Final Exam Review PDF

Final Exam Review **Chapter 1 Major Characteristics of U.S. Health Care** **Delivery** Subsystems of U.S. Health Care Delivery Health Care Reform Characteristics of the U.S. Health Care System Systems Framework **Chapter 2 Foundations of U.S. Health Care Delivery** What is Illness and Disease...

Final Exam Review **Chapter 1 Major Characteristics of U.S. Health Care** **Delivery** Subsystems of U.S. Health Care Delivery Health Care Reform Characteristics of the U.S. Health Care System Systems Framework **Chapter 2 Foundations of U.S. Health Care Delivery** What is Illness and Disease -- illness is perception/feelings, disease is det by evaluation fr dr Acute and Chronic Conditions -- severe vs long Quality of Life Herd Immunity/the Cocoon Effect Determinants of Health Environment Behavior and Lifestyle Heredity Medical Care Distribution of Health Care Market Justice -- health care is economic good, willing/able customers purchasing health care Social Justice -- views health care as social resource, govt involvement for equal care for all Strategies to Improve Health Public Health **Chapter 3 Historical Overview of U.S. Health Care Delivery** Medical Services in Preindustrial America Medical Training -- none, no insurance Medical Practice Medical Institutions Medical Services in Postindustrial America Medical Profession -- scientific discoveries impacting medicine The American Medical Association -- protected interests of physicians Educational Reform Development of Hospitals Reform of Mental Health Care History of Health Insurance Worker's Compensation -- first broad-coverage insurance Emergence and Rise of Private Health Insurance Employment-Based Health Insurance Failure of National Health Insurance in the United States Creation of Medicare and Medicaid (Important!) -- 1965 Medical Services in the Corporate Era **Reduce health disparities** - **Nutritional programs** - **Work/environment safety efforts** - **Community based partnerships** - **Culturally appropriate care** - **Patient safety/medical error reduction** - **Prevention oriented effort** - **Coordinated care for chronically ill** **Chapter 4 Health Care Providers and Professionals** Physicians Dentists Pharmacists Other Doctoral-Level Health Professionals -- optometrists, psychologists, pediatrics,... Nurses -- largest group of healthcare professionals Non-physician Practitioners -- between physician and RN Allied Health Professionals Public Health Professionals -- focus on community as whole vs individual Community Health Workers -- socially orientated tasks and clinical tasks Health Services Administrators -- responsible for operational, clinical and financial outcomes of organization Patient-Centered Care -- respectful and responsive to ind patient preferences/needs/values Canada -- healthcare financed thr govt, healthcare delivered thr private providers UK -- healthcare financed thr govt, healthcare delivered the govt **10 Essential Public Health Services** 1. **Assess and monitor population health** -- rates of cancer or obesity 2. **Investigate, diagnose, and address health hazards and root causes** -- infections in water systems 3. **Communicate effectively to inform and educate** -- public health campaigns, no smoking advertisements 4. **Strengthen, support, and mobilize communities and partnerships** -- stopping wind turbines for better sleep 5. **Create, champion, and implement policies, plans and laws** -- tattoo licenses 6. **Utilize legal and regulatory actions** -- no smoking in public places 7. **Enable equitable access** -- distributing vaccinations in poor communities 8. **Build a diverse and skilled workforce** -- UB training individuals 9. **Improve and innovate through evaluation, research, and quality improvement** -- research at CDC, UB 10. **Build and maintain a strong organizational infrastructure for public** -- senate giving money and funding 330 Exam 2 Review [Chapter 5 Technology and Its Effects] What Is Medical Technology? - Practical application of knowledge to improve delivery of care Health Information Technology - What are the major categories? - Clinical information systems - Administrative information systems - Decision support systems - Internet and e-health Electronic Health Records: what are they? What are the benefits and costs? - Collection, storage health information, access to info, knowledge and decision support, improved health care process - Easier but more dangerous if there were a leak The Internet, E-Health, and E-Therapy - What are they? What are the benefits and costs? - E-health: forms of electronic health care delivered over internet -- info, edu, products, services - E-therapy: online interaction professional and patient Telemedicine and Remote Monitoring - What are they? What are the benefits and costs? - Diffusion and Utilization of Medical Technology - How do cultural beliefs and values affect utilization and uptake of medical technologies? - What is the effect on medical training and practice? - How does it influence insurance coverage? - Why does medical technology create competition among providers? The Government's Role in Technology Diffusion - Regulation of Drugs, Devices, and