PHS exam 3

accreditation

the process of setting standards for educational and training institutions and enforcing these standards using a regularly schedules institutional self-study and outside review

credentialing

on the individual that verifies the individual has required qualifications to practice a profession

certification

a gernaric term that discribes the testing and educational process to get a stardarized for of credentialing

licensure

state government federal that requires certain certifications to practice

hospitalis

those who practice purely in the hospital

primary care

first contact providers that handle most of the common condtions

secondary care

specialty care provided by clinicians who focus on one or a small number of organ systems

tertiary care

subspecialty care, often in a academic or specialized hospital that is often defined by the problem they treat

medical home

the view that primary care is being considered a team effort

contact

ideal primary care: first contact with patients as they present for health care

comprehensive

ideal primary care: the ablity for primary care physicans to care completly for teh sickness or adress it

coordinated

ideal primary care: working together for the good of patients

continuity

ideal primary care: having communication to ensure that the patient is geting care that is in line with all clinicians they have seen

caring

ideal primary care: personalized relationship with pacients

community

ideal primary care: links health with broader institutions (public health)

fee-for-service

clinician paid for each covered seirvice

capitation

paid by amount of time vs service

episode of care

paid based on their comprehensive services that they provide to complete treatment of a diagnosis

salary

set amount of payment per time period

paid for performance (p4p)

compensation ajusted based on measures of the quality of care delivered

inpatient facilities

hospital, skilled nursing and rehabilitation facilities

outpatient facilities

one or more clinicians that provide diagnostic testing and treatment

hospital

inpatient facility that needs licenser, organized 24 hr nursing service and have a broad that is separate from clinician staff to ensure that federal and state requirments are met

activities of daily living

a reason why someone may move to a nursing home; the act of dressing, feeding, and taking care of themself

provider

encompasses the growing number of health professionals

structure

an assessment of quality: physical and organizational infrastructure in which care is delivered

process

an assessment of quality: delivery of care

outcome measure

an assessment of quality: the result of care and what complications happen

health care delivery system

an aim to connect inpatient and outpatient services as well as short term and long term clinical services to provide a coordinated system of care

clinician-pacient relationship

type of coordination: continuity to develop built knowledge and trust over time with patients

institutional coordination

type of coordination: medical information is easy between institutions

financial coordination

type of coordination: having comprehensive coverage for a full range of institutions; allows easy payment for administration and causes efficiency of care received

coordination between health care and public health

type of coordination: connections of care in public and clinical care

healthcare system

development of a system that is based off of common ownership ad governance

health information and data

coordination for healthcare delivery: past medical records

results management

coordination for healthcare delivery: intergrations of findings from multiple providers

order /entery mangement

coordination for healthcare delivery: electronic ordering of test and perscription to minimize error

decision support management

coordination for healthcare delivery: reminders to patients to follow up or adhere to new guidelines

electronic communication and connectivity

facilitation between communication between providers and patients electronically

reporting and population health

coordination for healthcare delivery: data on populations can be gathered more easily

patient support

coordination for healthcare delivery: allow patients to access education and involvement in descion making

administrative processes

coordination for healthcare delivery: facilitation of scheduling billing and other administrative services to increase productivity and decrease cost

mechanisms that monitor and ensure the quality of health care

• hospital privileges and approval to perform specific procedures

• accreditation of additional healthcare ordinations

• patient safety efforts\malpractice liability, not only for physicians but medical professionals

medical malpractice

when medical professionals get sued over not adhering to laws

medicare

federal insurance for 65+ and disabled people; it covers a) hospital, skilled nursing, home health after hospital, and hospice care b)(v) diagnostic and therapeutic services from EMD and outpatient hospitals c) special program designed to encounter medicare beneficiaries to enroll in prepaid health plans d) prescription and drug coverage (for people with part a and b) and is a permium

medicaid

a federal insurance plan for people in poverty and children; it includes most inpatient and outpatient services and preventive services, some states also include drugs eyeglasses and transportation services (not good comp. for clinicians)

out-of-pocket expenses

what the patient pays when insurance doesn’t cover all expenses (copayments, deductibles, balance billing)

state child health insurance program

a program that allots more funds to states to expand their medicad program to children

community rating

the cost of insurance was the same regardless of the of the health status of particular group of employees

experience rating

(medical underwriting) the concept that employees and employers pay based on their groups’ use of service in previous years

fee-for-service

consist of charges paid for specific services provided and as a payment system it encourages the provision of as many services as possible

capitation

the fixed amount of dollars per month to provide services to and enrolled member regardless of services provided

preferred provider organizations

in a fee-for-service insurance systems’ clinicians that they work with

point of service plans

health matinaince organization (HMO) that organizes capitation plans they may choose their health plan outside of the health plan but do have to pay more of out of network

health insurance exchange

a mechanism to obtain health insurance for those who are not eligible for other forms of comprehensive health insurance

affordable care act

2010 act that reduced the uninsured population from 15 to 10

essential health benfits

1. ambulatory care

2. emergcy services

3. hosplization

4. maternety and newborn care

5. heantal health and beahvioral health stuff

6. prescription drugs

7. rehabilitative and habilitative services

8. laboratory services

9. preventive and well\ness services and chronic disease management

10. pediatric care including oral and vision

workers comp

short-term help when job related injury occurs

social security disability insurance and social security income

compensate for when long term disabilities preventing them from working

the aging population

increasing the cost of health care in the US: older generation is living older

technological innovations

increasing the cost of health care in the US: increased interventions

successes of medical care over the last half century have raised the expectations of patient

increasing the cost of health care in the US: patient expect access to technology and nice facilities

single payer

when is one source pays for insurance

cost control through reimbursement incentives

reduces cost in US: refines the reimbursement that hospital receive from DGR

cost sharing

reduces cost in US: shifting of cost from insurance comities to individuals

regulation

reduces cost in US: government funded and owned insurance for all

restriction on malpractice

reduces cost in US: reduces the amount of tests because sueing in not an option

cap

a total amount of $ coverage an insurance will cover per benfit period or lifetime

copayment

the amount that the insured is responsible for paying even when the service is covered by the insurance

coinsurance

the percentage of charges that the insured is responcible for paying

covered service

a service for wich health insurance will provide payment or coverage if individual is elegible- all duductiable must be paid

customary, prevailing and resonable

standards used in the past to determine the amount that would be paid to the provider for services. Many employer based plans, the provider may bill patients above and beyond this amount. balanced billing

deductible

the amount that an individual or family is responcible for paying before becoming elegible for insurance coverage

eligible

the criteria to get insurance; may include income level (medicaid) or employment requirements

medical loss ratio

the ratio of benfit payments to premiums collected (are you paying a fair price

portability

the ability to continue employer based health insurance and is responsible for the uninsured. employees generally get 18 months of insurance but at the employee’s expence

premium

the price paid by the purchaser for the insurance policy on a monthly or yearly basis