Term
|
Definition
| A viewpoint about health that focuses on the diagnosis and treatment of disease |
|
|
Term
|
Definition
| A viewpoint abou thealth that focuses on the prevention of disease |
|
|
Term
|
Definition
| The data from Human populations that describe vital statistics, size and distribution |
|
|
Term
| Foundation of the US health System |
|
Definition
-allocation of resources
-organizational ability of government
-free enterprise system |
|
|
Term
|
Definition
-Financing
-Regulation
-Organization and delivery |
|
|
Term
|
Definition
-Financing
-Organization and delivery |
|
|
Term
| Government source of power |
|
Definition
|
|
Term
| Free enterprise source of power |
|
Definition
|
|
Term
|
Definition
Source of responsibility: individual
Heath Care: Earned Reward
Tx of Poor: Private Charity |
|
|
Term
|
Definition
Source of responsibility: Society
Health Care: Prerequisite for Work
Treatment of Poor: Government Programs |
|
|
Term
| Government has the power to |
|
Definition
Unilaterally ascertain
restrict
permit
direct resources of private individuals & organizations |
|
|
Term
| What are two reasons the government would interject? |
|
Definition
-failure of the private market to work as expected
-consensus among the governed populace for government action |
|
|
Term
|
Definition
Philosophy: Competing philosophies/little science
Funding: private Pay
Primary location of care: home
Role of government: none
Concept of disablement: No social response
Status of OT/PT: None
Primary health objective: Standarize and improve quality |
|
|
Term
|
Definition
Philosophy: Allopaths/rise of bioscientific model
Funding: private Pay/small ins. industry
Primary location of care: hospital
Role of government: state reg.
Concept of disablement:medical problem
Status of OT/PT: dominated by medicine/rationalized within organizations
Primary health objective: improve access to care |
|
|
Term
|
Definition
Philosophy:understanding the sociology and economics of health care
Funding: large ins./small private pay
Primary location of care: outpatient settings
Role of government: federal ins. programs
Concept of disablement: medical and social response
Status of OT/PT: growth of private practic; acute/postacute environments
Primary health objective: restrain growth in cost |
|
|
Term
|
Definition
Explains problem in terms of basic science/cellular pathology
-medical necessity |
|
|
Term
|
Definition
disablement is created as the result of a social process Of marginalization of persons w/disabilities by larger society and policies
-civil rights |
|
|
Term
|
Definition
disablement is not a condition that affects a few individuals but a situation to be recognized by the entire population at risk
|
|
|
Term
|
Definition
| created by how people see you, the medical model, created by diagnosis |
|
|
Term
|
Definition
age
sex
race
education
socioeconomic status
occupation |
|
|
Term
| need for healthcare is created by what personal factor |
|
Definition
| perception of healthcare status |
|
|
Term
|
Definition
convenience
personal income
system characteristics
health insurance |
|
|
Term
| Availability (access factor) |
|
Definition
| the amount ad type of service provided in relation to the population's need |
|
|
Term
| accessability (access factor) |
|
Definition
| the location and supply of health care services in relation to the population's location and transportation resources |
|
|
Term
| acceptability (access factor) |
|
Definition
| the attitude between health care providers and the population towards one another |
|
|
Term
|
Definition
| the price of health care services in relation to the population's ability to pay |
|
|
Term
| Reason for growth in medical care expenditures |
|
Definition
A. Economic
1. Inflation
1. Market Structure
3. Insurance
B. demographic change
C. System
1. providor behavior
2. technology |
|
|
Term
|
Definition
A method of reimbursment that pre-sets the fee that will be paid for the service that is provided
(provider paid for each procedure rendered)
(incentive for provider to provide more tx because payment is dependent on quantity not quality) |
|
|
Term
|
Definition
Provider pays for each episode of care
(shared risk with payer)
based on quality instead of quantity |
|
|
Term
|
Definition
provider is paid a flat rate for services
(ex. if the employee uses fewer services, the provider keeps the difference. If the employee uses more services, the provider absorbs the cost)
*creates insentive to provide fewer services to the patient |
|
|
Term
|
Definition
Flat, all-inclusive budgeting
- costs are capped, price is known |
|
|
Term
|
Definition
| The activity of providing goods and services to customers for profit |
|
|
Term
| Function of Healthcare as a business |
|
Definition
management
marketing
accounting
production
information technology (HIPAA) |
|
|
Term
|
Definition
One owner, personally liable
owner pays income tax
simple formation |
|
|
Term
|
Definition
at least two partners, personally Liable
owners pay income tax
more complex formation |
|
|
Term
|
Definition
infinite ownership (share holders)
-legal liability limited to initial investment
-corporation pays tax on income