Biologics - responsible for ensuring that drugs and medical devices are safe and effective for their intended use - Research on Technology - law requires reporting of all injuries and deaths resulting from medical devices Impact of Medical Technology - Impact on Quality of Care - Prevent or delay disease, accurate diagnosis, quick cure,... - Not always lead to high quality care, only produce quality care when certain outcomes are achieved, wasteful if no improved quality, can cause harm - Impact on Quality of Life - Typically improve bc management of conditions, pain relief, fast recovery - Impact on Health Care Costs - Expensive AF - Impact on Access - Geographic access improved with mobile equipment/communication tech that allows remote access to equipment and specialized personnel - Impact on the Structure and Processes of Health Care Delivery - Outpatient services and tech available in-patient homes - Impact on Bioethics - Gene mapping, cloning, stem cell research, genetic engineering - The FDA and it's three classes of medical devices Assessment of Medical Technology (compared to traditional practices) - Safety, Efficacy, Cost effectiveness Benefits of Technology Assessment - Delivering Value -- New technologies must deliver actual value over previously accepted practices. - Cost Containment -- Process that allows us to answer questions, such as: How do companies reduce the cost of medical technologies to improve the profitability of their companies? How to maintain quality of technology when reducing cost? How to reduce cost to increase access? - Standardized Practice Protocols [Chapter 6 Financing and Reimbursement Methods] Effects of Health Care Financing and Insurance (pay special attention to exhibit 6.1 in text; be able to summarize the main points of the section) A screenshot of a white page Description automatically generated Insurance: Its Nature and Purpose - Basic Insurance Concepts -- risk is unpredictable for individual, can be predicted for group or pop, shifts risk from ind to group through pooling resources - Cost Sharing -- shared across all members of insured group Private Insurance (Define types, compare and contrast, consider the costs and benefits of each) - Group Insurance -- spread risk and cost among group - Self-Insurance -- large employers assume risk by budgeting funds to pay medical claims incurred by employees - Direct-Purchase Private Insurance -- most expensive, ALL on you to purchase insurance - Managed Care Plans -- most common - High-Deductible Health Plans -- pay certain amount before insurance kicks in Public Insurance - Medicare -- financed through individual paychecks, pay into the system - Policy is the same through every state determined by federal government - Medicaid -- financed through taxes by general public - Policy varies state to state for services - Children's Health Insurance Program -- financed through state and federal govt - Administered by states Issues with Medicaid (Describe the main problem---inadequate reimbursement) Reimbursement Methods (Define, describe, compare and contract types, consider costs and benefits) - Fee for Service -- reimbursement where providers are paid for each service they perform: visits, tests, x-rays, shot - Bundled Payments -- package pricing where service has one time set fee: example vaginal birth with fee but includes all services pre and post delivery - Resource-Based Relative Value Scale - Reimbursement Under Managed Care - From Retrospective to Prospective Reimbursement - Retrospective -- how used to be done, extra charges, more money, AFTER hospital visit - Prospective -- occurs BEFORE get to hospital, pay prior to treatment Payment Reform Initiatives National Health Expenditures - Spending for all health services and related activities, 18% GDP spent on healthcare - Will have to cut out education, national defense, public health -- raising at much higher rate than general inflation [Chapter 7 Outpatient Services and Primary Care] What is outpatient care? Scope of outpatient services (How are each of these related to outpatient care?) -- reasons for growth - Reimbursement -- financial incentives to reimburse for outpatient care - Technological factors -- less invasive procedures, faster recovery - Utilization control factors -- inpatient hospital stay discouraged - Social factors -- patients prefer to receive health care in home settings Outpatient care settings and methods of delivery (Define, consider the pros and cons) - Private practice -- office-based physicians, primary care services, limited exam/testing, short visits -- backbone of ambulatory care - Hospital outpatient clinics -- prominent in inner-city, community safety net, primary care to indigent (poor) and uninsured - Freestanding facilities -- walk in clinic, urgent care centers, surgicenters - Mobile facilities for medical, diagnostic, and screening services -- mobile health units (transport TO patients) - Telephone or internet triage -- care over phone, typically when clinic is closed - Home care -- alternate to institutionalization, least restrictive environment, nursing care, change dressings, medication monitoring, bathing... - Hospice care -- method of care, NOT