Healthcare Systems Exam 2 Topics

Parts of the Iron Triangle

Cost, Access, and Quality

Triple Aim

Framework meant to work on better outcome, experience, and costs, focusing on population health overall.

Goal of Healthy People 2030

Improving health equity, thriving lives, and addressing the social determinants of health.

Social Determinants of Health (SDoH)

Non-medical factors (education, income, housing, environment) that shape health outcomes and disparities.

Value-Based Care

Payment and care models that reward outcomes and efficiency instead of volume of services (e.g., ACOs, MIPS).

What are the six quality aims from the Institute of Medicine (STEEEP)?

Safe, Timely, Effective, Efficient, Equitable, Patient-centered.

What are the two main types of health policy?

Allocative (distributes resources, e.g., Medicare) and Regulatory (sets rules/standards, e.g., FDA).

Problem Identification

First stage of the health policy process

Policy Formulation

Second stage of the health policy process

Policy Adoption

Third stage of the health policy process

Implementation

Fourth stage of the health policy process

Evalution and Feedback

Fifth stage of the health policy process

Medicare

Federal insurance for seniors & disabled, created in 1965

Medicaid

Joint federal-state program for low-income individuals created in 1965

CMS

Agency under the HHS that runs Medicare/Medicaid

FDA

Agency under the HHS that regulates drugs and devices

CDC

Agency under the HHS that focuses on prevention and disease control

Medical Technology

Any scientific application that improves health outcomes — includes equipment, drugs, procedures, and health IT.

Germ Theory

That microorganisms cause disease; which revolutionized sterilization and infection control.

Technology Diffusion

The process by which new medical technologies spread through the health system.

Managed Care

A system to control costs and improve quality by managing utilization and coordinating care via MCOs.

HMO

Plan that restricts care to in-network providers using PCP referrals

PPO

Plan that offers more flexibility but with higher premiums and out-of-pocket expenses.

Utilization Management

Techniques (prior authorization, concurrent review, case management) to ensure appropriate service use.

Capitation

Providers paid a fixed amount per patient per month, incentivizing efficiency and preventive care.

Population Health

Health outcomes of a group, including how those outcomes are distributed within the group.

Health Disparities

Systematic, avoidable differences in outcomes between groups (e.g., by race, income, geography).

Personalized Medicine

Tailoring treatments to individual genetic or biomarker profiles for better efficacy.

Hospital without Walls

Shift of care from hospitals to outpatient, home, or virtual settings supported by technology.

To Err is Human

Report that caused a push for the Triple Aim mindset

Quality Payment Program (QPP)

Part of MACRA to replace Medicare’s FFS system and to incentivize value-based care

Merit-Based Incentive Payment System (MIPS)

Under the QPP, a performance-based payment program for clinicians employed by Medicare

Advanced Alternative Payment Model (APM)

Payment arrangement other than MIPS that rewards quality, low-cost care

Legislative Branch

What drafts and enacts healthcare policy

Executive Branch

Implements policies through federal agencies like the HHS

Judicial Branch

What interprets healthcare laws and resolves disputes

Health Resources and Services Administration (HRSA)

Organization under the HHS meant to improve healthcare access for underserved populations

Information Asymmetry

Where patients lack the expertise to evaluate treatment quality

Externalities

Cases where individual health decisions affect broader public health

Moral Hazard

Where insurance coverage changes utilization behavior

Part A

Medicare insurance for hospitals (inpatient care, skilled nursing, hospice). Normally includes no premiums.

Part B

Medicare insurance for outpatient care, doctor services, and preventive services. Requires a monthly premium.

Part C

Medicare Advantage plans (with private insurers) that often include all other Medicare parts and other benefits

Part D

Medicare insurance for prescription drug coverage

mHealth

A part of eHealth technologies species to mobile apps and wireless devices

Two examples of Health Information Networks (HINs)

National Health Information Network (NHIN) and the Public and Information Network

Prospective Utilization Review

Prior authorization before services

Concurrent Utilization Review

Support of case management and discharge planning (during services)

Retrospective Utilization Review

The appeal process for denials (after services)