Study Guide Ch. 1-4 Dyn. of Healthcare Test

Premium

The amount of money you have to pay for insurance

Deductable

How much you pay for something out of pocket before insurance starts paying

Copay

When you have to pay a specific dollar amount for something (like $25 a visit)

Out-of-pocket

• What you have to pay yourself

Out-of-pocket Maximum

• The most you’ll have to pay in any one year

Provider Network

A list of doctors and hospitals that are connected to your plan

In-network

Providers that have a contract with your insurance and usually are lower-priced because of discounts

Out-of-network

Providers that aren’t in insurance plan and usually have to pay insurance

Centers for Medicare and Medicaid (CMS)

• Agency of the HHS (U.S. Department of Health and Human Services) that manages Medicare and Medicaid

• Strives to ensure effective, up-to-date healthcare coverage and to promote quality care for beneficiaries

Food and Drug Administration (FDA):

Makes sure that:

• food is safe, pure, wholesome

• human and animal drugs, biological products, and medical devices are safe and effective

• electronic products that emit radiation are safe

Centers for Disease Control and Prevention (CDC):

Protects the public health of the nation by:

• Providing leadership and direction in the prevention and control of diseases and other preventable conditions

• Responds to public health emergencies

National Institutes of Health (NIH):

• Supports biomedical/behavioral research in the U.S. and abroad

• Conducts research in its own laboratories and clinics

• Trains promising young researchers

• Promotes collecting and sharing medical knowledge

Health Resources and Services Administration (HRSA):

Improves access to healthcare services for people who are:

• uninsured

• isolated

• medically vulnerable

Dual Eligible

• Eligible for both Medicare and Medicaid

What is the World Health Organization (WHO)?

A specialized agency of the United Nations which coordinates responses to international public health issues and emergencies 

What is an individual’s patient record stored on computer called?

Electronic Health Record (EHR)

What federal program provides health insurance for 65+ and what additional groups of people - give 2

Medicare:

• People with End-Stage Renal Disease (ESRD): This is permanent kidney failure requiring dialysis or a transplant.

• People with Certain Disabilities: Individuals who have been receiving Social Security disability benefits for at least 24 months, or have Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's disease), are eligible.

T/F: Going forward, healthcare practitioners will need to know how to manage chronic diseases due to longer life expectancy and the aging population.

True

T/F: In terms of jobs in the healthcare industry, hospitals employ the largest % of healthcare workers (39%), then offices of health practitioners (26%)

True

1973 Older Americans Act established 622 Area Agencies on Aging – what is their purpose? P.61

– To help Americans age in their homes

– Provides services like: nutrition, health and wellness, elder rights, caregiver support, and supportive services including transportation

What does Medicaid cover in dual-eligibility?

Pays their Medicare premiums

Covers prescription drugs

What are the only DIRECT healthcare services provided by the federal government?

TRICARE - DOD

VA - Veterans Affairs

Indian Health Servic

What are the four major forces that impacted the development of hospitals

-Advances in medical science, discovery of antiseptic techniques (disinfecting things) + sterilization processes, and the use of anesthesia

-Advances in medical education, especially use of scientific theory (control groups, testing) and standard academic training for physicians (like stitching techniques, anesthesia, etc.)

-Transformation of nursing into a profession

-Specialized technology: x-rays, blood typing, etc

Definition – Ambulatory Care

Care that is provided outside of institutional settings

What was the most important factor in the decline in mortality in the 20th century?

Improvements in sanitation/hygiene

What other factors improved death rates?

Nutrition

Vaccines (Universal Child Immunizations 1950’s)

Arrival of antibiotics in 1940’s

Definition- Mortality

-Refers to the number of deaths in a population.

(can usually get mixed with morbidity → which refers to the prevalence of illness or disease in a population.)

Definition – Health outcomes (two parts) p.12 Figure 1.7

Health outcomes are the measurable changes in the health of an individual, group, or population that result from healthcare interventions or public health activities.

• Length of life (50%)

• Quality of life (50%)

Extra info: percentage of health outcomes (length of life and quality of life) can be attributed to social and economic factors → 40%

Definition – Health Equity

everyone has a fair and just opportunity to be as healthy as possible

How has the US government impacted the healthcare system in the United States?

The U.S. government regulates, funds, and provides health care services.

Social Determinants of Health: statistics

• Health behaviors account for 30% of health outcomes

• Social and economic factors have the greatest influence 40%

• Centers for Medicare and Medicaid (CMS) Innovation programs

SDOH- What are they?

· What are they?

The conditions in which people are born, grow, work, live, and age

Ex: Lack of access to:

stable housing

Nutritious food

Employment

Education

Personal safety

Reliable transportation

How do SDOH impact health outcomes?