location, provide services for terminally ill (6 mo or less), pain management and psychosocial/spiritual support - Outpatient long-term care services -- nursing home, case management, adult day care - Public health services -- provided by local health dept, STI, screening, immunization - Community health centers -- 1960s to serve medically underserved - Free clinics -- provide general ambulatory care to poor, little to no charge, trained volunteers - Alternative medicine clinics -- not western medication, nontraditional Primary care - What is primary care? -- approach to providing health care, set of basic and routine services - Domains of primary care? Point of entry (first contact patient has with system), community based, coordination of care (give advice, comprehensive, discuss options), essential care (goal to optimize health: country w focus on primary care = better health, weak primary care = poor health, high costs), integrated care (any stage of life, combine services to best meet needs, seamless process, continuous care), accountability (clinical system = provide quality care, good satisfaction, efficient. Patient = responsible for own health to extent) - What is community-oriented primary care? Convenient and accessible Consider the effectiveness of primary care - Hospitalizations and use of emergency care - Cost of care - Morbidity - Mortality The medical home strategy (What is it? Why is it important?) -- supports patients learning to manage own care How is information technology used in primary care? [Chapter 8 Hospitals] Evolution of the Hospital in the United States (General understanding of how hospitals came to be and evolved) Expansion and Downsizing of Hospitals in the United States (Consider why this happened? What factors were at play? What were the key events) Access and Utilization Measures - Measures of Access -- discharges -- patients released - Measures of Utilization -- average length of stay, census, occupancy rate Types of Hospitals (Know the population each serve, the services they provide, how they're funded, size, location, types of providers) - Community Hospitals -- nonfederal short-stay hospital available to general public (87% hospitals - MAJORITY) - Public Hospital -- govt owned, 25% hospitals, open to general public, high utilization - Private Nonprofit Hospitals -- voluntary hospitals, nongovernment and private ownership, make profit but don't pay taxes - Private For-Profit Hospital -- investor owned, operated for financial gain of stockholders - General Hospitals -- most, broad set of services - Specialty Hospitals -- distinct niche - Psychiatric Hospital -- treatment for mental illnesses - Rehabilitation Hospitals -- intensive care to restore max function - Children's Hospitals -- community hospital, high staffing ratio - Rural Hospitals -- county, large percent of poor/elderly - Teaching Hospitals -- graduate residency programs, goal to train - Osteopathic Hospitals -- holistic approach Licensure (every hospital MUST to be licensed to provide care (everyone has)), Certification (certified as specialist in certain cares), and Accreditation (voluntary, go through process to test for high quality, follow rules/policies (shows you are of high quality/standard)) Hospital Organization How is a hospital organized (e.g., Medical Board, CEO, Chief of Medicine, etc.) and why is this important?) Ethics and Public Trust - What are some guiding ethical principles? Informed consent, advanced directives - What are some ethical challenges for hospitals? - How are ethical issues addressed? Ethics committees [Chapter 9 Managed Care] What Is Managed Care? -- system of care where patients agree to visit only certain dr and hospitals and cost is monitored by managing company What are the main characteristics? - Manage financing, insurance, delivery and payment - Premiums are negotiated - Function like insurance company and assume risk - Arrange care - Manage utilization of health care services - Capitation (provider receives set amount of money for each patient assigned regardless of how much care patient receives), discounted fee, salary (missing motivation, don't want to work a lot if get same amount of money regardless of how many patients they see) Utilization Control Methods in Managed Care - MCOs use 3 major types of controls: - 1\. Expert eval of what services are medically necessary - 2\. Determine how services can be provided most inexpensively - 3\. Review course of medical treatment - Gatekeeping -- requires physician to coordinate all services needed by patient - Utilization Review -- eval process of appropriateness of services provided Types of Managed Care Plans (Note that the three types of models differ based on choice of providers, delivery of services, and payment and risk sharing---Exhibit 9.2) - HMO Plans (staff, group, network, independent) -- least flexible but cheapest - PPO Plans -- preferred provider organization, pay more to have more flexibility/freedom - Point-of-Service Plans -- go to whoever you want whenever (don't have anymore, unfair and expensive) Integrated Systems (Differentiate the two; an ACO is a type of IDS but it is especially concerned with clinical and fiscal