HA 150 Exam 1 Review Questions

What is the healthcare triturative

The relationship between cost, quality and access

Hospitalist

A physician that specializes in the care of hospitalized patients

Hospitalist were introduced to assist in

• Improved Efficiency & Continuity of Care

• Relief for Primary Care Physicians

• Better Patient Outcomes

• Growing Hospital Complexity

Medicare

A government-run program that provides health insurance for people:

- Age 65+

- Certain younger individuals with disabilities

- People with End-Stage Renal Disease (ESRD) or ALS

Medicaid

A state-run program that provides health insurance for people:

- Low-income individuals and families

- Pregnant women, children, elderly, and disabled with financial need

Centers for Medicare & Medicaid Services (CMS)

A division of the U.S. Department of Health and Human Services (HHS) that oversees Medicare and Medicaid

Diagnosis-Related Group (DRG)

A classification system that groups patients with similar diagnoses and treatments into categories for hospital payment purposes

Incentives for under treatment when using DRG

• They already getting paid so why use more energy

• Limiting expensive procedures or tests that could improve outcomes but reduce hospital profit.

• Lower staffing levels, potentially impacting patient care quality.

ICD-10

Disease classification and diagnoses all settings

ICD-10-PCS

A procedure coding system used to specify inpatient treatment and services

ICD-10 CPT

Current Procedural Terminology codes identify the services a patient receives

Who pays for private health insurance?

• Employers

• Individually Purchased 

Factors to consider when choosing a hospital

• Quality of Care and Patient Safety

• Accreditation and Reputation

• Location and Accessibility

• Whether or not a hospital is in your network

Accreditation

The action or process of officially recognizing someone as having a particular status or being qualified to perform a particular activity

Why are hospitals decreasing?

• Consolidation

• Staff shortages

• Financial challanges

How many hospitals are there in the US

6,129

Premium

The monthly payment to maintain health insurance coverage

Deductible

The amount you pay out of pocket for healthcare services before your insurance starts covering costs

Co-pay

A fixed amount you pay for certain medical services or prescriptions

Co-insurance

A percentage of costs you share with your insurer after meeting you deductible

Risk Pool

A group of individuals whose medical costs are averaged to determine insurance premiums. If a risk pool has higher medical costs, insurers increase premiums to cover expenses

The Hill-Burton Act (1946)

Aimed to increase hospitals, ensure that hospitals provide a reasonable amount of free or reduced-cost care to people who can't pay

What new laws did the Hill-Burton Act help create

• Civil Rights Laws & Anti-Discrimination in Healthcare

• Medicare & Medicaid (1965)

• Hill-Burton Free and Reduced-Cost Care Program (1975 Amendment)

• Emergency Medical Treatment and Labor Act (EMTALA) - 1986

Top 3 determinants of health for college-aged students

• Mental Health

• Health Behaviors

• Access to Healthcare & Preventive Services

Why Do Individuals Without Insurance Utilize Hospital Emergency Departments (EDs)?

• Lack of Access to Primary Care

• Immediate Care Needs

• Perceived Free Care

Overuse of EDs cost effect

Increased costs for future visits

Non profit hospitals

Operate on thin profit margins due to the high costs of care, staffing, and medical supplies

For profit hospitals

Generate profits from patient care, especially if they specialize in high-demand procedures that are reimbursed at higher rates

Managed care

Refers to healthcare system that aims at controlling costs while ensuring quality

Health Maintenance Organizations (HMO)

• Lower premiums and out-of-pocket costs.

• Limited provider choice (within the network).

• Requires referrals for specialist care.

Preferred Provider Organizations (PPO)

• Greater flexibility to see out-of-network providers (at a higher cost).

• No referrals needed for specialists.

• Higher premiums compared to HMO plans

Exclusive Provider Organizations (EPO)

• No out-of-network coverage (except for emergencies).

• Lower premiums than PPOs.

• Requires use of network providers for all care

Point of Service Plans (POS)

• Requires referral from PCP for specialists.

• Offers out-of-network options at higher costs.

• Higher premiums compared to HMO but generally lower than PPO

Gatekeeper

A PCP who “gates” patients to go see specialists (prevalent in HMO & POS plans)

Retrospective payment

Refers to a system where healthcare providers are paid after services have been delivered

Prospective payment

System where healthcare providers are paid a fixed amount for services before the treatment takes place (main payment method)

Allopathy (MD)

Diagnose using science based methods, including drugs and surgery

Osteopathy (DO)

Use traditional medicine but incorporate preventative care, understanding how the body is interconnected

Tertiary Care Hospital

A highly specialized facility that provides advanced medical treatment and complex procedures

Federally Qualified Health Center (FQHC)

A non-profit healthcare organization that provides comprehensive primary care services to underserved populations, regardless of their ability to pay, that is funded through federal grant and insurance companies

Why do a majority of new medical school graduates pursue a specialization?

• Higher Earning Potential

• Job Demand and Opportunities

• Interest in Complex and Challenging Cases

• Better Work-Life Balance

IMG (International Medical Graduate)

A physician who has completed their medical degree outside of the United States or Canada but seeks to practice medicine in the U.S.

Why are IMG’s important for the US delivery system

• Addressing Physician Shortages

• Providing Care in Underserved Areas

• Expanding the Healthcare Workforce

LPN (Licensed Practical Nurse)

1-year diploma/certificate

RN (Registered Nurse)

Associate’s Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)

BSN (Bachelor of Science in Nursing)

4-year degree (BSN)

NP (Nurse Practitioner)

Master’s or Doctorate in Nursing (MSN/DNP)

PA (Physician Assistant)

Master’s Degree (MPAS)

Life expectancy

Average number of years a person is expected to live based on their current age, health, and environmental factors

Life Expectancy at Birth

Average number of years a newborn is expected to live

What factors influence life expectancy

• Healthcare Access & Quality

• Economic Conditions & Poverty

• Lifestyle & Behavioral Factors

• War, Violence, and Political Instability

Utilization Trends

A shift towards more outpatient therapy due to cost, efficiency, and access

Nosocomial infection

Infection that a patient contracts while receiving treatment in a healthcare facility, typically 48 hours or more after admission

Top 5 Medical Errors

• Patient falls 

• Wrong surgery 

• Unintended retention of foreign objects

• Delay in treatment

• Suicide

Why Does a PharmD’s Education Matter?

• Ensuring Cost-Effective Drug Selection 

• Reviewing Drug Safety & Efficacy

• Navigating Prior Authorization & Coverage Restrictions

• Advocating for Patient Access

State Children's Health Insurance Program (SCHIP)

Helps children be insured if their guardians are working more than one part-time job, but do not qualify for Medicaid

Moral Hazard

The idea that when people are protected from financial risk, they may behave differently than they would if they bore the full cost

Cost Shifting

A situation where one group or individual underpays for a service, causing another group or individual to have to pay a higher price to compensate for the shortfall

Uncompensated Care

Healthcare services that are provided to patients who cannot pay for their care