Genetic Counselors in the Healthcare Ecosystem Flashcards

Practice flashcards covering the economic, policy, and professional integration concepts of the genetic counseling healthcare ecosystem in the US and globally.

Universal Healthcare Coverage (UHC)

A system where all people can access doctor visits for sickness or preventive care and governments ensure they have the ability to pay for that care.

Accountable Care Organization (ACO)

An Integrated Health System where the same overall entity acts as both an insurer and healthcare provider, incentivizing cost control and quality care.

Commercial Insurance

Private health insurance covers an estimated $64.9\%$ of US residents, typically purchased through employers or directly by individuals.

Medicare

Federal public insurance provided to individuals aged $65$ or older, as well as younger individuals with specific disabilities or conditions like ALS and End-Stage Renal Disease.

Medicaid

A joint federal and state program providing insurance to individuals with disabilities or those below specific income thresholds, such as children, pregnant women, and the elderly.

Genetic Information Nondiscrimination Act (GINA)

A $2008$ law preventing health insurers from using genetic information to determine eligibility or premiums, and prohibiting employers from using genetic data in employment decisions.

Affordable Care Act (ACA)

A $2010$ healthcare law that expanded insurance access through subsidies and mandates coverage for pre-existing conditions and specific preventive health measures.

21st Century Cures Act

A $2016$ law designed to accelerate drug development for rare diseases and promote communication between electronic health records while penalizing information blocking.

Access to Genetic Counselor Services Act

Proposed legislation that would amend the Social Security Act to recognize genetic counselors as healthcare providers under Medicare.

Food and Drug Administration (FDA)

The federal agency tasked with regulating food safety, pharmaceuticals, medical devices, and Laboratory Developed Tests (LDTs).

National Coverage Determination (NCD)

Minimum standards issued by CMS for services that should be covered for all Medicare beneficiaries nationwide.

Medicare Administrative Contractors (MACs)

Private companies delegated by Medicare to process claims and establish Local Coverage Determinations (LCDs) for specific regions.

Balance Billing

The practice where a provider bills a patient for the difference between the provider’s total charge and the insurance-allowed amount.

Current Procedural Terminology (CPT)

The official standard for communicating medical procedures between providers and insurers, legislated under HIPAA.

International Classification of Diseases (ICD)

Standardized codes, such as ICD-$10$, used to communicate patient diagnoses for billing and public health reasons.

Prior Authorization

A tool used by insurers to provide feedback before a service is performed to determine if it is medically necessary.

Board Certification

A voluntary process managed by a body like the American Board of Genetic Counseling (ABGC) to measure a professional's competency to practice independently.

Licensure

Legal authority granted by state law to work in an occupation, intended to protect the public from unqualified practitioners.

Credentialing

A process where institutions or private payers verify a provider’s qualifications to allow them to bill for services and receive reimbursement.

Incident to Billing

A billing method where services provided by non-physician practitioners are billed under a supervising physician's NPI, generally reimbursed at $100\%$ of the physician fee schedule.

Patient-Related Activities (PRAs)

Activities conducted outside of face-to-face appointments, such as medical record review, letter writing, and care coordination, which take approximately $3$ hours for every $45$-minute patient session.

Telegenetics

A service delivery model utilizing video or telephone technology to provide remote genetic counseling, which increased from $28\%$ to $82\%$ usage among genetic counselors following the COVID-$19$ pandemic.

Genetic Counseling Assistant (GCA)

A clinical support staff member who handles tasks not requiring a counselor, such as pedigree drawing and records requests, to increase clinical efficiency.

Point of Care Testing (Mainstreaming)

A model where non-genetics providers order testing for a designated group of patients, while genetic counselors provide oversight or see only complex cases.

Business Case

A tool that demonstrates a proposal solves a relevant problem and is a good investment, often by showing financial impact through cost savings or increased revenue.

Downstream Revenue

The financial gain from additional consults, imaging, surgeries, or screenings that occur as a result of a patient's genetics consult or test result.

Explanation of Benefits (EOB)

A document sent by an insurer to a patient detailing services provided, the amount billed, the covered amount, and the patient's remaining financial responsibility.

COBRA

A provision allowing individuals to continue their current health coverage without a gap for a limited time after losing their job.

Relative Value Unit (RVU)

The measure of work used to reimburse providers, composed of work value, practice expense, and malpractice risk.

Social Security Disability Insurance (SSDI)

A program for adults disabled since childhood or workers who have paid into the Social Security trust funds through their earnings.

Supplemental Security Income (SSI)

A needs-based public assistance program for disabled individuals with limited income and resources, which does not require a work history.

504 Plan

A plan ensuring students with disabilities receive accommodations and access to the learning environment, often used when the student has typical cognition.

Individualized Education Program (IEP)

A plan for students who require specially designed instruction with measurable goals due to a qualifying disability.

Institutional Review Board (IRB)

A local regulatory committee that evaluates research designs to protect the rights and welfare of human research participants.

Assent

The affirmative agreement of a minor (typically aged $7$ and older) to participate in research, which is required in addition to parental consent.

Vulnerable Populations in Research\n\n

Groups that may face additional risks in research, such as children, prisoners, the elderly, or individuals with cognitive impairments, requiring special ethical considerations and protections.\n\n

HIPAA Exceptions\n\n

Circumstances under which protected health information can be disclosed without patient consent, such as emergencies, public health activities, or when required by law.\n\n

Human Subject Research Exceptions\n\n

Certain studies may not require full IRB review if they involve minimal risk or utilize existing data without identifying information, such as retrospective studies or educational practices.\n\n

Research Participant Obligations\n\n

Participants should comply with study protocols, attend scheduled visits, report accurate information, and inform researchers of any adverse effects experienced during the study.\n\n

Medicare Coverage for Genetic Counselors\n\n

Medicare may cover genetic counseling services if they are performed by certified genetic counselors and deemed medically necessary, facilitating appropriate genetic testing and care.\n\n

Medical Decision-Making Tree for Minors\n\n

A decision framework that guides medical choices for individuals under 18, typically involving both parental consent and minor assent to ensure shared decision-making.\n\n

Medical Decision-Making Tree for Adults\n\n

A decision model that empowers individuals over 18 to make autonomous healthcare decisions, typically with informed consent and consideration of patient preferences.\n\n

Clinical Research vs. Medical Care\n\n

Clinical research aims to test hypotheses and gather data, often involving greater risks, while standard medical care focuses on individual patient well-being and treatment.\n\n

Adolescent Consent in Research\n\n

In some cases, adolescents may provide consent for participation in research, especially when they have sufficient understanding of the risks and benefits involved.\n\n

Non-Maleficence in Research Ethics\n\n

A principle ensuring that researchers avoid causing harm to participants during studies, requiring careful risk assessment and ethical oversight.\n\n