance coverage for a prescribed scope of basic healthcare services to Americans who qualified based on income parameters.
Medicare
Title XVIII (Social Security Act, 1935) medicare guarantees a minimum level of health insurance benefits to all Americans beginning at age 56
complementary medicine
Treatment that is not mainstream medicine but is used together with mainstream medicine. An example of complementary medicine would be using acupuncture to treat allergies in addition to obtaining conventional allergy medication prescribed by an allergist.
Employer Mandate
Under the ACA, it requires all business with 50 or more full-time equivalent employees to provide health insurance to at-least 95% of their full-time employees and dependents up to age 26, or pay a fee by 2016. Employers are subject to ha $2,000 fee per full-time employee (in excess of 30 employees). The Mandate does not apply to businesses with 49 or fewer employees.
individual mandate
Under the ACA, the requirement that all American citizens (with specific exclusions) obtain health insurance coverage or pay a penalty.
Merit-based Incentive Payment System (MIPS)
Under the MACRA, combines three previous quality reporting programs into one reporting system, scoring eligible professionals (EPs) on quality , resources use, clinical practice improvement activities, and meaningful use of certified EHR technology. The composite MIPS performance score determines whether EPs will receive an annual upward, downward , or no payment adjustment.
Co-morbidity
When two disorders or illnesses occur in the same person, simultaneously, or one after another.
national center for complementary and integrative health (NCCIH)
a center of the national institutes of health devoted to defining through rigorous scientific investigation, the usefulness and safety of complementary and integrative interventions and providing the public with research based information to guide health care decision making
health information technology for economic and clinical health act (HITECH Act)
a component of the American Recovery and Reinvestment Act of 2009 dedicated to promoting nationwide adoption and use of electronic health records
Healthcare Effectiveness Data and Information Set (HEDIS)
a data collection and aggregation system that provides a standardized method for MCO's to collect, calculate and report information about their performance to allow employers, other purchasers, and consumers to compared different health insurance plans.
ambulatory surgery center (ASC)
a facility performing surgical and nonsurgical procedures on an ambulatory (outpatient) basis in a hospital or freestanding center's general operating rooms
Accountable Care Organization (ACO)
a group of suppliers of healthcare who voluntarily work together to provide coordinated care for Medicare patients. They share in the savings to the federal government based on their improvement of quality in reducing cost.
Capitation
a managed care reimbursement method that prepays providers for services on a per-member per-month basis whether or not services are used. if providers exceed that predetermined capitation amount, they may incur a financial penalty. if providers use fewer resources than predicted, they may retain the excess as profit
natural history of disease
a matrix used by epidemiologist and health service planners that places everything known about a particular disease or condition in the sequence of its origin and progression when untreated. the matrix identifies causes and stages of a particular disease or condition and facilitates matching of causes and stages with appropriate types or interventions intended to prevent the condition's occurrence or to arrest it progress after onset
Health Information Exchange (HIE)
a network that enables the sharing of health-related information among provider organizations according to nationally recognized standards
Hospice
a philosophy supporting a coordinated program of care for the terminally ill that focuses on maintaining comfort and quality of life. the most common criterion for admission into hospice is a diagnosis of a terminal illness with a limited life expectancy of six months or less
Accreditation
a process whereby a professional organization or non-governmental agency grants recognition to a school, educational program, or healthcare institution for demonstrated ability to meet predetermined criteria for established standards
case series
a published summary of a small number of individual case in the biomedical literature that usually occur for extremely rare conditions or for new illnesses or syndromes and often when the diagnosis is unknown, typically without rigorous analysis. Case series generally are developed by experts and undergo peer review before they are published.
Certification
a regulatory process, much less stringent than licensure, under which a state or professional organization attest to an individual's advanced training and performance abilities in a field of healthcare practices.
intergrative medicine
a treatment approach that brings conventional medicine and complementary medicine together in a coordinated manner
long-term care facility (LTCF)
an institution such as a nursing home, skilled nursing facility or assisted living facility that provides health care to people who are unable to manage independently in the community
health system agency (HSA)
an organization created by the National Health Planning and Resources Development Act of 1974 that included broad representation of healthcare providers and consumers on governing boards and committees to deliberate and recommend healthcare resource allocations to their respective federal and state governing bodies
Federally Qualified Health Centers
community-based primary care center staffed by a multidisciplinary team of health care and related support personnel, with fees adjusted based n the ability to pay. also provide services to link patients with other community resources
Horizontal Integration
consolidation of two or more hospitals of other entities under one owner through merger or acquisition
National Prevention, Health Promotion, and Public Health Council
established by the ACA and chaired by the U.S. Surgeon general, an organization charged with developing and leading a national prevention strategy and making recommendations to the president and congress for federal policy changes that support public health goals.
