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US Healthcare Systems Exam 1
Questions and Correct Answers
Access - ANSThe ability of persons needing health services to obtain appropriate care in a timely manner. Can you get medical care when you need it? If yes, you have access to medical care. Access is not the same as health insurance coverage, although insurance coverage is a strong predictor of access for primary care services. Activities of Daily Living (ADLs) - ANSThe most commonly used measure of disability. They determine whether an individual needs assistance to perform basic activities, such as eating, bathing, dressing, toileting, and getting into or out of a bed or chair. See functional status. adjusted community rating - ANSAlso called modified community rating, it is a method of determining health insurance premiums that takes into account demographic factors such as age, gender, geography, and family composition, while ignoring other risk factors. Administrative costs - ANSCosts that are incidental to the delivery of health services. These costs are not only associated with the billing and collection of claims for services delivered but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, costs incurred by insurance and managed care organizations to market their products, and time and effort involved in the negotiation of rates.
Administrative information systems - ANSDesigned to assist in carrying out financial and administrative support activities such as payroll, patient accounting, materials management, and office automation. adverse selection - ANSA phenomenon in which individuals who are likely to use more health care services than others due to poor health enroll in health insurance plans in greater numbers, compared to people who are healthy. Affordable Care Act (ACA) - ANSShortened name for the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010, and also nicknamed Obamacare. Almshouse (also called a poorhouse) - ANSCommon ancestor of hospitals and nursing homes. Served, primarily, general welfare functions by providing food and shelter to the destitute of society. Main function was custodial. Caring for the sick was incidental. American Medical Association (organized medicine) - ANSGained control over medical practice, licensing, and education; for example, licensing was contingent on graduation from AMA-approved schools. Asynchronous technology - ANSUse of store-and-forward technology that allows the users to review the information at a later time. Balanced bill - ANSThe ability to charge the patient the amount above the program's set fees and recoup the difference
churning - ANSA phenomenon in which people gain and lose health insurance periodically claim - ANSA demand for payment of covered medical expenses sent to an insurance company Clinical practice guidelines (medical practice guidelines) - ANSStandardized guidelines in the form of scientifically established protocols, representing preferred processes in medical practice. coinsurance - ANSA portion of health care charges that the insured has to pay under the terms of his or her policy community rating - ANSSame insurance rate for everyone, as opposed to experience rating. Compare illness vs disease. - ANSIllness - person's perception or evaluation of their status/feeling. Disease - based on professional evaluation and can be caused by more than one single factor. consumer-driven health plan - ANSA high deductible health plan that carries a savings option to pay for routine health care expenses copayment - ANSpart of the cost of a medical visit or procedure that the patient must pay out of pocket
Cost efficiency (cost effectiveness) - ANSA service is cost efficient when the benefit received is greater than the cost incurred to provide the service. See efficiency cost sharing - ANSSharing in the cost of health insurance premiums by those enrolled and/or payment of certain medical costs out of pocket, such as copayments and deductibles. Cost-benefit analysis - ANSUsed to evaluate benefits in relation to costs when both are expressed in dollars. Hence, cost benefit analysis is subject to a more rigorous quantitative analysis compared to cost-effectiveness analysis. Cost-effectiveness analysis - ANSA step beyond the determination of efficacy. Whereas efficacy is concerned only with the benefit to be derived from the use of technology, cost-effectiveness evaluates the additional (marginal) benefits be derived in relation to the additional (marginal) costs to be incurred. cost-plus - ANSreimbursement to a provider based on cost plus a factor to cover the value of capital cost-shifting (cross-subsidizing) - ANSIn general, shifting of costs from one entity to another as a way of making up losses in one area by charging more in other areas. For example, when care is provided to the uninsured, the provider makes up the cost for those services by charging more to the insured.
Department of Health and Human Services (DHHS) - ANSThe principal US federal agency responsible for protecting the health of all Americans and providing essential services. Describe Blum's model of health determinants. - ANS1. Environment - sociocultural, physical / somatic
- Lifestyle - attitudes, behaviors, diet, exercise
- Heredity
- Medical care Describe health care during the Post-Industrial Era (late 19th to late 20th century). - ANS1. Growth of professional sovereignty - as tech/meds advanced, status of physicians rose.
- Physicians succeeded in retaining private practice of medicine and resisting national healthcare.
