Healthcare Delivery Chapter 7 & 8 Flashcards
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Questions and Answers

Which of the following is one of the largest U.S. employers?

  • Healthcare (correct)
  • Education
  • Retail
  • Manufacturing

    • How many new healthcare jobs are projected to be created in the next decade?

    5.6 million

    Where is the highest employment growth expected in healthcare?

  • Pharmaceuticals
  • Academia
  • Laboratories
  • Health plans (correct)

    • Specialized positions in healthcare reduce flexibility.

    <p>True</p> Signup and view all the answers

    What is necessary to protect citizens from incompetent healthcare practitioners?

    <p>Government regulation</p> Signup and view all the answers

    What is the most restrictive type of regulation in healthcare?

    <p>State licensure</p> Signup and view all the answers

    What is one of the shortcomings of state licensure?

    <p>Lax discipline</p> Signup and view all the answers

    What do state or national certifications provide?

    <p>Attestation to education and performance abilities</p> Signup and view all the answers

    What did the 1800s movement aim to do in healthcare?

    <p>Insure workers against lost wages due to work injuries</p> Signup and view all the answers

    What is the primary source of health coverage for most working Americans?

    <p>Employers</p> Signup and view all the answers

    The ACA aims to change the fundamental public/private financing mechanisms of U.S. healthcare.

    <p>False</p> Signup and view all the answers

    Public funding includes _____ and _____ programs.

    <p>Medicare, Medicaid</p> Signup and view all the answers

    What has been a significant tension in healthcare financing?

    <p>Public versus private roles</p> Signup and view all the answers

    What does HEDIS stand for?

    <p>Healthcare Effectiveness Data and Information Set</p> Signup and view all the answers

    What was a major focus of the National Committee on Quality Assurance (NCQA)?

    <p>Accreditation services</p> Signup and view all the answers

    What is Medicare Part A?

    <p>Hospital insurance</p> Signup and view all the answers

    What does Medicare Part B cover?

    <p>Voluntary MD coverage, tests, medical equipment, home health; funded by beneficiary premiums matched with federal revenues</p> Signup and view all the answers

    What is cost sharing in Medicare?

    <p>Deductibles, co-insurance; medi-gap policies</p> Signup and view all the answers

    What is Medicare Part C?

    <p>Managed Care Options for Private Health Plan Enrollment (1997)</p> Signup and view all the answers

    What is Medicare Part D?

    <p>Prescription Drug Coverage (2003)</p> Signup and view all the answers

    What did the Comprehensive Health Planning Act aim to do?

    <p>Support states in conducting local health planning to ensure adequate facilities and services and avoid duplications.</p> Signup and view all the answers

    What replaced the Comprehensive Health Planning Act in 1974?

    <p>Health Planning Resources and Development Act</p> Signup and view all the answers

    What are QIOs?

    <p>(Quality Improvement Organizations)</p> Signup and view all the answers

    What is the Tax Equity & Fiscal Responsibility Act (TEFRA)?

    <p>1982: Peer Review Organizations (PROs) replaced PSROs, providing clearer cost/quality criteria.</p> Signup and view all the answers

    What did Professional Standards Review Organizations do?

    <p>Review Medicare hospital care.</p> Signup and view all the answers

    What are DRGs?

    <p>Diagnosis-Related Groups (1983)</p> Signup and view all the answers

    What act requires hospitals to treat all patients presenting in their emergency departments?

    <p>Emergency Medical Treatment and Labor Act of 1986 (EMTALA)</p> Signup and view all the answers

    What is 'Hospital Compare'?

    <p>A website launched by Medicare to assess and compare hospital performance.</p> Signup and view all the answers

    What is Medicaid?

    <p>A joint federal-state program providing health coverage for economically needy individuals.</p> Signup and view all the answers

    What is HIPAA?

    <p>The Health Insurance Portability and Accountability Act of 1996</p> Signup and view all the answers

    What does SCHIP stand for?

    <p>State Children's Health Insurance Program</p> Signup and view all the answers

    What three types of coverage does Medicaid provide?

    <p>Health insurance for low-income families with children, long-term care, and supplemental coverage for low-income Medicare beneficiaries.</p> Signup and view all the answers

    What are the CHIP quality initiatives?

    <p>Initiatives developed for assessing the quality of Medicaid services for adults.</p> Signup and view all the answers

    What is the Individual Mandate?

    <p>The requirement for most Americans to carry health insurance coverage or pay a penalty.</p> Signup and view all the answers

    What do Health Insurance Exchanges do?

    <p>Establish a competitive health insurance market and provide information to consumers.</p> Signup and view all the answers

    What is the Bundled Payments for Care Improvement Initiative (BPCI)?

    <p>A program designed to improve patient outcomes through bundled payments.</p> Signup and view all the answers

    What are essential health benefits?

    <p>Minimum coverage benefits established by the ACA in ten categories.</p> Signup and view all the answers

    Study Notes

    Employment in Healthcare

    • Healthcare is one of the largest employers in the U.S.
    • The industry is projected to create approximately 5.6 million new jobs in the next decade, outpacing any other sector.
    • The highest employment growth rates are seen in health plans, ambulatory clinics, home health, and practitioners' offices.

    Impact of Regulations

    • Specialized jobs have emerged from medical advancements, which also lead to reduced flexibility and increased service costs.
    • Credentialing and regulatory measures are necessary to protect citizens from unethical practices.
    • Regulatory restrictions can limit healthcare organizations' personnel usage and innovation in patient care.