-difficult formation process |
|
|
Term
| ACA (affordable Care act) |
|
Definition
| Healthcare reformed aimed at reducing the rate of uninsured, reduce healthcare costs, increase the quality and affordability of health insurance. |
|
|
Term
|
Definition
| Making a profit is identified as the primary reason for the buisness to exist |
|
|
Term
|
Definition
| the primary reason for the buisness to exist is some reason other than profit |
|
|
Term
|
Definition
| Federal law that mandates insurance portability and sets up procedures for electronic data exchange |
|
|
Term
|
Definition
| an economy with only a few sellers |
|
|
Term
|
Definition
| economy with only one seller |
|
|
Term
|
Definition
| The amount of a good a buyer is willing to purchase at a given price |
|
|
Term
|
Definition
| supply is the amount of some product producers are willing and able to sell at a given price |
|
|
Term
|
Definition
| an area of federal law that prohibits monopolization and other activities that lessen competition in the marketplace |
|
|
Term
|
Definition
| National organization that evaluates and accredits health care organizations |
|
|
Term
| CDC (center for disease control and Prevention) |
|
Definition
| a group of federal government agencies responsible for collecting and interpreting healthcare statstics |
|
|
Term
|
Definition
| the study of the nature, cause, control and determinants or the frequency of disease, disability and death in human populations |
|
|
Term
|
Definition
| Describes the combination of payments for health care and delivery of services into one system |
|
|
Term
| insurance (business definition) |
|
Definition
| business Of shifting the risk of loss from the individual to a third party |
|
|
Term
| How does an ins. company make a profit? |
|
Definition
| by predicting they will be taking in more money than they will have to pay out. |
|
|
Term
|
Definition
| the Process of combining all the insureds into one group so the group's overall risk of loss is reduced. |
|
|
Term
| If you have ___ employees you are required by the ACA to have insurance policies for your employees? |
|
Definition
|
|
Term
| Who payes the healthcare provider for contracted services? |
|
Definition
| Managed care organization or insurer |
|
|
Term
| what does the patient pay the healthcare provider to recieve services? |
|
Definition
| copayment/deductible/or private pay |
|
|
Term
| what does the patient or the patient's employer pay the managed care organization or insurer? |
|
Definition
|
|
Term
| What two contracts is insurance made up of? |
|
Definition
-insurance company and contract holder
-insurance company and health care provider |
|
|
Term
| Who regulates private insurance companies? |
|
Definition
the state governments
(requires insurance companies to maintain adequate financial reserves to cover the needs of the risk pool) |
|
|
Term
|
Definition
| Calculation of annuity risks, premiums and dividends |
|
|
Term
| What types of things can be a moral hazard in regards to insurance? |
|
Definition
-financially irresponsible behavior (not choosing to purchase health insurance when able
-utilizing unnecessary medical care covered by ins. (going to the Dr. for chapped lips)
|
|
|
Term
| what determines the price for a benefit package? |
|
Definition
| The number of people being Insured and the general state of their health |
|
|
Term
|
Definition
|
|
Term
|
Definition
| when employees decide to take advantage of the benefits being offered by the employers |
|
|
Term
| what are employees known as if the accept the insurance benefits? |
|
Definition
|
|
Term
|
Definition
| dollar amount of services that must be paid by the patient |
|
|
Term
|
Definition
| paid at the time that services are rendered |
|
|
Term
|
Definition
the lifetime amount an ins. company would ever make you pay or how much they will pay out.
(maybe $1,000,000) |
|
|
Term
| what determines which third party pays for services? |
|
Definition
| coordination of benefits clause |
|
|
Term
|
Definition
| request for reimbursment for the services that have been provided |
|
|
Term
|
Definition
| process of correctly coding what diagnoses, procedure and services were provided to the patient |
|
|
Term
| What are two systems of coding |
|
Definition
ICD-9-CM (international classification of diseases, 9th revision, clinical modification)
HCPCS (Healthcare Common Procedure Coding System)
-used in hospitals/outpatient facilities and clinics |
|
|
Term
| where do billers send the charges (claims)? |
|
Definition
|
|
Term
|
Definition
| negotiated list of payment rates by health care procedure |
|
|
Term
|
Definition
Per-Diem: all procedure inclusive daily payment rate
Per Visit: all procedures inclusive payment rate for each visit
Per Episode: All procedure inclusive rate for a treatment episode |
|
|
Term
| Capitation (definition 2) |
|
Definition
| payment to provider based on number Of members in health plan |
|
|
Term
|
Definition
0ne party is exempt from incurred liabiliies by the other party
-once the patient pays, the ins. company will reimburse the patient or provider.
|
|
|
Term
|
Definition
a plan where an employer pays for an employees health ins.