Children's Health Insurance Program (CHIP)
established by the balanced budget act of 1997, the CHIP targets uninsured, eligible children for medicaid enrollment. it has successfully enrolled millions of children in medicaid and has been re-funded continously since its inception, including for two additional years through the medicare access and CHIPS reauthroization act of 2015
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
extends funding for medicaid's children health insurance program (CHIP) for two years and establishes a physician payment schedule that predictably specifies the inflation rate for medicare physician reimbursement. Also proposes paying for value and quality of care rather than quantity through programs streamlining physicians participation in quality reporting and payment incentives using the merit based incentive payment system and alternative payment model
disproportionate share hospital (DSH) payment
federal law requires these medicaid payments to states for hospitals serving large numbers of medicaid and low income, uninsured individuals
Hill-Burton Act of 1946
federal law that provided funding to construct new and expand existing U.S. hospitals
descriptive studies
identifying factors and conditions that determine the distribution of health and disease among specific populations using patient records, interviews surveys, various databases and other information sources to provide details or characteristics of disease or biological phenomena and the prevalence or magnitude of their occurrence
medicare modernization and prescription drug act of 2003
in addition to adding drug coverage for medicare beneficiaries, the act established medicare advantage plans with new parameters to replace the medicare+choice option created by the balance budget act of 1997
informed consent
legally recognized patient right, formalized in a document for a patient's signature, to ensure patient's understanding of the risk and benefits of a medical intervention
block grants
mechanism to shift the federal government's direct support and administration of healthcare programs to state and local governments
Ecological Model
model that identify causes of public health problems rooted in the physical and/or social environment and behavior related to an individual
clinical research
primarily focuses on steps in the process of medical care such as the early detection, diagnosis, and treatment of disease or injury
Insitutional Review Board
professionally constituted expert group of individuals who judge the merit of research studies and ensure appropriate and ethical participant safeguards are provided to protect research subjects safety. a primary function of an IRB is to ensure fully informed consent and research subjects' understanding of risk and benefits of participation
Bundled Payments for Care Improvement Initiative (BPCI)
recognizes that separate medicare fee-for-service payments for individual services provided during a beneficiary's single illness result in fragmented care with minimal coordination across providers and settings, rewarding service quantity rather than quality. Testing whether payments for bundled episodes of care can align incentives for hospitals and physicians to achieve improved patient outcomes at lower cost
emergency medical treatment and labor act (EMTLA)
requires hospitals to treat everyone who presents in their emergency department regardless of their ability to pay
continuing care retirement community
residences on a retirement campus, typically in apartment complexes designed for functional older adults. CCRC's offer a comprehensive program of social services, meals, and access to contractual medical services in addition to housing
Department of Health and Human Services
the federal government's principal agency concerned with health protection and promotion and provision of health and other human services to vulnerable populations
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
the first national standardized publicly reported survey of patient's perspectives of hospital care created by the department of health and human services
accreditation council for graduate medical education
the independent, not for profit professional organization that accredits 3-7 year programs of advanced education and clinical practice required by physicians to provide direct patient care in a recognized medical specialty
experimental studies
the investigator actively intervenes by manipulating one variable to see what happens to the other. although they are the best test of cause and effect, they often raise ethical issues and are difficult to carry out
Flexner Report (1910)
the landmark report resulting from a comprehensive review of the quality of education in U.S. and Canadian medical schools, funded by the carnegie foundation, the report was a searing indictment of the most medical schools of the time. the report gave increased leverage to medical education reformers and stimulated financial support from foundations and wealthy individuals which enabled university-affiliated medical schools to gain significant influence over the direction of medical education
expert opinion
the lowest or least rigrous form of evidence, but also the most commonly practiced; usually expresses opinion of a medical specialist in an area of interest to a particular patient; can occur over the phone or face-to-face
Deinstitutionalization
the mental health movement beginning in the 1960's through which severely mentally ill patients previously confined to large state or county psychiatric hospitals were discharged to community boarding or nursing homes. movement marked a major shift of mental health service provision from primarily inpatient settings to community-based facilities
Licensure
the most restrictive form of health professional regulation administered by individual states. defines a professional's scope of practice and educational and testing requirements to engage legally in the practice of a profession
Disability Adjusted Life Year (DALY)
the total number of years of life lost to illness, disability, or premature death within a given population