Term
The World Health Organization has defined primary care to include three elements.
List and explain. |
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Definition
Point of entry – “gatekeeping” (1st contact)
Coordination of care- delivery of, b/t pt. & myriad delivery components
Essential care- optimize pop.health/ minimize health disparities |
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Term
| . List 5 examples of out-patient services. |
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Definition
| Clinic services, 1 –day surgery, rehab, physical exams, eye exams,….. |
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Term
| Explain the role of gatekeeping in primary care. |
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Definition
| First contact feature, the interposition of primary care that protects pt. from unnecessary procedures and overtreatment |
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Term
Home health care typically includes what types of nursing care. What is the
philosophy of home health care? |
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Definition
Home health typically includes post acute and rehab therapies. Designed to keep the pt. within the hospital system. Services are brought to the pt. It is skilled nursing care.
philosophy “maintaining people in the least restrictive environment possible.” |
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Term
. List the 2 primary areas of emphasis in Hospice care. Name the largest source of
Financing for Hospice. |
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Definition
1)Pain & symptom management (palliation)
2) psychosocial and spiritual support
Medicare is the largest source of financing for hospice service. |
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Term
Name and define the three categories of conditions for which patients present
themselves to the Emergency Room. |
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Definition
Emergent: critical, time delay is harmful, potentially life threatening
Urgent: requires medical attention within hours, dangerous
Nonurgent: not requiring resources of ER, disorder nonacute or minor in severity |
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Term
| Describe the types of services provided by public health systems in the United States. |
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Definition
| Services are limited in scope, do not directly compete w/ private practioners, and are targeted to serve inner city, poor, uninsured populations. Examples: well baby care, venereal diseases, family planning, screening & treat. for TB, ambulatory mental health |
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Term
| List conditions that make a patient eligible for home health services under Medicare. |
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Definition
| Pt. is required to be homebound, have a plan of treatment and a periodical review by a physician and require intermittent or part time skilled nursing and/or rehab therapy |
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Term
Explain the reasons why a patient would go to the emergency department with a
nonurgent condition. Explain the consequences. |
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Definition
· Erroneous self assessment of severity of ailment/injury
· 24 hour open door policy
· Convenience
· Unavailability of primary care providers
· Uninsured lacking access to routine primary care
Causes overcrowding, bed shortages, high pt. volume, too few examination spaces, not enough RN’s, costs become high, it wastes precious resources |
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Term
Describe why it is an advantage for hospitals to focus on outpatient services, instead
of only traditional inpatient services. |
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Definition
Medicaid reimbursement is a biggy!
Range of services that could be provided to an outpatient basis continues to expand, people are going to seek those services, b/c they don’t want to be hospitalized, and it’s expensive. So if hospitals want to keep those “customers” they need to provide outpatient services, which are a large portion of healthcare needs |
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Term
| According to the American Hospital Association a hospital is an institution that must have what main 5 characteristics? |
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Definition
· at least 6 beds
· must be licensed
· must have an organized physician, and staff and services under supervision of registered nurses
· must have a governing body for legal responsibilities, a CEO, maintenance of medical records, pharmacy services supervised by a regis.pharmacist.