-the employer assumes the risk of loss for medical cost.
|
|
|
Term
| what type of third party payer is exempt from state ins. regulation? |
|
Definition
|
|
Term
| What regulates self-insurers |
|
Definition
Employee Retirement Income Security Act of 1974
(ERISA) |
|
|
Term
| Who started Blue cross Blue shield? |
|
Definition
| Teachers In the 1920s; to recieve medical care (21 days hospitalization) in exchange for a small monthly sum |
|
|
Term
| Blue Cross Blue Shield was originally a _____ status, but some plans converted to ____ in the 1990s |
|
Definition
|
|
Term
| Third Party administrator (TPA) |
|
Definition
| A company that manages the paperwork for an employer who establishes a self-insured plan |
|
|
Term
Health Maintenance Act of 1973 |
|
Definition
federal legislation that provided incentives for the formation of Health Maintenance Organizations
|
|
|
Term
Health Maintenance Organization (HMO) |
|
Definition
-prepaid health plans
-hire physicians and staff to work for them
-pay for services by capitation
-each patient/group has a fixed dollar amount of services provided for a time period |
|
|
Term
|
Definition
-pays for services and delivers services
|
|
|
Term
| Health Maintenance Act of 1973 |
|
Definition
| gave incentives to companies to become managed care organizations and required them to carry managed care and indemnity ins. |
|
|
Term
| Two types of delivery models |
|
Definition
PPO (preferred provider org.)
-manages and neotiates contracts on behalf of the providers, who provide services at lower cost
EPO (Exclusive Provider Org)
The insured must select designated providers or services are not covered |
|
|
Term
|
Definition
| The process Of restricting access to services |
|
|
Term
| COBRA (Consolidated Budget Reconciliation act of 1985) |
|
Definition
| Mandates that individuals who lose employment based health care ins. for reasons other than gross misconduct are eligible to continue coverage for 18 months at full cost to themselves. |
|
|
Term
HIPAA (Health Insurance portability and accountability act of 1996)
|
|
Definition
limits inability of insurance companies to deny coverage based On preexisting conditions
-assist w/job lock |
|
|
Term
|
Definition
| that individuals have insurance coverage and businesses, small and large, provide ins. coverage |
|
|
Term
|
Definition
-created in 1965 as part of the SSA
-federal program that pays for Health care cost for the elderly, the permanently disabled and those with end-stage renal disease |
|
|
Term
| Center for Medicare and Medicaid Services |
|
Definition
| Federal agency that administers the medicare and medicaid programs; previously known as the Health Care Financing Administration |
|
|
Term
| Who is eligible for medicare |
|
Definition
-if he/she is over 65 and eligible for SS retirement benefits
-is permanently disabled
-has end-stage renal desease.
