PUBH 3130: Exam 2 Actual questions and answers with 100% accuracy(VERIFIED BY PROFESSOR)

Revenue

Earnings from providing services

Volume forecasting

estimating the number of patients to be seen and the insurance reimbursement rate per visit

expenses

the cost of providing services

cost allocation units

cost centers and profit centers

cost centers

organizational subunits that incur costs but do not directly generate revenue (ex: management staff)

profit centers

organizational subunits that generate revenue and costs (ex: providers)

types of cost

fixed and variable

fixed costs

stay the same regardless of changes in amount of services provided (ex: rent)

variable costs

change as amount of services provided changes (ex: disposable supplies)

economies of scale

cost advantage gained by increased productivity

profit margin

profit / revenue

operating budget

includes annual operating costs

balancing sheet

includes assets and liabilities

conventional/incremental budgeting

use previous budget as starting point and make adjustments to reflect changes in circumstances

zero-based budgeting

all line items start at zero; justify revenue and expenses based on expected service volume and costs

break-even analysis

determining the level of volume where the total costs of producing a good or service equals the total revenue generated from that good or service

Arguments of To Err is Human

- 3rd pary payment systems do not incentivize safety or quality

- decentralized and fragmented helathcare delivery system contributes to unsafe conditions

- many people die from preventable medical errors in hospitals annually

6 quality domains (STEEEP)

safe

timely

effective

efficient

equitable

patient-centered

3 pillars of triple aim

population health

experience of care

per capita cost

5 pillars of quintuple aim

triple aim (population health, experience of care, per capita cost) AND

health equity

workforce wellbeing and safety

Healthy people 2030

"data-driven national objectives designed to improve health and well-being across the United States over the course of a decade"

2 types of quality measures

population measures and subjective measures

examples of population measures

deaths, births, life expectancy, incidence of chronic disease, infant mortality

examples of subjective measures

number of healthy days, number of disability days, morbidity, ADLs limitations

healthcare quality measures

structure, process, outcome, patient experience

healthcare quality measures: structure

org's capacity and systems to provide high quality care (ex: ratio of providers to patients)

healthcare quality measures: process

what the org does to maintain or improve patient health (ex: patients w/ diabetes who had their BP measured and controlled, % patients receiving flu vaccines)

healthcare quality measures: outcome

impact of healthcare service or intervention on patient health status (ex: % of people readmitted to hospital, rate of hospital-acquired infections, % of patients who died as a result of surgery)

healthcare quality measures: patient experience

feedback on care experience (ex: length of wait time)

How does medicare pay for hospital charges (i.e. what fee method do they use)?

flat base-rate payment set in advance which is adjusted for patient health, service intensity, geographic location, disproportionate share of low-income paitents, and residency training

How does private insurance pay for hospital charges (i.e. what fee method do they use)?

flat rate per stay that may vary by patient's health/diagnosis

OR

per diem, which is a flat daily rate

OR

discounted charge in which payer pays a % of hospital's list price

What defines a health system?

- 1 acute care hospital

- 1 group of physicians (primary and specialty care)

- at least 50 total physicians and at least 10 primary care physicians

- connected through common ownership or joint management

3 types of consolidation

horizontal, vertical, cross-market

horizontal consolidation

2 direct competitors merge -> prices increase (less competition)

vertical consolidation

entities that are not direct competitors but are in the same supply chain merge

cross-market consolidation

entitie from separate geographic areas merge

4 steps of a SWOT analysis

strengths, weaknesses, opportunities, threats

Which part of SWOT analysis are internal to the org

strengths and weaknesses

Which part of SWOT analysis are external to the org

opportunities and threats

What type of market is the electronic health records market

oligopoly (few owners)

strengths of electronic health records

easy information sharing and organization

weaknesses of electronic health records

cost, privacy/security, interoperability (compatibility w/ other software)

Section 1557 main idea

prohibits discrimination in health coverage and access to care

4 things covered under section 1557

race/color/national origin, sex, age, disability

which of the four things covered under section 1557 was new/being covered for the first time?

sex

What healthcare domains does section 1557 apply to?

- health programs and activities that receive federal money

- health programs and activities administered by federal agencies

- ACA marketplaces

What type of market is the prescription drug market

oligopoly

WHY is the prescription drug market an oligopoly

- few sellers

- reliance on advertising

- product differentiation

- interdependence

What are pharmacy benefit managers

develop insurance plans' drug formularies by creating a tiered system where generic drugs are typically tier one and are the lowest cost, and tier 5 holds specialty drugs w/ high copays

Why do PBMs negatively impact patient care?

because they get the money from the rebates and the money the patients pay for prescriptions

cost-benefit and cost-effectiveness analysis

economic methods to assist decision-making that involves weighing the pros and cons of alternative interventions

advantages of cost-benefit and cost-effectiveness analysis

can compare alternatives or identify programs that do/don't make good use of resources

disadvantage of cost-benefit and cost-effectiveness analysis

do not consider/address ethical dilemas

measurements of cost-benefit analysis

costs measured in dollars $</p><p>benefits measured in dollars$

-> ex: does surgery add enough years to life expectancy to justify its cost?

measurements of cost-effective analysis

costs measured in dollars $$

benefits measured in health units ++

ex: which treatment alternative provides the most additional years of life expectancy per dollar spent?

cost utility analysis

subset/type of cost-effectiveness analysis in which outcomes are measures in QALYs

what type of measure are QALYs

population measure

what are QALYs

quantity of life adjusted for desirability of living in a particular state

- assigned a utility score from 0 (death) to 1 (perfect health)

cons of the methodology behind QALYs

- considers a limited number of domains

- focuses on mitigation of primary condition

- doesn't account for how accessibility and adaptations can impact quality of life

other criticisms of QALYs

- undervalues palliative care

- undervalues people w/ disabilities

- presumes that disabilities reduce quality of life

- does not consider side effects of treatment

alternative to cost-utility analysis (use of QALYs)

cost-effectiveness analysis

Who is the primary payer of long term care

medicaid (pays over half)

has employment in nursing homes rebounded to pre-pandemic levels?

no, unlike other health sector employment fields

underwriting

insurance companies determine your health status to determine if they are going to provide coverage for service

does underwriting apply to long term care?

yes

Why have long-term care premiums increased over time?

- demand for more comprehensive benefits

- inadequate medical underwriting -> premiums raise over time

- incorrect prediction of future claims (under-predicted demand)

qualities of high-performing teams

- clear roles and responsibilities

- clear values and shared vision

- shared mental mode

- optimized resources

- strong leadership

- regular feedback

- establish and refine goals/assess goal effectiveness

- differentiate between higher vs. lower priorities

- strong sense of collective trust and confidence

- mechanisms to cooperate and coordinate/manage conflict

- distribute work thoughtfully

what are the two motivation theories

theory x and theory y

theory x

This management style assumes that the typical worker has little ambition, avoids responsibility, and is individual-goal oriented.

theory y

Theory Y managers assume employees are internally motivated, enjoy their job, and work to better themselves without a direct reward in return.

requirements of the mediare hospice benefit

- patient must agree to forgo curative care

- two doctors must certify patients have less than 6 months to live

- medicare pays providers a set rate per patient per day

- nurses must visit patients home 2x/month

- providers must repay medicare when average length of stay of all patients exceeds 6 mos

- providers are inspected once every three years