· must have food services operations to meet nutritional/therapeutic requirements of the patients. |
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Term
| What is the percent of hospital revenue that the government pays? What is the percent of hospital revenue that is paid by other sources than the government? |
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Definition
| Medicaid, Medicare, state, and local tax dollars pay for almost 80% of services. |
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Term
| Medicaid, Medicare, state, and local tax dollars pay for almost 80% of services. |
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Definition
· Primitive institutions of social welfare, from almshouses and pesthouses
· Distinct institutions of care for the sick
· Organized institutions of medical practice, with advances in medical services
· Advanced institutions of medical training and research
· Consolidated systems of health services delivery |
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Term
| 4. Name the key person (position) of hospital inpatient utilization. |
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Definition
| Utilization review case manager |
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Term
| 5. Explain how Swing beds and Critical Access Hospital affect rural hospitals. |
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Definition
| Additional revenue can be created for rural hospitals by allowing them to switch the use of beds between acute and long term care. Where previously they had financial pressures and lots of closings. |
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Term
| Explain average length of stay |
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Definition
| The average length of stay is a measure of how many days on average, a patient spends in the hospital (is an indicator of the severity of illness) and is calculated by dividing the total days of care by the total number of discharges. |
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Term
| . Explain average daily census. |
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Definition
| Average daily census is the average number of beds occupied each day in a hospital and is a common measure used to define occupancy of inpatient beds in a hospital. The total inpatient days during a given period (days of care) are divided by the number of days in that period to arrive at the average daily census. |
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Term
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Definition
| indicate the proportion of a hospital’s total inpatient capacity that is actually utilized and is also commonly used for other types of inpatient facilities, such as nursing homes, and is often used as a measure of performance, in a competitive environment, facilities with higher occupancy rates are considered more successful than those with lower occupancy rates. Divide the average daily census for that period by the number of available beds (capacity) |
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Term
| Define a long-term hospital. List one example. Why have these hospitals declined in the United States? |
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Definition
| A long term care hospital is a special type that must have met the Medicare’s conditions of participation for acute or short term stay AND must have an ALOS of more than 25 days. These pt.s have complex medical needs and may suffer from multiple chronic problems requiring long term hospitalization. Many are admitted from short stay units with respiratory/ventilator dependent or other complications. The demand for long term hospitals (ex. TB) have declined b/c the disease has been eradicated or controlled with modern drugs. |
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Term
| 9. Name the single largest hospital system in the country and who runs that system. |
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Definition
| VA (veterans) operates the single largest system in the country with 163 medical centers, owned by the federal government. |
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Term
| 10. Define the Bill of Rights. |
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Definition
| Document that reflects the law concerning issues such as confidentiality and consent. Other rights include the right to make decisions regarding medical care to be informed about diagnosis and treatment, to refuse treatment and to formulate advanced directives. |
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Term
| 11. Define Advanced Directives. Name three types of Advanced Directives that are commonly used. |
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Definition
Advanced directives refer to the patients wishes RE: continuation or withdrawal from treatment when the patient lacks decision making capacity. Advance directives are intended to ensure that the patient’s end of wishes are carried out.
· DNR = do not resuscitate
· Living wills
· Durable powers of attorney |
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Term
| 12. Define the principles of beneficence and nonmaleficence. |
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Definition
Principal of beneficence implies that all individuals have some moral obligation to benefit others. Health care organizations are ethically obligated to do all it can to alleviate suffering caused by ill health and injury. [to help]
Principal of nonmaleficence implies that people have moral obligations not to harm others. [do no harm] |
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Term
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Definition
| Licensure is carried out through the state’s depart. of health, sets standards to emphasize compliance with building codes, fire safety, climate control, space allocation, and sanitation. Minimum standards established for equipment and personnel. State licensure is not directly tied to the quality of care a health care facility delivers. A hospital cannot operate unless it is licensed. |
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Term
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Definition
| Certification entitles a hospital to participate in Medicaid/Medicare. Conditions of participation are to protect pt. safety and health and help assure that quality care is furnished to all patients. It must be certified by DHHS. Standards are verified through periodic inspections by the state’s department. |
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Term
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Definition
Accreditation is a voluntary, private mechanism designed to assure that accredited health care facilities meet certain basic standards. Accreditation confers deemed status on a hospital, which exempts it from Medicare and Medicaid certification.
The Joint Commission on Accreditation of Healthcare Organization (JCAHO) has the authority to accredit a hospital. The American osteopathic association also has deeming authority to accredit a hospital. |
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Term
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Definition
| an organized approach to delivering a comprehensive array of healthcare services to a group of enrolled members through efficient management of services needed by the members, and negotiation of prices or payment arrangements with providers. |
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Term
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Definition
| the provider is paid a fixed monthly sum per enrollee, often called per member per month (PMPM) payment. The provider receives the capitated fee per enrollee, regardless of whether the enrollee uses health care services and regardless of the quantity of services used. The provider is responsible for furnishing all needed health care services determined to be medically necessary. Thus, under capitation, risk is shifted from the MCO to the provider. Capitation is the antithesis of fee-for-service, in which the provider can bill separately for each provided. |
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Term
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Definition
| After services have been delivered, the provider can bill the MCO for each service separately but is paid according to a prenegotiated schedule called a fee schedule. In this case, risk is borne by the MCO, but the MCO can lower its costs by paying discounted rates. Providers agree to discount their regular fees in exchange for the volume of business the MCO brings them |
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Term
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Definition
| often coupled with bonuses or withholdings. In this case, the provider is an employee of the MCO. The physicians, for instance, are paid fixed salaries. At the end of the year, a pool of money is distributed among the physicians in the form of bonuses based on various performance measures. From an economic perspective, the physicians are paid only partial compensation up front. The remainder is withheld and is paid on condition that certain performance standards are met. Hence, under this method of payment some risk is shifted from the MCO to the physicians. |
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Term
| . List three main avenues of cost control with managed care organizations and explain each. |
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Definition
1) an expert evaluation of which services are medically necessary in a given case. Such an evaluation ensures that unnecessary services are minized.
