What is cost containment?
an attempt to control the rising cost in healthcare and maximize benefits
What are the three things that makes healthcare more expensive?
technological advancementsaging population that require more health care servicessue happy people make healthcare services require insurance to prevent from being harmed if sued
What are the three main ways to help cost containment?
Diagnostic related groups (DRGs)Outpatient servicesEnergy Conservation
What are Diagnostic Related Groups (DRGs)?
a classification scheme developed by the federal government as a means to establish a uniform reimbursement for a variety of diagnostic conditions- patient's diagnosis determines the amount the provider will be paid- a fee for service that compensated your doctor
What are "value-based compensation" payments?
where the provider is paid for each diagnosis made rather than each service rendered to try to make providers consider the necessity of services or treatments
What is the point of combination of services?
organizations like HMOs or PPOs that try to lower costs by packing health care agencies and specific services into one building in an attempt to lower costs
What are outpatient services?
patients who receive care without being admitted to hospitals or other care facilities/ lowering the amount of days where the patient is necessary to stay in the hospital
What is the purpose of mass or bulk purchasing?
large quantities of goods bought lowers the price of said products, thus saving money
What do early intervention or preventive services do?
by regularly getting visits to the doctor, patient education, or providing care before prolonged disease takes place allows for extreme healthcare systems to be not used as frequently
What does environmental protection do?
is an expensive but necessary way to dispose of waste properly as to not eventually result in a lawsuit
What are the three types of waste?
Infectious Medical Waste- waste that can transfer infectionsRadioactive Medical Waste- contains radioactive materialHazardous Medical Waste- dangerous but not necessarily infectious
What does energy conservation do?
by controlling the amount of energy used it allows for resources to be controlled and costs to be lowered
What does the Agency for Healthcare Research and Quality (AHRQ) do?
attempts to lower costs but improve quality of health care
What is home health care?
services provided in patients home- considered a type of cost containment because it is less expensive to provide this type of care-is rapidly growing
Why is geriatric care important?
it is becoming a larger field as the "baby boomer" generation is growing exceptionally larger and there are studies done that show that population growth will decrease in future years but the amount of elderly people will double in growth
What is OBRA?
Omnibus Budget Reconciliation Act of 1987- set standards of care and education needed to work for the elderly- used to try to protect residents from abuse and neglect
What is are some requirements from OBRA?
for nurses to require the minimum skills necessary to pass the National Nurse Aid Assessment Program (NNAAP) which is created by the National Council of State Boards of Nursing (NCSBN)
What is telemedicine?
use of video, audio, and computer systems to provide medical and/ or health care services
What are some examples of telemedicine?
-surgeons directing surgery through a robot many miles away-electronic health/ medical records (EHR or EMR) allows for rapid transmission of medical records to any location-technology to administer and treat chronic illnesses or diseases at home without a trip to the doctoronline doctor appointments
What is wellness?
the state of being in optimum health with a balanced relationship between physical, mental, and social health
What is physical wellness?
promotes proper body care so we function normally (diets, routine examinations, and avoidance of addictions)
What is emotional wellness?
the ability to understand your own feelings, accept your limitations, and achieve emotional stability
What is social wellness?
developing and maintaining meaningful interpersonal relationships
What is mental wellness?
a state in which your mind is engaged in lively interaction with the world around you (continuously learning)
What is holistic health care?
promoted physical, emotional, social, intellectual, and spiritual well-being by treating the whole body, mind, and spirit.
What does holistic health care use?
western medicine and alternative methods to help restore the mind
What is CAM?
complementary and alternative medicine - C= compliments western treatment (therapy)- A= no western treatment- M= medicine
What is integrated health care?
facilities that use mainstream medical treatments and CAM to treat patients
What does CAM health care believe?
that the mind affects the healing process of patients
What is the purpose of NCCAM (National Center for Complementary and Alternative Medicine)?
to research the various alternative medicine methods and determine the standards of quality care
What is a pandemic?
worldwide epidemic
What is biotechnology?
the use of genetic and biochemical processes of living systems and organisms to develop or modify useful products specific to a person's genes
What is genomics?
the study of genomes
What are hospitals classified by?
their sources of income
What are the classifications of hospitals?
- religious- public (nonprofit)- profit- government
What are the types of hospitals classified by?
the people they serve
What are the different types of hospitals?
- general (nonspecific)- specialty hospitals ( provide care for specific conditions or age groups)- government (operated by and care for government officials)- university (for college students and staff)
Who are long-term care facilities (LTCs) for?
generally elderly people but can also provide care for disable people or individuals with long-term diseases
What are the three types of LTC facilities?