accountability) - Integrated Delivery Systems: expanding reach of health system - Accountable Care Organizations: held responsible for all care received, if successful can make lots of money but can lose lots - get x amount of money and take care of [everything] (billing, where patient goes to get care, scheduling, quality of care, etc.) Types of Integration - Integration Based on Major Participants - Integration Based on Type of Ownership or Affiliation - Acquisitions -- buying & absorbing other companies, now part of ur company - Mergers -- buy two and become new company, merge together - Joint ventures -- both have equal power - Alliances -- join forces - Integration Based on Service Consolidation - Horizontal integration -- one hospital owning another hospital - Vertical integration -- hospital and want to expand elsewhere (ex. Organization owns hospital and nursing home) Medicare and Medicaid on cost containment, access and quality of care - Cost containment -- if cannot control rising costs, then must forgo other basic goods and services, resources should be directed to highest valued uses - Access -- ability to obtain personal health services that are needed, affordable, convenient, acceptable and effective - Quality of care  A chart with text on it Description automatically generated [Chapter 10 Long-Term Care Services] What Is Long-Term Care? - A Variety of Health Care Services - Individualized Services - Coordination of Services - Maximum Possible Functional Independence - Extended Period of Time - Holistic Approach - Quality of Life Activities of daily living: eating, bathing, dressing, toilet, bowel/bladder control, transferring Community-Based Long-Term Care Services - Home Health Care - Adult Day Care - Adult Foster Care - Senior Centers - Home-Delivered and Congregate Meals - Homemaker and Handyman Services - Emergency Response Systems - Case Management Institutional Long-Term Care - Retirement Facilities - Personal Care Facilities - Assisted Living Facilities - Skilled Nursing Facilities - Subacute Care Facilities - Specialized Care Facilities Licensing and Certification of Nursing Homes (Define each. Consider why they are important.) - Licensing - Certification Other Long-Term Care Services - Respite Care -- temporary service that provides relief for caregivers by offering substitute care or living arrangements for the person they care for - Restorative Care -- focuses on helping individuals maintain or regain their highest level of functioning after an illness or injury - Hospice Care -- care and support for terminally ill How did the Affordable Care Act impact long-term care? -- expanded Medicaid, promoted home and community-based services, improved coordination [Chapter 11-Special Population] Pre-disposing characteristics -- age, race/ethnicity, gender, geographic location Enabling characteristics -- insurance status, homelessness Uninsured vs under insured -- attempted to alleviate issue w Medicaid Health Disparities -- NOT inevitable, action to reduce social disadvantages can also reduce gaps in health outcomes, quality of care and access The Affordable Care Act and other federal initiatives -- Children's Health Insurance Program CHIP, Women Infants and Children WIC Socioeconomic disparities -- factors (income, job, info/edu access) influence health outcomes Mental Health Disability and Chronic Illness [Chapter 12 Cost, Access, and Quality] Cost of Health Care -- Viewed through 3 perspectives - In terms of national expenditures - On individual basis: cost of insurance and out of pocket - Providers: staff salaries, building cost, equipment, supplies The High Cost of U.S. Health Care -- massively increasing Reasons for High Health Care Costs - Third-Party Payment - Growth of Technology - Increase in Elderly pop - Medical Model of Health Care Delivery - Multi-payer System and Administrative Costs - Defensive Medicine - Waste and Abuse - Practice Variations Cost Containment - Health Planning -- employs rationing to control expenditures - Price Controls -- Medicare reimbursement from retrospective to prospective plan - Peer Review -- medical review by physicians - Competitive Approaches -- encourages consumers to be cost conscious in selecting insurance plan - Chronic Disease Prevention and Management -- 70% of all healthcare costs are generated by the 10% of patients w 1 or + chronic diseases Unequal Access to Health Care - Data on Access -- one of key determinants of health status - Access Disparities -- predicted by race, income, occupation - Access Initiatives -- sheppard-towne act, ww2 care for wives and children of low-rank personnel, cancer screening and immunization to medicare and states given \$24 mill for CHIP/ Health Care Quality - Micro perspective: individual basis, small level, health outcomes, quality of life, patient satisfaction - Macro perspective: national expenditures, access to care, population health - Structure -- resource inputs, foundation of quality of care - Process -- actual delivery of healthcare - Outcome -- bottom line measure of effectiveness of delivery system Quality Strategies and Initiatives Developments in Process Improvement - Clinical Practice Guidelines -- explicit descriptions of