2) it requires a determination of how those services can be provided most inexpensively while maintain acceptable quality standards
3) It requires a review of the process of care and changes in the patient’s condition to revise the course of medical treatment in necessary. |
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Term
| Explain the differences between a Health maintenance organization and Preferred provider organization. |
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Definition
They differentiated the PPO product by offering open-panel options for enrollees and offering noncapitation payment to providers. The enrollees agree to use a selected set of physicians and hospitals with whom the PPO has contracts. The main appeal of PPOs is that they allow patients the choice of using physicians and hospitals outside the panel, for which the patients must pay higher copayments than if they used in-network providers. The additional out-of-pocket expenses act largely as a deterrent to going outside the panel. In paying providers, PPOs substitute discounted fee-for-service for capitation, which is more commonly used by HMOs.
HMOs have organizational mechanisms to assume corporate responsibility for cost containment and quality assessment, PPOs do not have such intrinsic controls. PPOs also apply fewer restrictions to the care-seeking behavior of enrollees. In most instances, primary care gatekeeping is not employed, which allows enrollees to see specialists without being referred by a primary care physician. |
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Term
| Explain Point-of-service plans. |
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Definition
| combine features of classic HMOs with some of the characteristics of patient choice found in PPOs. Hence, they are sometimes referred to as hybrid plans or open-ended HMOs. These plans have a two-pronged objective: retain the benefits of tight utilization management found in HMOs but offer an alternative to their unpopular feature of restricted choice. The features borrowed from HMOs are capitation or other risks-based provider reimbursement and the gatekeeping method of utilization control. Each enrollee chooses a primary care provider. The feature borrowed from PPOs is the patient’s ability to chose a non participating provider at the point (time) of receiving services, hence the name, “point of-service.” Of course, the enrollee has to pay extra for the privilege of using nonparticipating provides because these providers are paid their fee-for service rates. From the consumer’s perspective, free choice of providers is a majo selling pint for POS plans. They grew in popularity soon after they first emerged in 1988. However, after they first emerged in 1988. However, after reaching a peak in popularity in 1998 and 1999, enrollment in POS plans has gradually declined (Figure 9-12), mainly due to the increased out-of-pocket cost enrollees must incur. |
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Term
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Definition
| HMO employs its own salaried physicians. Based on the physician’s productivity and the HMO’s performance, bonuses may be added to salary. Physicians work only for their employer HMO and provide services to the HMO’s enrollees. Staff model HMOs must employ physicians in all the common specialties to provide for the health care needs of their members. Contracts with selected subspecialties are established for infrequently needed services. The HMO operates one or more ambulatory care facilities that contain physicians’ offices, employs support staff, and may have ancillary support facilities, such as laboratory and radiology departments. In most instances, the HMO contracts with area hospital for inpatient services |
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Term
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Definition
| HMO contracts with a single multispecialty group practice and separately with one or more hospitals to provide comprehensive services to its members. The physicians in the group practice are employed by the group practice, not the HMO. The HMO generally pays an all-inclusive capitation fee to the group practice to provide physician services to its members. The group practice may be an independent practice, in which case the physicians may also generally treat nonHMO patients. Under a different scenario, the HMO may own the group practice may provide services exclusively to the HMO’s members. An exclusive contract with a group practice enables the HMO to exercise better control over utilization. |
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Term
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Definition
HMO contracts with more than one medical group practice. This model is specially adaptable to large metropolitan areas and widespread geographic regions where group practices are located. A common arrangement in the network model is to have contracts only with group practices of primary care physicians. Enrollees generally may select physicians from any of these groups. Each group is paid a capitation fee based on the number of enrollees. The group is responsible for providing all physician services. It can make referrals to specialists but is financially responsible for reimbursing them for any referrals it makes. In some cases, the HMO may contract with a panel of specialists, in which case, referrals can be made only to physicians serving on the panel.
