PPR 4255 - Midterm

Front: How does the US healthcare system differ from other industries?
Back: No direct buyer-seller interactions, third-party payers, nonprofit sectors, heavy regulation, local organization, slow tech adoption.

Front: What role do third-party payers play in US healthcare?
Back: Mediate between buyers and sellers, influencing costs and access.

Front: Why is cost and quality measurement difficult in US healthcare?
Back: Many sectors are nonprofit, making standardization challenging.

Front: What makes healthcare slow to adopt new technology?
Back: Inefficient information flow, regulatory barriers, and decentralized organization.

Front: What factors complicate US healthcare problems?
Back: Lack of transparency, high costs, strained provider-patient relationships, aging population, administrative costs.

Front: How does moral hazard affect US healthcare?
Back: Insurance reduces out-of-pocket costs, leading to potential overuse of services.

Front: How does government play a dual role in US healthcare?
Back: Acts as both a buyer (Medicare, Medicaid) and a regulator.

Front: What are primary, secondary, and tertiary care?
Back: Primary (general care), Secondary (specialist referral), Tertiary (complex hospital care).

Front: Who provides primary care?
Back: Family physicians, general practitioners, NPs, PAs.

Front: What is an example of secondary care?
Back: Surgery, cardiology, dermatology, obstetrics/gynecology.

Front: What are examples of tertiary care?
Back: Cancer treatment, neurology, orthopedic surgery, neonatology.

Front: What are the five components of the healthcare value chain?
Back: Payers, Insurers, Providers, Distributors, Suppliers.

Front: Who are the main payers in healthcare?
Back: Government, Private Insurers, Employers.

Front: What is the role of insurers in healthcare?
Back: Manage risk, process claims, negotiate provider payments.

Front: How do providers fit into the healthcare value chain?
Back: Deliver care (hospitals, physicians, pharmacies, clinics).

Front: What is the role of distributors in healthcare?
Back: Manage the supply chain (wholesalers, logistics companies).

Front: Who are healthcare suppliers?
Back: Pharmaceutical and medical device companies.

Front: What is the general flow of money in the healthcare system?
Back: From payers to providers via insurers.

Front: How does innovation move in healthcare?
Back: From suppliers to providers (new drugs, devices, treatments).

Front: What is the Hsiao framework?
Back: A model for understanding healthcare system interactions.

Front: What are the five components of the Hsiao framework?
Back: Financing, Payment, Organization, Regulation, Behavior.

Front: What determines healthcare financing?
Back: Taxes, private insurance, out-of-pocket payments.

Front: How are healthcare providers reimbursed?
Back: Fee-for-service, capitation, value-based payments.

Front: What defines healthcare organization in the Hsiao framework?
Back: Structure of care delivery (hospitals, clinics, networks).

Front: What is the purpose of healthcare regulation?
Back: Control quality, pricing, licensing, and safety.

Front: How does behavior impact healthcare?
Back: Influences patient adherence, provider choices, and preventive care.

Front: How does financing influence healthcare organization?
Back: Affects structure and availability of services.

Front: How do regulations shape provider behavior?
Back: Mandate safety, prescribing rules, and quality measures.

Front: What are the three levels of the nested ecosystem model in healthcare?
Back: Micro system, Macro system, Societal system.

Front: What does the micro system in healthcare focus on?
Back: Individual patient-physician relationships (health literacy, adherence, trust).

Front: What does the macro system in healthcare involve?
Back: Interactions between insurers, providers, distributors, and suppliers.

Front: What does the societal system in healthcare consider?
Back: Population health and social determinants (poverty, education, environment).

Front: What is an accountable care organization (ACO)?
Back: A group of providers coordinating care to improve quality and reduce costs.

Front: What is the goal of an ACO?
Back: Provide the right care at the right time, reduce errors, and cut costs.

Front: How are ACOs funded?
Back: Medicare and private insurers.

Front: What are key benefits of ACOs?
Back: Cost savings, better care coordination, higher quality scores.

Front: What are major challenges of ACOs?
Back: Implementation difficulties, provider buy-in, data-sharing barriers.

Front: What are the three aims of IHI’s Triple Aim?
Back: Improve patient experience, improve population health, reduce per capita costs.

Front: What was added in IHI’s Quadruple Aim?
Back: Work-life balance for healthcare providers.

Front: What was added in IHI’s Quintuple Aim?
Back: Health equity.

Front: Why is achieving all of IHI’s aims difficult?
Back: Cost reduction may increase provider burnout; social determinants require systemic change.

Front: What are the key steps in the brand-name drug distribution model?
Back: Manufacturer → Wholesaler → Pharmacy → Insurer/PBM → Patient.