-84% are eligible b/c of age
|
|
|
Term
|
Definition
Hospital Insurance
-covers inpatient hosspital services, critical access hospitals, skilled nursing facilities, limited, necessary home care, hospice |
|
|
Term
|
Definition
-Covers physicians services
(outpatient hospital care, some services and supplies)
if income is less than $85,000
Premium 2010: $110.50 Mo
Deductible: $155.00 Mo |
|
|
Term
|
Definition
-introduced in 1997 as part of the Balanced Budget Act
-Medicare+choice
-offers a variety of managed care-type options
|
|
|
Term
|
Definition
-Prescription Drug, Improvement and Modernization Act of 2003
- adds Perscriptions/prevention services
medi-gap plans/replaces medicare + choice with Medicare advantage
made changes to the fee-for-service payments |
|
|
Term
|
Definition
-American Recovery and Reinvestment Act
(cardiac rehab and HIV screaning) |
|
|
Term
|
Definition
Patient Protection and ACA
(closing the coverage gap in medicare part D, improving coverage of prevention benefits) |
|
|
Term
| What system does Medicare use to reimburse providers? |
|
Definition
| Prospective Payment System |
|
|
Term
| Who does the federal government have contracts with to process payments? |
|
Definition
| private insurance companies |
|
|
Term
|
Definition
-federal and state program that funds health care based on the recipient's income
-transfere program, funded by taxpayers' income tax payments
-administered at state and federal level. |
|
|
Term
| In 2007, what percentage of medicaid was the total national health expenditure made up of? |
|
Definition
|
|
Term
| For a state to recieve federal funds, what must they do? |
|
Definition
| provide Medicaid coverage to certain individuals |
|
|
Term
| What are the two major eligibitliy groups for Medicaid? |
|
Definition
-Poverty related
-medically needy |
|
|
Term
|
Definition
| people who would otherwise not meet the income limits can use unpaid medical bills to lower, or spind down, their income |
|
|
Term
| The ACA has expanded medicaid programs what population? |
|
Definition
| all non-medicare eligible people under age 65 with incomes up to 133% of the federal poverty level |
|
|
Term
| Who are the predominant recipients of Medicaid? |
|
Definition
| white under the age of 18 |
|
|
Term
| Who mandates the benifits Of medicaid? |
|
Definition
|
|
Term
| what is the state required to cover through medicaid? |
|
Definition
| hospital and physician services |
|
|
Term
| what may the state choose to cover under Medicaid? |
|
Definition
| pharmaceutical, dental, eye care |
|
|
Term
| how does Medicaid reimburse providers? |
|
Definition
| on a fee-for-service/episode-of-care basis |
|
|
Term
| under the ACA how much will reimbursements to phyicans who provide primary care be increased? |
|
Definition
| 100% of the medicare rate |
|
|
Term
| Why are some physicians and nursing homes reluctant to accept Medicaid patients? |
|
Definition
| because the rates set by the state are too low to make their participation in the program financially worthwhile. |
|
|
Term
| what facilities are not required to accept Medicaid patients? |
|
Definition
Physicians and nursing homes
What will this do?
limit a patient's ability to choose what provider they would prefer |
|
|
Term
| SCHIP (State Children's Health Insurance Program) |
|
Definition
-covers low-income children whose parents do not qualify for Medicaid but are unable to afford private health insurance
|
|
|
Term
| Who is eligible for SCHIP? |
|
Definition
| Children under the age of 19, incuding the unborn |
|
|
Term
| What does the ACA require to protect from Waste, Fraud and Abuse of the medicare/medicaid programs? |
|
Definition
| provider screening and enhanced oversight of new providers |
|
|
Term
| what ways may fraud be commited? |
|
Definition
intentionally to obtain payments the provider is not otherwise entitled to recieve (submit a claim for service with code that provides higher riembursment than for actual services recieved)
-for good intention (patient service may not be covered, so practicioner codes service so it will be covered) |
|
|
Term
| what types of things are prohibited by federal legislation? |
|
Definition
| kickbacks and self-referral arrangements |
|
|
Term
| self-referral arrangement |
|
Definition
| unlawfully referring patients to laboratories or other health services in which they have a financial interest |
|
|
Term
|
Definition
Mandatory under the ACA
(a program that is implemented in a business to ensure the business stays in compliance with current legeslation, especially changes in medicare/medicaid |
|
|
Term
| Federal Employees Health Benefits Program (FEHBP) |
|
Definition
| covers federal employees, families, retirees and survivors |
|
|
Term
|
Definition
Covers people in the uniformed services
-a variety of managed care options such as HMO, preferred providers and fee-for-service.