• They influence the delivery and outcome of healthcare as well as the cost of health care

Affordable Care Act

· What else is it called?

→ Obamacare

ACA: What was the MAJOR impact?

Expanding access to affordable health insurance coverage

United States overall healthcare System- How is it different than countries that have Universal Health Care?

We don’t have mandatory national coverage, instead we have private/public insurance

What are the Five broad Categories of healthcare services? Know examples

Health promotion: Aims to reduce risk of illness and follow healthy lifestyle

• Prenatal care education

• Fitness classes

Disease prevention: Educational efforts aimed at involving consumers in their own care

• Women participating in cervical cancer screening

• Smoking cessation classes

Diagnosis & Treatment: usually provided in hospital or ambulatory care setting

Rehabilitation: involves the restoration of a person to normal or near normal after a physical or mental illness

Chronic care: ongoing care for chronic health conditions

· What is the World Health Organization (WHO)?

-A specialized agency of the United Nations which coordinates responses to international public health issues and emergencies

o WHO vs CDC – what is the difference in focus?

WHO → addresses global public health issues

CDC → primarily focuses on health within the United States.

What are the only DIRECT healthcare services provided by the federal government?

TRICARE - DOD

VA - Veterans Affairs

Indian Health Service

Fee-For-Service (FFS): Pros/ Cons

Pros:

• Focuses on providing all necessary treatments to a patient rather than attending to large number of patients. A patient receives precise assistance

• Profitwise → system generates more revenue for healthcare providers are patients are charged for every prescribed treatment

Cons: 

-Expensive for patients

-Patients may receive unnecessary treatments as healthcare providers probably suggest a few treatments that aren’t truly needed (since they’d get paid)

What’s not good about FFS?

Before the ACA was implemented, there was a payment for each service at the time of service. Doctor, hospital, or clinic is financially rewarded for volume rather than quality and cost control (value)

What isn’t good about FFS → When doctors aren’t held accountable + don’t get paid for the health of their patients, they do little to get them preventative care. (Basically says that treating sick patients is more profitable than keeping patients healthy)

Capitation: What is it? What are the pros + cons?

Capitation: A set amount paid to a doctor for each patient s/he attends within a set timeframe.

• System is based off of performance of healthcare provider rather than the number of treatments provided to a patient

Pros:

• Cost effective: Only a set amount is paid to the doctor for each patient, so it’s more cost-effective

• Financially balanced: The system provides a financial balance to the doctors and patients

Cons: 

• Lack of assistance: Since doctors are focused on attending to a large number of patients, a patient may receive less than required assistance

• Lack of care: Patients may receive less care as the providers might restrict the rests or treatment to lower the costs

Compare + Contrast Capitation and FFS

Fee-for-Service (FFS):

• Providers are paid for each service (visit, test, procedure).

• Incentive = more services = more payment (can drive up costs).

• Patients have freedom of choice, but it can lead to unnecessary care.

Capitation:

• Providers are paid a set amount per patient per month (regardless of how much care is used).

• Incentive = keep patients healthy and avoid unnecessary services since payment is fixed.

• Risk shifts to the provider (if patients need a lot of care, provider still gets the same amount).

👉 Key Contrast:

• FFS rewards volume of care.

• Capitation rewards value and cost control.

IADLs – Examples

Managing money

Shopping

Preparing meals

Taking prescribed medications

ADLs – Examples

Eating

Bathing

Dressing

Personal Hygiene (Continence + Toileting)

Mobility

Medicaid use in Medicare population (dual eligible)

-Why do these people get Medicaid and Medicare?

Because they quality for both programs based on their age/disability and low income/limited resources

What does the Medicaid cover?

Pays their Medicare premiums

Covers prescription drugs

What Federal Act established Medicaid and Medicare?

Social Security Act of 1965

Who is usually lacking in health literacy?

• lower socioeconomic and minority groups

• those with low English proficiency (immigrants)

• older adults

Why is health literacy important?

To make sure you can understand your treatment

You can better manage chronic conditions and follow treatment plans, leading to improved health outcomes

Save costs by understanding what to do

1973 Older Americans Act established 622 Area Agencies on Aging – what is their purpose? P.61

– To help Americans age in their homes

– Provides services like: nutrition, health and wellness, elder rights, caregiver support, and supportive services including transportation

T/F Going forward, healthcare practitioners will need to know how to manage chronic diseases due to longer life expectancy and the aging population.

True

T/F:  In terms of jobs in the healthcare industry, hospitals employ the largest % of healthcare workers (_39_%), then offices of health practitioners (26%) – Page 20

True

Telemedicine

Use of electronic communications and information technologies to provide or support clinical care at a distance