Front: What is the role of drug manufacturers in distribution?
Back: Develop drugs, set list prices, sell to wholesalers.

Front: What do wholesalers do in drug distribution?
Back: Buy from manufacturers, sell to pharmacies, handle chargebacks.

Front: How do PBMs affect drug pricing?
Back: Negotiate rebates but may keep savings instead of passing to patients.

Front: Why do brand-name drugs have high out-of-pocket costs?
Back: Insurers calculate costs based on list prices, not discounted prices.

Front: What are major concerns driving PBM reform?
Back: Lack of transparency, high costs, restrictive formularies, vertical integration.

Front: How do PBMs contribute to high drug costs?
Back: They keep a portion of negotiated rebates instead of reducing patient costs.

Front: What are potential PBM reforms?
Back: Increase transparency, pass savings to patients, ban spread pricing.

Front: What is provider status for pharmacists?
Back: Ability to bill insurance for clinical services.

Front: What new roles could provider status create for pharmacists?
Back: Medication management, chronic disease care, preventative services.

Front: What services can pharmacists offer with provider status?
Back: MTM, vaccinations, telehealth consultations.

Front: What are challenges of pharmacist provider status?
Back: Need for new reimbursement models, additional training requirements.

Front: What are the four main healthcare models?
Back: Beveridge, Bismarck, National Health Insurance, Private Insurance.

Front: How is the Beveridge model funded?
Back: Tax-funded, government-run healthcare.

Front: Which countries use the Bismarck model?
Back: Germany, Japan, France.

Front: How is the National Health Insurance model structured?
Back: Single-payer, private providers, government-funded.

Front: What are key differences between US and Canadian healthcare?
Back: US: private insurance, higher costs. Canada: single-payer, longer wait times.

Front: How does US healthcare rank in the "Mirror, Mirror" report?
Back: Last place among high-income nations.

Front: What is "mortality amenable to healthcare"?
Back: Avoidable deaths with timely medical care.

Front: Why does the US underperform in healthcare outcomes?
Back: No universal coverage, high costs, inefficient primary care.

Front: What percentage of US GDP is spent on healthcare (2022)?
Back: 17.3%.

Front: What are key reasons for rising US healthcare costs?
Back: High admin costs, expensive drugs, hospital pricing, advanced technology.

Front: How have US healthcare costs changed since 1970?
Back: Increased from 7.2% to over 17% of GDP.

Front: What percentage of US healthcare spending goes to prescription drugs?
Back: ~18%.

Front: Why are prescription drugs more expensive in the US?
Back: No government price negotiation, patent protections, PBM rebates.

Front: What percentage of US prescriptions are generics?
Back: 90%.

Front: What are the four types of Medicare coverage?
Back: Part A (hospital), Part B (outpatient), Part C (Advantage), Part D (drugs).

Front: Who qualifies for Medicare?
Back: 65+ or disabled individuals.

Front: How is Medicaid different from Medicare?
Back: Medicaid is for low-income individuals, jointly funded by state and federal government.

Front: What is Tricare?
Back: Military healthcare system.

Front: How do HMOs and PPOs differ?
Back: HMOs require referrals, PPOs allow more provider choice.

Front: What is an insurance premium?
Back: Monthly payment for coverage.

Front: What is a copay?
Back: Fixed amount paid per visit or prescription.

Front: What is coinsurance?
Back: Percentage of costs paid by the patient.

Front: What drugs are covered under Medicare Part B?
Back: Vaccines, chemotherapy, certain injectable drugs.

Front: What are the four main ways people pay for medications in the US?
Back: Out-of-pocket, private insurance, employer-based insurance, government programs.

Front: How do insurers cover prescriptions differently from medical services?
Back: Use formularies instead of coded billing.

Front: What is a drug formulary?
Back: A list of covered drugs managed by insurers.

Front: What are common formulary restrictions?
Back: Step therapy, prior authorization, quantity limits.

Front: What is step therapy?
Back: Patients must try cheaper alternatives before expensive drugs are covered.

Front: What major Medicare drug cost changes take effect in 2025?
Back: $2,000 out-of-pocket cap, elimination of coverage gap.

Front: Who may not benefit from Medicare's 2025 drug cost changes?
Back: Those with low drug costs, Medicare Extra Help recipients.

Front: What are key reasons for high US drug prices?
Back: Manufacturer pricing, PBM rebates, patent protections, high R&D costs.

Front: How do Pharmacy Benefit Managers (PBMs) impact drug prices?
Back: Negotiate rebates but don’t always pass savings to patients.

Front: Why do patents keep drug prices high?
Back: Delay generic competition.