evidence-based processes, key to efficient practice - Cost-Efficiency -- when benefit received is greater than cost incurred - Critical Pathways -- interdisciplinary tools to provide consistent care coordination, limit variations - Risk Management -- avoid medical malpractice, enhances quality of care Patient Safety - safety event (wrong medication, fall) **Notes:** - cost access and quality -- all interrelated - essential services of long-term care (individualized, coordinated, promote functional independence, extended period of time, max quality of life, spiritual needs) - hospice is a form of care, **not** a location - history of healthcare spending -- almost doubled since 1970s - reasons for high-cost health care - Third-party payment - Technology - More old people - Medical model ([prevention] vs medical) - Defensive medicine (more tests because worried about getting sued) - Waste and abuse - Variations in practice - Cost containments to control healthcare costs - Health planning (rationing) - Price controls (reimbursement) - Peer review (someone else deciding what services the dr can provide) - Competitive approaches (one place doing surgery cheaper than another places) - Chronic disease prevention and management - Access to healthcare -- key determinant of health status w environment lifestyle heredity - Predicted by race, income, occupation, geo location - Defining and Measuring Quality 1. Structure -- foundation of quality of care (facility ex. hospital, staff, equipment) 2. Process -- actual delivery of care (dr physically touching/working on you) 3. Outcome -- bottom line of effectiveness of delivery system (satisfaction, health status, recovery) - Health information technology - Used for many things ex. Billing software, electronic medical records, etc - Quality -- bad quality/satisfaction = less money **Different ways providers are paid/ reimbursement:** - Fee for service -- reimbursement where providers are paid for each service they perform: visits, tests, x-rays, shot - Bundle payment -- package pricing where service has one time set fee: example vaginal birth with fee but includes all services pre and post delivery - Capitation -- payment arrangement in which a healthcare provider receives certain amount of money each month for x amount of patients whether you see them or not (more tests = less money)  **[Function and Importance of Policy within Healthcare Financing-Review Sheet]** [What is healthcare financing policy?] - Healthcare financing policy establishes the mechanisms for funding healthcare services. This includes how money is **raised**, **pooled** and **distributed** to providers. - Taxes, copays, deductibles, premiums [What is the benefit of healthcare financing policy?] - It impacts accessibility, affordability, and quality of healthcare for individuals within a population and community. [What is the importance of healthcare financing policy?] - It ensures equitable access to necessary care by managing costs, mitigating financial risk for patients, and incentivizing efficient healthcare delivery practices through policy design. [Key functions of healthcare financing policy:] - Revenue generation= Raise funds for healthcare (Ex: Taxes, Employer contributions, Individual premiums) - Risk Pooling= Establish how providers are reimbursed for services delivered (Ex: Fee-for-Service, Bundled payments, Performance-based incentives) - Benefit design= Determines which healthcare services are covered and the extent of the coverage within a plan - Regulation and oversight= Sets standards for healthcare financing practices (This ensures quality and prevents abuse) [Additional reasons why healthcare financing policy is important:] - Access to care= Policies can ensure that individuals can access necessary healthcare services without facing significant financial barriers - Financial protection= Mitigates catastrophic healthcare costs which protect individuals from financial ruin due to medical expenses - Quality improvements= Incentivize healthcare providers to deliver high-quality care and improve efficiency - Equity and social justice= Addresses disparities in access to care based on socioeconomic factors - Cost control= Help manage healthcare costs and promote resource allocation efficiency [Examples of healthcare financing policies:] - Universal health coverage= A policy that aims to provide comprehensive health insurance to all citizens - Ex. Canada -- takes forever to get care, limited resources - Employer-sponsored health insurance= A system where employers provide health insurance to their employees - Medicare = Government programs that provide health insurance to seniors - Medicaid= "" low-income individuals - Health savings accounts (HSAs)= Tax-advantaged accounts for individuals to save money for future medical expenses A close-up of a medical procedure Description automatically generated  **Chapter 13 Health Policy** - Define Health Policy -- the **aggregate of principles that characterize the distribution of resources, services, and political influence that impact on the health of the population** - Types of health policies in the U.S. - Medicare and Medicaid, ACA, and their influence - Describe how health policies can be used as regulatory tools.  - Govt may prescribe and control the behavior of a particular target group by monitoring the group and imposing sanctions for failure to comply - Some health policies are self regulatory - Define allocative tools. - How can allocative tools be distributive? -- spreads the benefit throughout society to benefit all populations - How can allocative tools be re-distributive? -- involves policies that obtain resources from one group and allocate to another group - What are the principles features of health policy? - Role of govt as subsidiary to private sector - Fragmented system, incremental, piecemeal reform - Many interest groups involving politics - De-centralized role of state - Impact of presidential leadership - Research community - What are the 5 components of the policy cycle? Define each.  -- example secondhand smoking for restaurant workers - Issue raising - Policy design - Building of public support - Legislative decision making - Policy implementation - What are some of the critical policy issues in the U.S.? Explain each.  - Access to care - Providers - Public funding - Access -- elderly, minority, rural areas, low income - Smoking and tobacco use - Cost containment - Quality of care - Mental health - What is the impact of the Patient Protection and Affordable Care Act (ACA0 and the Health Care and Education Reconciliation Act of 2010? - significantly reduced the number of uninsured Americans by providing affordable coverage through Medicaid and the health insurance marketplace. **Chapter 14 The Future of Health Services Delivery** - Forces of Future Change (just note that these things exist and are the facts that force changes to occur in how healthcare is delivered) - Social demographic and cultural trends - Economic Conditions - Political Will and Legal Rulings - Technological Innovations  - Global Health Issues - Ecological Events - Coverage, Cost, and Access Dilemmas - g - The Future of Health Care Reform - **Value based shared saving payments** **--**   - **Tighter consolidation** within one organization, which finances, insures, delivers, and pays providers - **Community outreach** through education services focusing on prevention and management of chronic disease - **Virtual care. **This may include remote monitoring and virtual consultations  - **Technology driven home visits** - Future Models of Care Delivery (**important!!** We're not looking for every detail but have a general understanding) - Value-Based Shared Savings Payments - - Population Health - - Community Outreach - - Virtual Care - - Technology-Driven Home Visits - - Future Workforce Challenges - Global Challenges (travel, cooperation with national and international health organizations, the role of war and conflict in health across the globe, threat of bioterrorism) - New Frontiers in Clinical Technology Also know - Medical homes -- primary care delivery based on partnership between patient and primary care provider, includes provider doing referrals when necessary - Health planning -- cost containment strategy that uses supply side rationing Important topics - Reimbursement methods - Fee for service - Bundled payments - Reimbursement under managed care - Retrospective reimbursement -- pay for services after visit - Prospective reimbursement-- pay for services prior to visit - Concurrent reimbursement -- checking utilization of cost during care process - Value scale - Providers are paid by outcomes, not by the number of services provided - Ensures the providers are providing good outcomes for the prices the patients are paying - looks at things such as high infection rate, re-administration rates, blood sugar and pressure levels (if these factors are not good, the value is low) - payments are directly tied to the quality of care delivered to patients - Why do you need health care policies? To ensure providers are held to a higher standard - Canada -- healthcare financed thr govt, healthcare delivered thr private providers - UK -- healthcare financed thr govt, healthcare delivered the govt - KNOW THE STEPS NEEDED IN ORDER TO IMPLEMENT POLICIES\*\*\* - Complex process involving private and public sectors and multiple levels of government 1. Issue raising 2. Policy design 3. Building of public support 4. Legislative decision making and building of policy support - Complex and combative at times 5. Policy implementation - Medicare -- financed through payroll tax paid by employees, employers, and self employed - Medicaid -- financed by the states and federal government - The medical home strategy (What is it? Why is it important?) -- supports patients learning to manage own care Known Test Questions !!!\*\*\*\* **Describe how healthcare is financed through Medicaid program** - **Federal and state tax that everyone pays, only some receive benefits** Medicare - tax payers contribute and everyone gets benefits when 65+ (tax on workers' paychecks) **List stakeholders in healthcare systems and how they interact with each other** - Patients (receive the care, tax payers) - Doctors (provides services for patients at hospital) - Insurance companies (provide insurance to patients) - Providers - Hospital director