    Licensure and Certification

    • State licensure is the most restrictive regulation that defines practice scopes, education, and testing criteria to prevent misuse of professional titles.
    • State licensure primarily assesses qualifications on entry, with minimal ongoing competency evaluation.
    • National and state certification programs attest to education and performance but lack legal authority against incompetent practices.

    Training and Education in Nursing

    • The first nursing training program began in 1861 at Philadelphia Women's Hospital, with a focus on public health and private duty.
    • Various nursing education pathways exist: 2-year associate degrees, hospital diploma programs, and bachelor's degrees.
    • Licensed Practical Nurses (LPNs) undergo one year of training and require state licensing; Registered Nurses (RNs) often pursue advanced education for specialization.

    Employment of Medical Providers

    • A significant number of first-year residency positions are filled by graduates from foreign medical schools.
    • Physician specialties often require 3-8 years of residency training, with further fellowships for certification in subspecialties.

    Allied Health and Administration

    • Over 200 allied health occupations support primary providers, categorized into laboratory technologists, therapeutic practitioners, behavioral scientists, and support services.
    • Health care administrators manage services and operations within healthcare facilities, requiring various levels of education.

    Healthcare Demand Influencers

    • Demand for health personnel is influenced by medical and technological advancements and shifts towards community healthcare settings due to an aging population.
    • The National Health Care Workforce Commission (NHCWC) is a key agency in addressing healthcare workforce needs.

    Financing and Coverage in Healthcare

    • The Affordable Care Act (ACA) did not alter public/private financing structures but aimed to decrease uninsured rates.
    • Medicare serves the elderly, while Medicaid provides coverage for low-income populations, though public funding remains a significant part of coverage.

    Expenditures and Economic Factors

    • U.S. healthcare spending comprises a large portion of the national economy yet results in lower life expectancy and poorer health outcomes compared to other developed countries.
    • Major expenses include hospitals, physician services, and prescription drugs; approximately 20-40% of spending is estimated to be wasteful or inefficient.

    Evolution of Health Insurance

    • Health insurance developed in the early 1900s, evolving from indemnity coverage to comprehensive hospital and physician coverage models.
    • Managed Care Organizations (MCOs) emerged to control costs and improve service efficiency, with structures including HMOs and PPOs.

    Government Regulations and Quality Assurance

    • Various acts, including the Health Maintenance Organization Act and the Tax Equity & Fiscal Responsibility Act, have restructured health services to improve quality and cost management.
    • The National Committee on Quality Assurance (NCQA) focuses on accreditation standards for MCOs, ensuring quality across health plans.

    Medicare Components

    • Medicare Part A provides mandatory coverage for various health services, funded through payroll taxes.
    • Medicare Part B is voluntary, covering additional medical services for which beneficiaries pay premiums.

    Legislative Milestones in Health Planning

    • The Comprehensive Health Planning Act and the Health Planning Resources and Development Act established frameworks for health resource planning, highlighting the necessity of state-approved major projects.

    Challenges in Healthcare Delivery

    • Quality Improvement Organizations (QIOs) were introduced to enhance care quality under Medicare.
    • The implementation of DRGs shifted hospital reimbursement models, rewarding efficient care while addressing patient dumping issues in emergency departments.### Emergency Medical Treatment and Labor Act (EMTALA)
    • Enacted in 1986 to prevent inappropriate patient transfers by hospitals.
    • Non-compliance leads to stiff financial penalties and the risk of losing Medicare certification.

    Hospital Compare

    • Launched by Medicare with the Hospital Quality Alliance.
    • Assesses hospital performance based on evidence-based practice.
    • Reporting is mandatory for hospitals to qualify for Medicare rate updates.

    Medicaid

    • A joint federal-state program administered by the CMS.
    • Provides healthcare services for economically needy individuals.
    • Established to replace a fragmented system of state and local health services.
    • Covers health insurance for low-income families, long-term care for older Americans, and supplemental coverage for low-income Medicare beneficiaries.

    CHIP Quality Initiatives

    • The CMS and State Operations oversee Medicaid quality assessments.
    • Five criteria for Medicaid services quality include prevention, management of acute and chronic conditions, family experience, and availability of services.

    Individual Mandate

    • A component of the ACA requiring most Americans to have health insurance or incur a penalty.
    • Exemptions apply to certain low-income individuals, religious exemptions, undocumented immigrants, incarcerated individuals, and tribal members.

    Health Insurance Exchanges (HIE)

    • ACA mandates the establishment of health benefit exchanges for individuals and small employers.
    • Aimed at creating a competitive insurance market with user-friendly access to plan comparisons and standardized pricing.

    Bundled Payments for Care Improvement Initiative (BPCI)

    • Developed by the CMS Center for Medicare & Medicaid Innovation.
    • Addresses fragmented care due to separate Medicare payments for services.
    • Promotes bundled payments to incentivize coordinated care and improve patient outcomes while reducing costs.

    Essential Health Benefits

    • Health plans participating in exchanges must offer minimum coverage as defined by the ACA.
    • Includes ten categories of services:
      • Ambulatory patient services
      • Emergency services
      • Hospitalization
      • Maternity and newborn care
      • Mental health and substance use disorder services
      • Prescription drugs
      • Rehabilitative and habilitative services
      • Laboratory services
      • Preventive and wellness services
      • Pediatric services, including oral and vision care.

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    Test your knowledge with these flashcards covering key concepts from chapters 7 and 8 of Healthcare Delivery. This interactive quiz includes important terms and definitions relevant to employment and vocations in the healthcare sector.

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