Front: What percentage of US adults skipped a medication due to cost in 2022?
Back: 18%.

Front: What are consequences of high drug costs?
Back: Nonadherence, financial burden, worse health outcomes.

Front: What is medication adherence?
Back: Taking medication as prescribed.

Front: What percentage adherence is considered "good"?
Back: 80%.

Front: What are common reasons for poor medication adherence?
Back: High costs, side effects, complex dosing, lack of understanding.

Front: How can medication adherence be improved?
Back: Lower costs, pharmacist support, simplified regimens.

Front: What is the role of pharmacists in medication access?
Back: Identify cost barriers, recommend generics, assist with insurance.

Front: What is the 340B Drug Pricing Program?
Back: Discounts for uninsured and low-income patients.

Front: What are Pharmaceutical Assistance Programs (PAPs)?
Back: Manufacturer programs that help with drug costs.

Front: How can Medicaid help with medication costs?
Back: Provides low copays for eligible patients.

Front: What are the 8 leadership components that support teamwork in healthcare?
Back: Communication, mutual support, situational awareness, decision-making, team structure, trust, adaptability, conflict resolution.

Front: What does SBAR stand for in healthcare communication?
Back: Situation, Background, Assessment, Recommendation.

Front: Where is SBAR commonly used?
Back: Shift hand-offs, emergency situations, nurse-physician and pharmacist-physician communication.

Front: What is mutual support in healthcare teams?
Back: Team members actively assist each other to improve patient safety.

Front: What are key techniques to promote mutual support?
Back: Task assistance, feedback, advocacy, two-challenge rule, CUS technique.

Front: What is the two-challenge rule?
Back: If a safety concern is ignored, challenge twice before escalating.

Front: What does the CUS acronym stand for?
Back: Concerned, Uncomfortable, Safety issue.

Front: What are the four main types of healthcare teams?
Back: Core, Contingency, Coordinating, Ancillary.

Front: What are examples of core healthcare teams?
Back: Inpatient teams, outpatient clinics, ICU teams.

Front: What are examples of contingency teams?
Back: Code Blue teams, pandemic response teams.

Front: What are examples of coordinating teams?
Back: Pharmacy formulary committees, patient transfer teams.

Front: What are examples of ancillary teams?
Back: Billing teams, IT, supply chain management.

Front: What does the STEP model assess?
Back: Patient status, team members, environment, progress.

Front: What does the I’M SAFE checklist evaluate?
Back: Illness, medication, stress, alcohol, fatigue, eating/elimination.

Front: What is the purpose of the TeamSTEPPS program?
Back: Improve teamwork to enhance patient safety.

Front: What are the four core components of TeamSTEPPS?
Back: Leadership, Communication, Situation Monitoring, Mutual Support.

Front: How does TeamSTEPPS improve healthcare?
Back: Reduces errors, improves outcomes, enhances efficiency.

Front: What is the goal of situation monitoring in TeamSTEPPS?
Back: Maintain awareness of patient and team needs.

Front: What is the primary function of mutual support in TeamSTEPPS?
Back: Encourage teamwork and prevent errors.

Front: What are Lencioni’s 5 team dysfunctions?
Back: Absence of trust, fear of conflict, lack of commitment, avoidance of accountability, inattention to results.

Front: In what order should Lencioni’s team dysfunctions be corrected?
Back: Build trust → Encourage conflict → Create commitment → Establish accountability → Focus on results.

Front: What are the three major sections of Kotter’s 8-step change model?
Back: Creating the climate for change, engaging & enabling the organization, implementing & sustaining change.

Front: What are the first three steps of Kotter’s model?
Back: Establish urgency, build a guiding coalition, develop a vision & strategy.

Front: Why do organizational changes fail?
Back: No urgency, poor leadership, unclear vision, failure to communicate.

Front: What are the five conflict management styles in the Thomas-Kilmann model?
Back: Competing, Avoiding, Accommodating, Compromising, Collaborating.

Front: Which conflict style is best for quick, decisive action?
Back: Competing.

Front: Which conflict style is best for long-term solutions where both sides benefit?
Back: Collaborating.

Front: What are the five steps of handling a difficult conversation?
Back: Prepare, adopt a learning mindset, acknowledge emotions, reframe, develop resolution.

Front: What are common factors underlying difficult conversations?
Back: Differing facts, assumptions about intent, emotional impact.

Front: What are best practices for improving difficult conversations?
Back: Active listening, using “I” statements, separating impact from intent.

Front: What are key strategies for effective team formation?
Back: Clear goals, defined roles, trust, structured problem-solving.

Front: What are best practices for long-term team success?
Back: Regular check-ins, constructive feedback, workload balance, recognition.