- Employers took on a well-defined role in providing health care.
- Growth of private health insurance.
- Development of public health Describe health care in the Pre-Industrial Era (Mid-18th to late 19th century) - ANSThe consumer was sovereign in the market and healthcare was delivered under free market conditions. Medical practice was in disarray, medical procedures were primitive, the institutional core was missing, demand was unstable, and medical education was substandard.
Describe Health Technology Assessment (HTA). - ANSAny process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use, cost, and cost-effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended. Describe Medicaid. - ANS- Helps indigent populations pay for health care.
- Eligibility determined via a means test.
- A state run program, funded in part by federal government to match state contributions (Kerr-Mills Act). Describe National Health Insurance (NHI). - ANSGovernment controls & coordinates financing, insurance, and payment; delivery of health care is private. Ex: Canada. Describe National Health System (NHS). - ANSGovernment controls all 4 functions of the health care delivery system. Ex: Britain Describe organized medicine. - ANSThe concerted efforts of physicians through the AMA which equated to professional cohesiveness. Describe Socialized Health Insurance (SHI). - ANSInsurance and payment are integrated. Government mandates contributions to sickness funds by employers/employees. Delivery of health care is privatized. Ex: Israel, Germany, Japan
Employer mandate - ANSA legal requirement for employers to help pay for their employees' health insurance. Enabling services - ANSEnable people to receive medical care that otherwise would not be received despite insurance coverage, for example, transportation and translation services. entitlement - ANSa program whose benefits are available to anyone who meets the eligibility requirements Epidemic - ANSAn outbreak of an infectious disease that spreads rapidly and affects many individuals within a population. Epidemiology - ANSThe study of the distribution and determinants of health, health-related behavior, disease, disorder, and death in a population group. experience rating - ANSInsurance rating according to which high-risk individuals pay more than the average premium price, and low-risk individuals pay less than the average price Favorable risk selection - ANSAlso called "risk selection." A phenomenon in which healthy people are disproportionately enrolled into a health plan. See adverse selection. fee schedule - ANSA list of fees for various health care services.
fee-for-service - ANSPayment of separate fees to the providers for each separate service, such as examination, administering a test, and hospitalization. fiscal intermediaries - ANSOutside contractor that processes claims for US government programs like Medicare and Medicaid Flat-of-the-curve medicine - ANSMedical care that produces relatively little or no benefit for the patient because of diminishing marginal returns. Food and Drug Administration Safety Innovations Act - ANSAllows the FDA to use markers that are thought to predict or that are reasonably likely to predict clinical benefit to qualify a drug for accelerated approval if the drug is indicated for a serious condition and fills and unmet medical need. Free market - ANSCharacterized by the unencumbered operation of the forces of supply and demand when numerous buyers and sellers freely interact in a competitive market. Gatekeeper - ANSA primary care physician who functions as the provider of first contact to deliver primary care services and to make referrals for specialty care. Gatekeeping - ANSThe use of primary care physicians to coordinate health care services needed by an enrollee in a managed care plan.
Health information organization (HIO) - ANSAn independent organization that brings together health care stakeholders within a defined geographic area and governs electronic information exchange among these stakeholders with the objective of improving the delivery of health care in the community Health plan - ANSThe contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to. Health technology assessment - ANSAny process of examining and reporting properties of a medical technology used in health care, such as safety, effectiveness, feasibility, and indications for use, cost, and cost effectiveness, as well as social, economic, and ethical consequences, whether intended or unintended. high-deductible health plan - ANSA health plan that combines a savings option with a health insurance plan carrying a high deductible High-risk pools - ANSState-based pools, before 2014, to make health insurance available to people who otherwise would have been uninsurable because of pre-existing health conditions. Holistic Medicine - ANSA philosophy of health care that emphasizes the well-being of every aspect of a person, including the physical, mental, social, and spiritual aspects of health.