- residential care facilities (nursing or geriatric homes)- extended care or skilled care facilities - independent or assisted living facilities
What are nursing homes for?
to provide basic physical and emotional care for individuals who can no longer take care of themselves; help people with activities of daily living (ADLs)
What are extended care facilities for?
to provide skilled nursing and rehabilitative care to people who are expected to eventually leave
What are assisted living facilities for?
to provide an apartment that gives housekeeping, laundry, meals, basic medical care, and social events to people who can mainly take care of themselves but need help with certain things
Why are some assisted living facilities connected or partnered with nursing homes?
to allow for an easy transition between care facilities if needed
What are medical offices?
offices that carry physicians (can be many/ one or specialized in certain medical care)
What is the traditional care at a medical office?
- exam- simple lab tests- diagnosis- treatment
What is concierge medicine?
an enhanced relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer (allows for the physician to have fewer patients but more availability)
What are dental offices?
clinics that deal with teeth (can offer specialize care like an orthodontist)
What are clinics?
specialized medical offices
What are some examples of clinics?
- surgical clinics (provide minor surgery or cosmetic procedures and don't require a long patient stay)- emergency clinics (provide emergency care or first aid)- rehabilitation clinics (offer physical, occupational, speech, and other similar therapies)-substance abuse (provide rehabilitation for substance abuse)- specialty clinics (provide care for specific diseases- outpatient clinics (provide care for people who aren't admitted to the hospital)- health department clinics ( special services)- medical center clinics ( usually on a college campus and offer various treatments and learning experiences)
What do optical care centers do?
provide vision examinations, prescriptions, and check for the presence of eye diseases
What do emergency care services do?
provide special care for victims of accidents or sudden acute illness
What are some examples of services they provide?
ambulances, rescue squads, helicopter transportation, special clinics and centers
What are laboratories?
medical care that can perform special diagnostic tests that work with body fluids
What do dental laboratories do?
prepare false teeth and other devices to repair or replace teeth
What does home health care provide?
care in a patient's home like- therapy- housekeeping-nursing- CNA duties (personal care)
What is hospice?
end of life care that focuses on comfort for both the patient before death and for the patient's family after death
What are mental health facilities?
a facility that treats patients with mental disorders and diseases by providing counseling and therapy along with guidance
What do genetic counseling centers do?
work with pregnant people or those who want to become pregnant by performing prenatal tests, check for genetic abnormalities and birth defects, give counseling if a defect is present and give options for the patient
What do rehabilitation facilities do?
provide care to help patients who have physical or mental disabilities through therapy and other cares to maximize self-care and function
What are health maintenance organizations (HMOs)?
a type of health care delivery systems and a health insurance plan
What do HMOs do?
provide total health care services that are directed toward preventive health and is a prepaid system that includes basic medical services (may use services from other health care facilities)
What are industrial health care centers?
clinics that are found in large companies or industries
What do industrial health care centers do?
provide health care for employees of the industry through basic examinations, education and prevention methods, and emergency care
What do school health care services do?
provide emergency care for students, perform speech, hearing, and vision tests, promote health education, counseling, and maintain a sanitary school environment
What do pharmaceutical services do?
- prepares and dispenses prescription medications- drug therapy- safety through education- offer over-the-counter drugs
What is the World Health Organization (WHO)?
diseases and illnesses that spread over the world
What is the U.S. Department of Health and Human Services (USDHHS) ?
deals with the health problems in the US
What is the National Institutes of Health (NIH)?
is involved in researching disease and conducting scientific studies
What is the Centers for Disease Control and Prevention (CDC)?
deals with the spread control and causes for diseases
What is the Food and Drug Administration (FDA)?
a federal agency charged with enforcing regulations against selling and distributing adulterated, misbranded, or hazardous food and drug products
What is the Agency for Healthcare Research and Quality (AHRQ)?
a federal agency established to improve the safety and effectiveness of health care for americans
What is the Occupational Safety and Health Administration (OSHA)?
establishes and enforces standards that protect workers form job-related injuries and illnesses
What is the Office of the National Coordinator for Health Information Technology (ONC)?
leads national efforts to build a private and secure nationwide health information exchange
What do Public Health Systems/ Departments do?
- provide health services as directed by the USDHHS- recommend mandates- give testing-immunization-inspections for sanitization - transport-educationrecreations
What are voluntary (non-profit) agenices?
provide health services at the national, state, and local levels and are supported by donations, membership fees, and federal or state grants
What is the Joint Commission?
a nonprofit, U.S based organization that was created to ensure that patients receive the safest, highest quality care in any health care setting
What do non-profit agencies normally do?
are focused towards a specific cause like focusing on research and education or to fund treatments for a certain illness
What is the purpose of an organizational structure in an health care system?
to provide a set structure to health care facilities to tell you who you should report to and to make an organized system to be efficient
What is a premium?
a payment on a monthly/ annual basis to uphold your insurance
What is a deductible?
amount that must be paid before insurance kicks in
What is co-insurance?
