Health Ch 13--Health Care Delivery in the United States

What kind of education do limited (restricted) care providers have?

a doctoral degree in a health care specialty

Describe some of the major changes that have taken place in health care delivery over the years.

care moved from homes to hospitals; new procedures; doctors more specialized

What are nonphysician practitioners (NPP)?

clinical professionals who practice in many of the areas similar to those in which physicians practice, but do not have an MD or DO degree

Define complementary and alternative medicine and give a few examples of each.

complementary--using a non-mainstream approach together with conventional medicine, (accupuncture with medicine to help lessen pain) alternative--using a non-mainstream approach in place of conventional medicine (using a special diet to treat cancer instead of chemotherapy)

What are three major problems facing the health care system in the United States?

cost containment, access, quality

Why has the number of home health care agencies increased in recent years?

due to restructuring of health care system, technological advances, and cost containment

What are advanced practice nurses (APNs)?

those with master or doctoral degrees

What is meant by a long-term care facility?

nursing homes, group homes, transitional care, day care, home health care

prospective reimbursement

uses pre-established criteria to determine in advance the amount of reimbursement

What role do public health professionals play in health care delivery?

work in public health organizations that are available to everyone; primary service economically disadvantaged

In what type of facility are most health care workers employed?

40% work in hospitals, 25% work in outpatient health care settings, 26% in nursing/residential care, 17% in home health care

What is covered in each of the four parts of Medicare?

A- hospital insurance B- medical insurance C- managed care plans D- prescription drug plans *A&B are guaranteed, C is not available everywhere and D is optional

How is the quality of health services measured?

AHRQ and NCQA measure quality

Why have some questioned whether the United States really has a health care system?

Health care in the U.S. is delivered by an array of providers, in a variety of settings, under the watchful eye of regulators, and paid for in a variety of ways. Other developed countries have national health insurance run or organized by the government and paid for, in large part, by general taxes. In these countries almost all citizens are entitled to receive health care services, including routine and basic health care.

almshouses

In colonial times, these were run by local government; provided public health for people who couldn't take care of themselves

What is the difference between LPNs and RNs?

LPN--those prepared in 1- to 2-year programs to provide non-technical bedside nursing care under the supervision of physicians or registered nurses RN--one who has successfully completed an accredited academic program and a state licensing examination

What is the difference between Medicare and Medicaid?

Medicare--federal health insurance program for those 65+ Medicaid--health insurance program for low-income, no age requirement

What is meant by a spectrum of health care?

Refers to the various types of care; four levels of practice have emerged: population-based public health practice, medical practice, long-term practice, and end-of-life practice

exclusion

a health condition written into the health insurance policy indicating what is not covered by the policy

What is meant by third-party payment?

a health insurance term indicating that bills will be paid by the insurer and not the patient or the health care provider; the standard method of payment in the U.S.

pre-existing condition

a medical condition that had been diagnosed or treated usually within the 6 months before the date a health insurance policy goes into effect

capitation

a method of paying for covered health care services on a per-person premium basis for a specific time period prior to the service being rendered

fee-for-service

a method of paying for health care in which after the service is rendered, a fee is paid

copayment

a negotiated set amount that a patient pays upfront for a certain service

pesthouses

a place of quarantine to protect others from infectious disease

premiums

a set amount of money for regular, periodic payments

What is the Children's Health Insurance Program (CHIP)?

a title insurance program under the Social Security Act that provides health insurance to uninsured children

policy

a written agreement between a private insurance company and an individual or group of individuals to pay for certain health care costs during a certain time period in return for regular, periodic payments

What are the differences between allopathic and nonallopathic health care providers?

allopathic--produce effects different from those of diseases (MD) osteopathic--more holistic; focus on relationship between body structure and function (DO)

point of service (POS)

an option of an HMO plan that enables enrollees to be at least partially reimbursed for selecting a health care provider outside of the plan

preferred provider organization (PPO)

an organization that buys fixed-rate health services from providers and sells them to consumers

exclusive provider organization (EPOs)

an organization that is like a PPO but with fewer providers and stronger financial incentives

What relationship does Medigap insurance have to Medicare?

fills in the gaps left from Medicare

health maintenance organizations (HMOs)

groups that supply prepaid comprehensive health care with an emphasis on prevention

consumer-related health plans

health plan options that combine more consumer responsibility for decisions with a tax-sheltered account to pay for out-of-pocket costs for health care and a high-deductible health insurance policy

What is the difference between independent and limited (restricted) care providers?

independent--specialized education and legal authority to treat any health problem or disease limited--advanced training in a health care specialty

What is the Joint Commission? What does it do?

predominant organization responsible for accrediting health care facilities; certifies more than 20,000 health care organizations and programs in the United States & other countries

What are the domains of practice noted in the spectrum of health care?

public health practice--incorporates interventions aimed at disease prevention and health promotion, specific protection, and a good share of case findings medical practice--those services usually provided by or under the supervision of a physician or other traditional health care provider long-term practice-- restorative care and long-term care for chronic conditions end-of-life practice--services provided shortly before death

resource-based relative value scale

reimbursement to physicians according to the relative value of the service provided

packaged pricing

several related health services are included in one price

deductible

the amount of expenses that the beneficiary must incur before the insurance company begins to pay for covered services

fixed indemnity

the maximum amount an insurer will pay for a certain service

co-insurance

the portion of the insurance company's improved amounts for covered services that a beneficiary is responsible for paying