-care is provided by civilian health care providers who contract with TRICARE |
|
|
Term
| What does TRICARE not cover? |
|
Definition
|
|
Term
| what is the federal governments role in the TRICARE program? |
|
Definition
|
|
Term
|
Definition
| A program that provides health care benefits to employees who are injured on the job |
|
|
Term
| what does Workers' Comp eliminate? |
|
Definition
| the need for an employee to sue the employer for negligence when the employee was injured in the workplace |
|
|
Term
| Who pays for Worker's comp? |
|
Definition
|
|
Term
| what determines benefits with workers' comp? |
|
Definition
| they type of injury and amount of time the employee will be unable to work |
|
|
Term
| Who is one of the largest purchasers of healthcare services ? |
|
Definition
|
|
Term
| what does cost savings translate into for certain categories of patients? |
|
Definition
|
|
Term
| How many people are employed by the health care industry? |
|
Definition
|
|
Term
| what types of healthcare employees take up 1/4 of the health care system? |
|
Definition
|
|
Term
| how many people does nursing employ? |
|
Definition
|
|
Term
|
Definition
| a process of treating disease by using standard Tx such as surgery and drugs. |
|
|
Term
|
Definition
| a Process of treating patients by providing preventive and holistic care |
|
|
Term
| Physicians Role in healthcare |
|
Definition
diagnosis and treat patient illness
|
|
|
Term
|
Definition
-get medical history
-physical exam
-diagnositc testing
-give advice on preventative care
-make suggestions about diet and hygine |
|
|
Term
|
Definition
MD (Dr. of medicine); fights disease w/drugs
OD (Dr. of osteopathy; focuses on preventing and understanding disease through understanding the body in a holistic way |
|
|
Term
|
Definition
treats for common health problems and preventative care
-internal medicine
-general family practive
-pediatrics |
|
|
Term
|
Definition
| focuses on problems associated w/body's organs |
|
|
Term
| general and family practicioners |
|
Definition
| diagnose and treat a wide variety of illnesses in pt of all ages |
|
|
Term
|
Definition
|
|
Term
| How many phyicians are there In the US? |
|
Definition
941,300
29% women
9% asian
4% Hispanics
3% African-Americans |
|
|
Term
|
Definition
| an area of medicine that focuses on the body's organs, such as the heart, eyes, ears and kidneys and the digestive and respiratory systems |
|
|
Term
| USMLE (U.S. Medical Licensing Exam) |
|
Definition
| Three-step exam required for licensure in the US |
|
|
Term
| what is the state specific requirenment for licensure are located where? |
|
Definition
|
|
Term
|
Definition
| an agreement between two states in which each accepts the professional licensing requirements of another state |
|
|
Term
| what are the two organizations that control board certification |
|
Definition
American Board of medical specialists
American osteopathic association |
|
|
Term
| Five stages in the nursing process |
|
Definition
-Assessment
-diagnosis
-care planning
-implementation
-outcome eval. |
|
|
Term
| planning in care for nurses involves what two things? |
|
Definition
writing goals
planning interventions to achieve goals |
|
|
Term
| Nursing Outcome Classification NOC |
|
Definition
| list of 385 identified outcomes that are responsive to nursing care |
|
|
Term
| Nursing intervention classification NIC |
|
Definition
| A list of 542 interventions that are the nursing Tx of choice for each nursing diagnosis |
|
|
Term
| What are an LPN/LVN duties? |
|
Definition
| basic bedside physical care of the patient |
|
|
Term
| What is the difference between an RN and LPN? |
|
Definition
| differences in supervision, legal responsibility and IV therapy |
|
|
Term
|
Definition
| A national Licenture Exam |
|
|
Term
|
Definition
| observe, assess, record symptoms, reactions, progress, administer IV meds and blood, perform patiet assessment and plan care |
|
|
Term
| where are the nurses requirements for practice by state located? |
|
Definition
|
|
Term
|
Definition
-Problems retaining people
-burnout
-matching the supply and demand of providers/services
|
|
|
Term
| Types of healthcare roles (office hospital visit) |
|
Definition
|
|
Term
| Providers of diagnostid testing |
|
Definition
technologiests and technicians (image tech, nuclear medicine tech., cardiovascular tech, diagnostic medical sonographers)
-medical lab specialists
-
|
|
|
Term
|
Definition
-PT
-OT
-Respiratory Therapy
OT
Recreational Therapy
-Speech Language Pathology
-Audiologies/pharmacists
-pharmacy tech |
|
|
Term
|
Definition
First Responder
EMT-Basic
EMT-intermediate
EMT-paramedic |
|
|
Term
|
Definition
| basic personnel care for patients at the accident scene and transport by ambulance |
|
|
Term
|
Definition
| Personnel can adminmister intravenous fluids, use defibrillators and advace airway techniques and equipment |
|
|
Term
|
Definition
| May administer drugs, interpret EKG and use complex equipment |
|
|
Term
| Total Health Care Program |
|
Definition
Dental
Eye
Chiro
Foot
diet and nutrition
|
|
|
Term
|
Definition
health administrators and managers
information tech
coding specialists |
|
|
Term
|
Definition
Ambulatory Care: patients are fully mobile and can bring themselves to physicians office
Acute care: short term; level of urgency
inpatient: hostpital
tertiary: specialized |
|
|
Term
| Hospitals are reqired to be licenced by what? |
|
Definition
| the state in which it is located |
|
|
Term
| what do hospitals voluntarily participate in (accreditation Standards) |
|
Definition
|
|
