Health Sci. 3700H
Medicare
Q: Who qualifies for Medicare?
A: People age 65+, those under 65 with certain disabilities after 24 months of SSDI, people with End-Stage Renal Disease, and people with Amyotrophic Lateral Sclerosis.
Q: What does Medicare Part A cover?
A: Inpatient hospital care, skilled nursing facility care, hospice, some home health.
Q: How is Part A funded?
A: Payroll taxes (FICA/Medicare taxes).
Q: What does Medicare Part B cover?
A: Physician visits, outpatient care, preventive care, labs, durable medical equipment.
Q: How is Part B funded?
A: Premiums + general federal revenues.
Q: What does Medicare Part C refer to?
A: Medicare Advantage—private plans that replace Original Medicare administration.
Q: Benefits of Medicare Advantage?
A: Often includes dental, vision, hearing, and sometimes prescription coverage.
Q: Drawbacks of Medicare Advantage?
A: Narrow networks and prior authorization.
Q: What does Medicare Part D cover?
A: Prescription drugs.
Q: What is Medigap?
A: Supplemental insurance that helps cover deductibles/copays for Original Medicare.
Q: Can Medigap be used with Medicare Advantage?
A: No.
Q: Who administers Medicare?
A: Centers for Medicare & Medicaid Services
Alternative Payment Models
Q: What is fee-for-service?
A: Providers paid per service performed.
Q: Major issue with fee-for-service?
A: Incentivizes volume over value.
Q: What are Alternative Payment Models trying to do?
A: Shift incentives from volume → value.
Q: What are bundled payments?
A: One payment for an entire episode of care.
Q: What is capitation?
A: Fixed payment per patient.
Q: Risk of capitation?
A: Under-treatment.
Q: What is pay-for-performance?
A: Bonuses tied to quality metrics.
Q: What is shared savings?
A: Providers share savings when they reduce costs while maintaining quality.
Q: What does HRRP stand for?
A: Hospital Readmissions Reduction Program
Q: Purpose of HRRP?
A: Reduce avoidable 30-day readmissions.
Q: What is an ACO?
A: Accountable Care Organization focused on population health outcomes and cost reduction.
Public Healthcare Programs
Q: Who does MHS serve?
A: Active military members.
Q: Who does TRICARE serve?
A: Military families, retirees, active-duty members.
Q: Who does the Veterans Health Administration serve?
A: Veterans.
Q: Major VA challenge?
A: Rural access/wait times.
Q: Who does Indian Health Service serve?
A: American Indians and Alaska Natives.
Q: Major IHS issue?
A: Underfunding.
Q: Court case requiring prison healthcare?
A: Estelle v. Gamble
Behavioral Health
Q: What is behavioral health?
A: Mental health, substance use disorders, and health-related behaviors.
Q: Largest payer of behavioral healthcare?
A: Medicaid
Q: Who provides therapy?
A: Psychologists, counselors, social workers, therapists.
Q: Who can prescribe psychiatric meds?
A: Psychiatrists, PCPs, nurse practitioners.
Q: Major barriers to behavioral healthcare?
A: Stigma, provider shortages, cost, rural access, fragmented care.
Q: Purpose of the Mental Health Parity and Addiction Equity Act?
A: Require equivalent mental/physical health coverage.
Dental Healthcare
Q: Why is dental separate from medical care?
A: Historical separation of profession and insurance systems.
Q: Does Medicare usually cover routine dental care?
A: No.
Q: Medicaid dental coverage for children?
A: Required.
Q: Medicaid dental coverage for adults?
A: Varies by state.
Q: Major limitation of private dental insurance?
A: Annual maximums.
Q: Major theme of PBS Frontline Dollars and Dentists?
A: Profit motives may lead to overtreatment.
Pharmaceuticals
Q: Why does the U.S. spend more on drugs?
A: High prices, weak price controls, advertising, patents.
Q: How long do patents last?
A: Typically 20 years from filing.
Q: Who approves drugs?
A: U.S. Food and Drug Administration
Q: Order of FDA approval process?
A: Preclinical → Phase 1 → Phase 2 → Phase 3 → NDA → approval → Phase 4
Q: What happens in Phase 1 trials?
A: Tests safety/dosing.
Q: What happens in Phase 2 trials?
A: Tests effectiveness + side effects.
Q: What happens in Phase 3 trials?
A: Large-scale confirmation of safety/effectiveness.
Q: What is a formulary?
A: List of covered drugs.
Q: What do PBMs do?
A: Negotiate prices, create formularies, process claims, manage pharmacy networks.
Q: Major PBM criticism?
A: Lack of transparency/rebate issues.
Q: Which law allows Medicare negotiation?
A: Inflation Reduction Act
International Healthcare Systems
Q: Universal healthcare definition?
A: Everyone has coverage.
Q: Single-payer definition?
A: One government payer finances care.
Q: Beveridge Model example?
A: United Kingdom / National Health Service
Q: Bismarck Model example?
A: Germany
Q: National Health Insurance model example?
A: Canada
Q: Out-of-pocket model?
A: Patients directly pay for care.
Q: Why is the U.S. considered mixed-model?
A: Uses aspects of all four systems.
U.S. Healthcare Performance
Q: What does the U.S. do well?
A: Innovation, specialty care, advanced technology.
Q: What does the U.S. do poorly?
A: Cost, access, equity, outcomes.
Quality & Safety
Q: What does STEEEP stand for?
A: Safe, Timely, Effective, Efficient, Equitable, Patient-centered
Q: What is a near miss?
A: Error with no patient harm.
Q: What is a sentinel event?
A: Serious patient harm/death event.
Q: Why are medical errors hard to measure?
A: Underreporting, fear of punishment, documentation issues.
Donabedian Model
Q: Structure?
A: Resources/settings
Q: Process?
A: What providers do
Q: Outcomes?
A: Patient results
Insurance Plans
Q: HMO characteristics?
A: Referrals required, in-network only, cheapest
Q: PPO characteristics?
A: Most flexibility, out-of-network allowed, expensive
Q: EPO characteristics?
A: In-network only but usually no referrals