Health Sci. 3700H
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72 Terms
Who qualifies for Medicare?
People age 65+, those under 65 with certain disabilities after 24 months of SSDI, people with End-Stage Renal Disease, and people with Amyotrophic Lateral Sclerosis.
What does Medicare Part A cover?
Inpatient hospital care, skilled nursing facility care, hospice, and some home health.
How is Part A funded?
Payroll taxes (FICA/Medicare taxes).
What does Medicare Part B cover?
Physician visits, outpatient care, preventive care, labs, and durable medical equipment.
How is Part B funded?
Premiums + general federal revenues.
What does Medicare Part C refer to?
Medicare Advantage—private plans that replace Original Medicare administration.
What are benefits of Medicare Advantage?
Often includes dental, vision, hearing, and sometimes prescription coverage.
What are drawbacks of Medicare Advantage?
Narrow networks and prior authorization.
What does Medicare Part D cover?
Prescription drugs.
What is Medigap?
Supplemental insurance that helps cover deductibles/copays for Original Medicare.
Can Medigap be used with Medicare Advantage?
No.
Who administers Medicare?
Centers for Medicare & Medicaid Services.
What is fee-for-service?
Providers paid per service performed.
What is a major issue with fee-for-service?
Incentivizes volume over value.
What are Alternative Payment Models trying to do?
Shift incentives from volume to value.
What are bundled payments?
One payment for an entire episode of care.
What is capitation?
Fixed payment per patient.
What is a risk of capitation?
Under-treatment.
What is pay-for-performance?
Bonuses tied to quality metrics.
What is shared savings?
Providers share savings when they reduce costs while maintaining quality.
What does HRRP stand for?
Hospital Readmissions Reduction Program.
What is the purpose of HRRP?
Reduce avoidable 30-day readmissions.
What is an ACO?
Accountable Care Organization focused on population health outcomes and cost reduction.
Who does MHS serve?
Active military members.
Who does TRICARE serve?
Military families, retirees, and active-duty members.
Who does the Veterans Health Administration serve?
Veterans.
What is a major challenge for the VA?
Rural access/wait times.
Who does the Indian Health Service serve?
American Indians and Alaska Natives.
What is a major issue with IHS?
Underfunding.
What court case required prison healthcare?
Estelle v. Gamble.
What is behavioral health?
Mental health, substance use disorders, and health-related behaviors.
Who is the largest payer of behavioral healthcare?
Medicaid.
Who provides therapy?
Psychologists, counselors, social workers, therapists.
Who can prescribe psychiatric medications?
Psychiatrists, PCPs, nurse practitioners.
What are major barriers to behavioral healthcare?
Stigma, provider shortages, cost, rural access, fragmented care.
What is the purpose of the Mental Health Parity and Addiction Equity Act?
Require equivalent mental/physical health coverage.
Why is dental care separate from medical care?
Historical separation of profession and insurance systems.
Does Medicare usually cover routine dental care?
No.
What is Medicaid dental coverage for children?
Required.
What does Medicaid dental coverage for adults do?
Varies by state.
What is a major limitation of private dental insurance?
Annual maximums.
What is a major theme of PBS Frontline Dollars and Dentists?
Profit motives may lead to overtreatment.
Why does the U.S. spend more on drugs?
High prices, weak price controls, advertising, and patents.
How long do patents last?
Typically 20 years from filing.
Who approves drugs?
U.S. Food and Drug Administration.
What is the order of the FDA approval process?
Preclinical → Phase 1 → Phase 2 → Phase 3 → NDA → approval → Phase 4.
What happens in Phase 1 trials?
Tests safety and dosing.
What happens in Phase 2 trials?
Tests effectiveness and side effects.
What happens in Phase 3 trials?
Large-scale confirmation of safety and effectiveness.
What is a formulary?
List of covered drugs.
What do PBMs do?
Negotiate prices, create formularies, process claims, and manage pharmacy networks.
What is a major criticism of PBMs?
Lack of transparency and rebate issues.
Which law allows Medicare negotiation?
Inflation Reduction Act.
What is universal healthcare?
Everyone has coverage.
What is single-payer healthcare?
One government payer finances care.
What is an example of the Beveridge Model?
United Kingdom / National Health Service.
What is an example of the Bismarck Model?
Germany.
What is an example of the National Health Insurance model?
Canada.
What is the out-of-pocket model?
Patients directly pay for care.
Why is the U.S. considered a mixed model healthcare system?
Uses aspects of all four systems.
What does the U.S. do well in healthcare?
Innovation, specialty care, advanced technology.
What does the U.S. do poorly in healthcare?
Cost, access, equity, outcomes.
What does STEEEP stand for?
Safe, Timely, Effective, Efficient, Equitable, Patient-centered.
What is a near miss in healthcare?
Error with no patient harm.
What is a sentinel event?
Serious patient harm or death event.
Why are medical errors hard to measure?
Underreporting, fear of punishment, documentation issues.
What does 'structure' refer to in the Donabedian Model?
Resources/settings.
What does 'process' refer to in the Donabedian Model?
What providers do.
What does 'outcomes' refer to in the Donabedian Model?
Patient results.
What are the characteristics of an HMO?
Referrals required, in-network only, cheapest.
What are the characteristics of a PPO?
Most flexibility, out-of-network allowed, expensive.
What are the characteristics of an EPO?
In-network only but usually no referrals.