How does the medical model of healthcare define health? - ANSThe absence of illness and disease In holistic medicine, what factors should diagnosis and treatment take into account? - ANSMental, emotional, spiritual, nutritional, environmental, and other factors surrounding the origin of disease. Incidence - ANSThe number of new cases of a disease in a defined population within a specified period. List 5 reasons why medical profession remained largely an insignificant trade in pre-industrial America - ANS1. Medical practice in disarray
- Primitive medical procedures
- An institutional core was mission
- Demand was unstable
- Medical education was substandard M-health - ANSShort for "mobile health," which is the use of wireless communication devices to support public health and clinical practice. Main features of the Affordable Care Act (ACA) - ANS1. Individual mandate
- Employer mandate
- Create "exchanges" through which individuals and small businesses can purchase insurance
- Expanded Medicaid to 133% of the federal poverty level (made optional by Supreme Court June 2012)
Medically underserved population (MUP) - ANSA federal designation for a group of persons who face economic, cultural, or linguistic barriers to health care. Medicare (also referred to as Title XVIII of the Social Security Amendment of 1965) - ANSDeveloped to provide publicly financed health insurance to the elderly Medicare Physician Fee Schedule - ANSA national price list for physician services established by Medicare Medigap - ANSCommercial health insurance policies purchased by individuals covered by Medicare to insure the expenses not covered by Medicare Misdistribution - ANSAn imbalance (i.e., surplus in some but shortage in others) of the distribution of health professionals, such as physicians, needed to maintain the health status of a given population at an optimum level. Geographic misdistribution refers to the surplus in some regions (e.g., metropolitan areas) but shortage in other regions (e.g., rural and inner cities) of needed health professionals. Specialty misdistribution refers to the surplus in some specialties (e.g., physician specialists) but shortage in others (e.g., primary care). Moral hazard - ANSConsumer behavior that leads to a higher utilization of health care services because people are covered by insurance.
national health insurance (NHI) - ANSA tax-supported national health care program in which services are financed by the government but are rendered by private providers (Canada for example) national health system (NHS) - ANSA tax-supported national health care program in which the government finances and also controls the service infrastructure (for example, Great Britian) need - ANSNeed for health services (in contrast to demand for health services) is based on individual judgment. The patient makes the primary determination of the need for health care and, under most circumstances, initiated contact with the system. The physician may make a professional judgment and determine need for referral to higher-level services. Nonprofit (organization) - ANSA private organization, such as a hospital, that operates under Internal Revenue Code, Section 501(c)(3). These organizations are tax exempt. In exchange for tax exemption, they must provide some defined public good, such as service, education, or community welfare, and not distribute profits to any individuals. Organized medicine - ANSThe concerted activities of physicians through the AMA are collectively referred to as organized medicine, to distinguish them from the uncoordinated actions of individual physicians competing in the marketplace. Osteopathic medicine - ANSA medical philosophy based on the holistic approach to treatment. It uses the traditional methods of medical practice,
Pesthouse - ANSOperated by local governments to quarantine people who had contracted a contagious disease, such as cholera, smallpox, typhoid, or yellow fever. Primary function was to isolate people with contagious diseases so disease would not spread among the inhabitants of a city. Phantom providers - ANSPractitioners who generally function in an adjunct capacity. The patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologist, radiologist, and pathologist. Play-or-pay - ANSProvision in which employers must either provide employees health insurance (play) or pay into a public health insurance program Premium - ANSThe insurer's charge for insurance coverage; the price for an insurance plan. Premium cost sharing - ANSRefers to the common practice by employers that require their employees to pay a portion of the health insurance costs. Prepaid plan - ANSA contractual agreement under which a provider must provide all needed services to a group of members (or enrollees) in exchanged for a fixed monthly fee paid in advance. Prevalence - ANSThe number of cases of a given disease in a given population at a certain point in time.
Primary care case management (PCCM) - ANSA managed care arrangement in which a state contracts directly with primary care providers, who agree to be responsible for the provision and/or coordination of medical services for Medicare recipients under their care. Primary prevention - ANSIn a strict epidemiological sense, it refers to prevention of disease, for example, health education, immunization, and environmental control measures. prospective reimbursement - ANSA method of payment in which certain pre-established criteria are used to determine in advance the amount of reimbursement Provider-induced demand - ANSArtificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes. Public health - ANSA wide variety of activities undertaken by state and local governments to ensure conditions that promote optimum health for society as a whole. Quad-function model - ANSThe four key functions necessary for health care delivery: financing, insurance, delivery, and payment Quality improvement organization (QIO) - ANSA private organization composed of practicing physicians and other health care professionals in each state that is paid by the Centers for Medicare & Medicaid Services under contract to review the care provided to Medicare beneficiaries.