The network model can generally offer a wider choice of physicians than the staff or group model. The main disadvantage is the dilution of utilization control. In 2005, there were 153 network model HMOs (33.6% of all HMOs) in the United States. |
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Term
| ) Independent Practice Association (IPA) Model of HMO |
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Definition
| a legal entity separate from the HMO. The IPA contracts with both independent solo practitioners and group activities. In turn, the HMO contracts with the IPA instead of contracting with individual physicians or group practices. Hence, the IPA is an intermediary representing a large number of physicians. The IPA is generally paid a capitation amount by the HMO. The IPA retains administrative control over how it pays its physicians. It may reimburse physicians through capitation or some other means, such as modified fee-for-service. The IPA often shares risk with the physicians and assumes the responsibility for utilization management and quality assessment. The IPA also generally carries stop-loss reinsurance, or the HMO may provide stop-loss coverage to prevent the IPA from going bankrupt. |
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Term
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Definition
| Involves a mutual agreement to unify two or more organizations into a single entity. The separate assets of two organizations are brought together, typically under a new name. Both entities cease to exist, and a new corporation is formed. A merger requires the willingness of all parties. All partners in the merger must assess the advantages and disadvantages of joining together. |
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Term
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Definition
| refers to the purchase of one organization by another. The acquired company ceases to exist as a separate entity and is absorbed into the purchasing corporation. |
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Term
| Explain the purpose of Mergers and acquisitions. Give examples. |
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Definition
| Small hospitals may merge to gain efficiencies by eliminating duplication of services. A large hospital may acquire smaller hospitals to serve as satellites in a major metropolitan area with sprawling suburbs. A regional health care system may be formed after a large hospital has acquired smaller hospitals and certain providers of long-term care, outpatient care, and rehabilitation to diversify its services. Multifacility nursing home chains and home health firms often acquire other facilities to enter new geographic markets. |
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Term
| What are the main objectives of Horizontal |
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Definition
| Horizontal integration is a growth strategy in which a health care delivery organization extends its core product or service. Commonly, the services are similar or may be substitutes for the existing services. Horizontal integration may be achieved through internal development, acquisition, or merger. Horizontally linked organizations may be closely coupled through alliances. The main objective of horizontal integration is to control the geographic distribution of a certain type of health care service. Multi-hospital chains, nursing facility chains, or a chain of drugstores, all under the same management, with member facilities offering the same core services or products, are horizontally integrated. Diversification into new products and/or services is not achieved through horizontal integration. |
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Term
| Explain the main objectives of VERTICAL integration |
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Definition
Vertical integration links services at different stages in the production process of health care – for example, organization of preventative services, primary care, acute care, and post acute service delivery around a hospital. The main objective vertical integration is to increase the comprehensiveness and continuum of health care services. Hence, vertical integration is a diversification strategy.
Vertical integration may be achieved through ownership consolidation, expansion into new services, joint ventures, or alliances. Formation of networks and virtual organizations can also involve vertical integration. Large hospitals systems are particularly attracted to group practices in the interest of vertical integration because group practices can give them a large slice of the patient market. In essence, this kind of integration extends a hospital’s control over the delivery of health services to the outpatient setting. Vertically integrated regional health systems may be the best positioned organizations to become the providers of choice for managed care or for direct contracting with self-insured employers. |
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Term
| Explain the main advantage of two organizations forming an alliance. |
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Definition
The main advantages of alliances are: 1) they are relatively simple to form
2) they provide the opportunity to evaluate financial and legal ramifications before a potential “marriage” takes place. Forming an alliance gives organizations the opportunity to evaluate the advantages of an eventual merger.
3) Alliances require little financial commitment and can be easily dissolved, similar to an engagement prior to a marriage. |
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Term
| Explain when a joint venture would be considered a preferable integration strategy. |
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Definition
| Joint ventures are often used to diversify when the new service can benefit all the partners and when competing against each other for that service would be undesirable. Hospitals in a given region may engage in a joint venture to form a home health agency that benefits all partners. An acute care hospital, a multispecialty physician group practice, a skilled nursing facility, and an insurer may join to offer a managed care plan. Each participant would continue to operate its own business, and they all would have a common stake in the new MCO. |
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