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HA150 Midterm
HA150
| Term | Definition |
|---|---|
| Determinants of Health | Genes Physical environment - pollution, clean water, weather, overcrowding Social environment Health care, economics, education Health behavior - controllable life choices |
| Features of US healthcare system | No central gov agency Tech driven Acute care high cost, unequal access, avg outcomes Imperfect market conditions Gov subsidiary of priv sector Market vs social model |
| 3rd party payer system | How the US pays for health care Patient, health insurance, and service |
| Inpatient care | Community hospital, nursing homes, tertiary hospital (deal with trauma, have helicopter pad) Overnight care |
| Outpatient care | Physician offices, urgent care centers, ambulatory/outpatient care centers, surgical centers Walk in to doctor, get care and leave Main money maker in hospitals |
| Private health insurance | Employer based Or purchased through ACA marketplace |
| Medicare | 65 or older end stage renial disease (kidney) disability and collect social security disability income |
| Medicaid | Low income Medically needy Disabled without social security disability income |
| State Children's health insurance program (SCHIP) | Children of parents w/o low health insurance, that make a low income but too high to qualify for medicaid Typically children of parents that have a job w/o insurance Program is under medicaid |
| Tricare/VA | Health insurance offered to active duty military and veterans |
| Healthcare Triumvirate | Interaction between cost, access, and quality of care |
| For profit hospitals | Profit of hospitals go to share holders |
| Not for profit hospitals | Profit goes back to hospital or community |
| Hill Burton Act | Gov expanded hospital access to rural areas, but overbuilt hospitals Led to Certificate of Need (CON) program Need to show panel of people that need demand for hospital |
| Major payers of healthcare | Private insurance is leading payer of healthcare, followed by medicare, other, and medicare |
| Hospitals | Hospitals lose money on patient care Need to have other revenue methods; pay for parking, gift shops, and cafeterias |
| Average length of stay in hospitals | 4 and a half days Decreased because of child birth being the most common stay in a hospital |
| Telehealth | Electronic and telecommunication care Meet online with doctor |
| Difference between MD and DO | Medical doctor (MD) vs doctor of osteopathic medicine (DO) Differ in philosophy; bone vs medical + surgery DOs emphasize "whole person" approach w/ focus on lifestyle & environmental factors, whereas MDs focus on disease specific allopathic treatment |
| International medical graduates | About 25% of US physicians Internal students that get jobs because they are paid cheaper as US has a supreme undersupply of PCPs |
| Advanced practice provider or Physician extenders | Physician assistants, nurse practitioner 2 APP = price of 1 PCP |
| Scope of practice | defines the procedures, actions, and processes that a licensed professional is legally permitted to undertake, based on their specific education, training, and experience |
| Nurses | Registered nurses and Bachelor of Science in Nursing have moderate to wide scope; can't prescribe or diagnosis Licensed practical nurse small scope NPs & PA - very wide scope, diagnosis prescribe, and treat themselves |
| Pharmacists | ensure the safe, effective use of prescription and over-the-counter drugs |
| PT | focus on restoring physical movement, strength, and mobility, especially after injury |
| OT | work for everyday functions or daily living fine motor skills |
| Healthcare administrators | Most growth in healthcare workforce Costs account for 34% of healthcare cost Demand is growing |
| independent private practice (solo or group) or Private physician clinics | More patients, more money Fee for service (traditional indemnity) based income for physicians |
| Corporate/institutional ownership or Affiliated identity | Type of ownership Salaries physicians, doesn't matter how many patients |
| Urgent care | Bridge b/w PCP and emergency departments Profit chains Not rly mortal diseases/injuries Don't have to treat you if you don't have insurance |
| Emergency medical treatment and law act (EMTALA 1986) | Law that made emergency rooms have to treat you even if you don't have insurance |
| Concierge medicine | Patients pay up front fee in addition to premium to physician, for unlimited visits |
| Most of outpatient services | Majority of outpatient services are to primary care |
| Risk of insurer in HI | Risk of insuring unhealthy people and having to pay for their care Uses actuaries to create a risk pool |
| Risk of patient in HI | Risk of paying wrong type of insurance and bearing medical costs |
| Premium | Amount you pay each money for health insurance |
| Deductible | Amount you pay out of pocket before health insurance kicks in |
| Copayment | Dollar amount you pay when you seek health care services; doesn't change, fixed rate |