a type of insurance plan where the employer and the employee both share the cost of insurance (like 70/30)
What is a co-payment?
the fee for service/ the added fees based off of your needs- like having to pay for each doctor that cares for you while in a hospital
What is an assignment of benefits?
an agreement that assigns the benefits of health insurance to a physician or health care facility so they can collect payment directly from an insurance company
What is a health maintenance organization (HMO)?
person receives needed services offered by the HMO, for a prepaid fee that does not change no matter how much health care is used, and they stress preventing disease and maintaining health
What is a preferred provider organization?
a health insurance plan that is offered in industrial work and forces you to see specific doctors and dentists at a reduced rate - require a deductible and co-payment
What is medicare?
a federal insurance program that provides individuals 65 and older + disable people that have had at least 2 years of social security benefits + someone with end-stage renal disease (ESRD) with insurance
What are the 4 types of medicare?
Type A: hospital insurance (hospital visits)Type B: medical insurance (doctor visits)- must pay a premium and deductibleType C: combo of bothType D: medication expenses
How much does medicare cover?
80% of services
What is a Medigap policy?
a health insurance plan that helps pay medical expenses not covered by Medicare- require a premium-they must meet specific federal guidelines- they allow options to how much the enrollee wants covered
What is Medicaid?
a medical assistance program that is jointly funded by the federal government and state governments but operated by individual states-coverage differs on the state regulations and standards - set the rate of payment based on the state
Who does Medicaid cover?
- low income families- children who qualify for public assistance- individuals who are physically disabled or blind
What programs does Medicaid cover?
normally hospital services, physician care, long-term services, some therapies- some Medicaid covers dental and eye care, and other specialized services
What is the Children's Health Insurance Program of 1997 (CHIP)?
a children's health insurance plan based on people who make too much for Medicaid but too little to afford private insurance
What does CHIP cover?
inpatient and outpatient care, surgical and medical care, laboratory and X-ray tests, well-child care including immunizations
What is worker's compensation?
a health insurance to provide treatment for on the job injuries and to pay for the amount of time healing from the injuries-administered by the state and payed for by the state and employers
What is TRICARE?
a U.S government health insurance plan that covers:- active duty members and their families- retired military- families of deceased military
What is managed care?
a type of health care that is most common with HMO and PPO where care can only be provided with a second opinion/ all health care used must have a purpose
What is the purpose of managed care?
to try to deescalate the rising costs in health care by providing quality care at a lower cost through preventive care rather than reactive
What is a fee-for-service compensation?
a type of health payment plan in which doctors or providers are paid a set amount for different types of service they provide to a patient
What is the downside to a fee-for-service compensation plan?
doctors have little incentive to consider the cost or necessity of services provided
What is a value-based compensation plan?
a health payment plan where doctors are paid for their performance - doctors and providers are paid a certain amount for each diagnosis or disease
What is the issue with value-based compensation?
the uniqueness of each patient and each disease complicates the idea of placing a measurable value on each case
What are the five components of the Health Insurance Portability and Accountability Act (HIPAA)?
1. Health care access, portability, and renewability2. Preventing health care fraud and abuse; administrative simplification, and medical liability reform3. Tax-related health provisions4. Application and enforcement of group health plan requirements5. Revenue offsets
What does the first component do?
limits exclusions on preexisting conditions to allow the continuance of insurance even with job changed; prohibits discrimination of an employee based on health status; provides special rights for people who lose insurance coverage through termination of employment or divorce
What does the second component do?
establishes methods for preventing fraud and abuse; reduces costs of health care through only one type of medical electronic standards; strict guidelines for confidentiality on health records; recommends limits for medical liability
What does the third component do?
promotes the use of medical savings account by allowing tax deductions for monies placed in the accounts; establishes standards for long-term care insurance; tax benefits; and the creation of state insurance pools
What does the fourth component do?
establishes standards that require group health care plans to offer portability, access, and renewability to all members of the group
What does the fifth component do?
provides changes to the Internal Revenue Code for HIPAA expenses
What did the Patient Protection and Affordable Care Act do?
added major changes to health care insurance to help the expenses of health care
What is consumer responsibility?
the responsibility of consumers to take an active role in lowering the cost of health care
What are some examples of consumer responsibility?
- take an active role in maintaining good health- evaluate different health care plans- research quality care- make informed decisions regarding health care- use health care benefits wisely- make every effort to save money on health care costs- help prevent medical errors
What is epidemiology?
the study of disease in populations to help identify which hazards with diseases are most important
What does bioethics do?
to investigate and study how health care decisions are made; to make sure medical practices benefit society as a whole
What does socioeconomic status (SES) do?
affects individuals' health outcomes and health care they receive; poorer health care if the SES is low which harms the cost of health care as a whole because treatment becomes reactive rather than preventive and results in the increasing number of low SES patients which creates a cycle of low SES patients