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WGU D391 Healthcare Ecosystems Exam
Healthcare Ecosystem .......Answer.........The whole structure that supports healthcare provision to members of society. Providers .......Answer.........Any person or place providing healthcare services. Insurance .......Answer.........Can be through a private company, your employer may offer as a benefit, some people choose through ACA, those who qualify may receive it publicly such as Medicare or Medicaid. Health and Human Services Workers .......Answer. ......Workers who support client health and well-being. Doctors .......Answer.........Healthcare professionals who diagnose and treat patients.
Mid-level Providers .......Answer.........Healthcare providers who work under the supervision of doctors. Nurses .......Answer.........Healthcare professionals who provide patient care and education. Occupational and Physical Therapists .......Answer.........Assists in rehabilitation. Mental Health Providers .......Answer.........Professionals who provide mental health services. Diagnostic/Lab Techs .......Answer.........Technicians who perform tests to diagnose health conditions. Healthcare Purchaser .......Answer.........An individual or organization that purchases health services.
Stakeholders .......Answer.........A group of people with a common interest, especially in a business. Advanced Practice Professional .......Answer....... Examples include nurse practitioners, physician assistants, or clinical nurse specialists. Five P's of the US healthcare ecosystem .......Answer. ..... Patients, Providers, Professional Administrators, Policymakers, Payers. Primary goal of the healthcare ecosystem .......Answer. .....To raise the standard of healthcare offered to members of society. Low service quality and wasted resources .......Answer.........Causes harm to patients/clients. U.S. Department of Health and Human Services .......Answer.........Manages Americans' health issues and concerns
and leads programs to advance medical research and public health. Quality Improvement in Healthcare .......Answer. .... Monitoring, evaluating, and raising standards for high-quality treatment. Roles of Health and Human Services Workers .......Answer.........They all aim to help those in need, whether because of a crisis or a chronic illness. Healthcare System .......Answer.........Includes many individuals in varying roles, as well as many different rules, people, and organizations. Roles of Healthcare Providers .......Answer.........Sees and treats patients.
Main Components of a Healthcare Delivery System .......Answer.........The three main components are the consumer, the staff, and payment for services in some type. Acute Care .......Answer.........A level of health care in which a patient is treated for a brief but severe episode of illness for conditions that are a result of disease or trauma or recovery during surgery. Hospitals are an example. Ambulatory Care .......Answer.........Refers to care being provided outside of the hospital; it's another term for outpatient services. Medical offices are a type of this; one example is the family doctor, the eye doctor, and the dentist. Behavioral Health Care .......Answer.........An umbrella term that includes mental health. It looks at how someone's behavior impacts their health, both physical and mental.
Home Health Care .......Answer.........This offers a wide range of health care services that can be given in the person's home for an illness or injury. Common for elderly. Organizational Structure in Healthcare .......Answer. Includes various roles and responsibilities within healthcare facilities. Board of Directors .......Answer.........The top governing body of a hospital, which includes a president and vice presidents covering career pathways. Vice Presidents .......Answer.........Executives in a hospital who usually cover various career pathways. Care Facilities .......Answer.........The appropriate facilities that provide care under the career pathways in a hospital.
Types of Government-Funded Healthcare in the US .......Answer.........Medicare and Medicaid. Self-Pay .......Answer.........When a patient pays for healthcare services out of their own pocket without insurance. Health Insurance Benefits .......Answer.........Makes access to healthcare easier, decreases mortality, enhances health, and increases productivity. Affordable Care Act Impact .......Answer.........Has increased the number of individuals with health insurance. Producers in Healthcare .......Answer.........Medical suppliers of products like technology, medical devices, supplies, and medications.
Insurance Models .......Answer.........Different systems of financing healthcare, including private and government options. Funding Models .......Answer.........The five main models are self- funded, Bismark, Beveridge, national health insurance, and hybrid Bismark-Beveridge. Value-Based Care Model .......Answer.........A model that improves patient quality and cuts costs, focusing on preventing problems before they start. Impacts of Limited Access to Healthcare .......Answer. ..... Lower life expectancy, increased mental health issues, and preventable deaths. Deductibles .......Answer.........The set amount of money that must be paid before insurance contributes to healthcare costs.
Adverse Selection .......Answer.........Where a consumer does not purchase health insurance until they need coverage. Indemnity Plan .......Answer.........Insurance policies that compensate the insured against the cost of medical care up to certain policy limits, which vary by company and policy. Prospective Fee Schedules .......Answer.........A list of pre- determined prices or reimbursement rates that healthcare providers use to charge for their services. Federal Regulation of Insurance .......Answer.........The Supreme Court determined that insurance should be governed at the federal level. Employee Retirement Income Security Act (ERISA) .......Answer.........A federal law that regulates self-insured plans.
False Claims Act .......Answer.........A law that aims to protect the government from being overcharged or sold substandard products and services; imposes penalties for submitting false claims to the federal government. Application of False Claims Act to Providers .......Answer. .....It applies when providers file false claims with insurance companies. Anti-Kickback Statute (AKS) .......Answer.........Prohibits offering, paying, soliciting, or receiving any remuneration to induce or reward a referral of an item or service paid for by a federal healthcare program. Example of Anti-Kickback Violation .......Answer.........A business in another field paying for a referral that produces a sale or income is illegal among healthcare providers under AKS.
HIPAA .......Answer.........One of the most significant laws in healthcare which protects patient information. Example of HIPAA protections .......Answer. ..... Insurance companies can no longer share information about a person, especially those with pre-existing conditions. Agencies that regulate hospitals .......Answer. ..... Accreditation and Licensure, Federal Executive Agency, Federal Executive Department, Independent Executive Agency, Judicial Government, Legislative Government, State Level Oversight. Employer-provided insurance plans .......Answer. ..... An employer-sponsored health plan, also called a group plan, shares the premium costs with the employee. (HMO) Health Maintenance Organizations .......Answer. .... A comprehensive model that limited coverage but controlled cost.
(PPO) Preferred Provider Organizations .......Answer. ..... Uses fee-for-service to pay for health services, but payment is less for providers and facilities out of the network. (EPO) Exclusive Provider Organizations .......Answer....... Similar to HMOs except that specialty referrals from a primary care provider are not required. (POS) Point-of-Service Plans .......Answer.........A managed care plan that blends HMO and PPO plans, but requires the patient to get PCP referrals. The significant difference between insurance plans is: .......Answer.........In- and out-of-network coverage. PDSA .......Answer.........A model used in healthcare for planning, doing, studying, and acting on processes to improve quality.
Investors .......Answer.........Individuals or entities that provide capital to healthcare organizations or initiatives. Purchasers .......Answer.........Entities that buy healthcare services on behalf of patients, often employers or government programs. Telehealth .......Answer.........The delivery of healthcare services through telecommunications technology. Electronic Medical Record .......Answer.........A digital version of a patient's paper chart, containing medical history and treatment information. Programmatic community services .......Answer. ...... Services designed to meet specific community health needs through organized programs.
Quadruple Aim Framework .......Answer.........A framework aimed at improving healthcare by focusing on enhancing patient experience, improving population health, reducing costs, and improving the work life of healthcare providers. Telemedicine .......Answer.........The use of telecommunication technology to provide clinical health care from a distance. (NCQA) National Committee for Quality Assurance .......Answer.........An organization that works to improve healthcare quality through measurement and accreditation. Health information exchange .......Answer.........The electronic sharing of health-related information among organizations. (JCAHO) Joint Commission on Accreditation of Healthcare Organizations .......Answer.........An organization that accredits