| Co-insurance | Percentage you pay when you seek services Can change but its a fixed ratio typically 90/10 or 80/20 |
| Exclusions | Services not covered by HI Ex- cosmetic surgery, adult dental/vision care, and LASIK surgery |
| Max dollar limit | Max amount insurance company will pay for claims in a given time period Prohibited except non-essential services |
| PPACA | Eliminated dollar limits on benefits for ambulatory/outpatients |
| Traditional indemnity (fee for service) | Doctors share what they want from insurances Heavily increased price of insurance |
| Managed care | Plans that contact w/ healthcare provider Facilities provide care @ reduced cost per member per month Emphasis placed on wellness and prevention; disease management |
| Prospective payment system | Providers know how much they are going to make off a patient before they even walk through the door |
| Health maintenance organization (HMO) | Restrictive, cheap premium PCP req & coordinates care; PCP needs to give referral Must stay in provider network Out of network = self pay |
| Preferred provider organization (PPO) | Less restrictive, more expensive, most popular due to more choices Copay |
| Point of Service (POS) | Expensive premiums Closest to traditional indemnity (fee for services) Most choices, least restrictive |
| Exclusive provider organization (EPO) | Like HMO, no out of network Don't need PCP referral or PCP Becoming more popular |
| Paneled provider | Clinician/hospital in insurance plan's network |
| Referral | Process of PCP refers to specialist |
| Gatekeeper | Term used to describe how PCP manages patients care; can deny referral |
| Denial | Plan's finding that subscriber didn't meet criteria for coverage so not payment will be made to provider |
| Adverse selection | Problem of attracting members sicker than general population, specifically members sicker than anticipated when developing reimbursement rates for care |
| Insolvency | Risk for managed care plans Plan no longer has enough reserve money to meet obligation of members |
| Moral hazard | Risk for managed care plans People more inclined to use insurance because they have it |
| Risks to consumers in managed care plans | Out of network costs Non-formulary items Exclusions Denials |
| Social insurance | Medicare - fed Medicaid - fed and state (state manages program) SCHIP - fed and state Tricare/VA - fed |
| Social insurance | Department of human health services -> Centers for Medicare and Medicaid -> medicare and medicaid |
| Four parts of medicare | Medicare A - hospital insurance, only thing that doesn't need to be paid for B - acute care outpatient or doctor physician fees C - managed care HMO D - prescription drugs |
| Uninsured population | Mostly hispanic adults Most are working Texas is the most insured state (18%) Uncompensated care |
| Uncompensated care | In order for hospitals to get money from somewhere they need insurance to raise prices (reimbursement rates), which makes the consumer pay more |
| In what month should you not visit a hospital in the US? | July -> hospital residences open in July, so there are a lot of newer doctors with less experience. This means that there are more likely to be medical errors in the hospital operations. |
| How does the US compare to other industrialized countries in medical errors? | The US ranks worst or near the worst in medical errors than other countries. This is due to universal health coverage, stronger primary care, better care coordination, and safer protocols/procedures. |
| PharmD | needs a lot of education bc they need to ensure combinations of medications are safe and don’t cause adverse effects Make sure drugs are on the formulary (list of drugs covered by insurance) so patients don't have to pay more money |
| Medical errors | Falls Wrong/errant surgery Unintended retention of foreign object (something entered patient’s body during surgery) Assault/homicide Wrong diagnosis |
| Hospital acquired infection | Nosocomial infection like MRSA |
| Federally qualified health centers | Federally qualified health center, federally funded serving underserved population; low income & uninsured |
| Retrospective payment | is a fee-for-service (aka traditional indemnity) Examples - Fee-For-Service (FFS), where providers (doctors, hospitals) deliver services and then bill insurers based on the actual costs of car |
| Patient Protection Affordable Care Act (PPACA) | protects essential health benefits, such as inpatient/outpatient care, emergency/rehab treatments, and preventive care. Expaned HI but doesn't guarantee access to everyone like universal health care |
| Tax equity and fiscal responsibility act | Created capitation on how much hospital can make so they dont overtreat and make too much money; created prospective payment |
| ICD-10 | International classification of diseases vol 10 PCS - produral coding system for inpatient CPT - current procedural terminology for outpatient |
| Ambulatory Payment Classification | Under part B of medicare (that you need to pay premium for) How outpatients classify disease and thus how diagnosis and care is paid for under medicare |
Created by:
phillipchristopherr