Outpt Services & Primary Care
Health care services that do not require an overnight stay in a health care facility.
What is outpatient care?
Type of care that involves at least an overnight stay (>=24 hrs).
What is inpatient?
Most stringent type of MCO. Members assigned PCP and required to stay in network for care to be covered.
What are HMOs?
Price x Quantity
What is the formula for health care expenditures?
Payment systems don't affect how health care systems are organized and delivered.
What is False?
Type of provider that treats common health problems and emphasizes preventive measures.
What is a primary care provider/generalist?
Usually consists of basic and routine services, but should be viewed more as an approach to care than as a set of specific services.
What is Primary Care?
Type of hospital that primarily provides diagnostic and treatment services for patients who have mental illnesses.
What are psychiatric hospitals?
Type of MCO that doesn't require a PCP gatekeeper and has out-of-network options.
What is a PPO?
Ability to get the care you need when you need it.
What is access to care?
A traditional payment model in which health care providers are paid for every service and procedure they provide. Can incentivize more and more services to be used.
Fee For Service
Type of care that is episodic and usually focuses on a specific organ system or part of the body.
What is specialty care?
Reimbursement, technology, utilization control, patient preference
What are factors contributing to growth of outpatient care (shift from inpt to outpt)?
These types of hospitals have to justify their tax-exempt status by providing community benefits.
What are private non-profit hospitals?
The term for several organizations, often under the same ownership, that provides and array of services to large communities.
What is an integrated delivery system (IDS)?
Name at least two factors that contribute to high health care costs.
What are: general inflation, medical inflation, population growth, expensive technology, increased demand due to insurance, emphasis on medical model of health care, defensive medicine, people living longer/aging of population, physician induced demand, high administrative costs, waste & abuse
Reimbursement scheme often used by HMOs under which a provider is paid a set monthly fee per enrollee under their care (per member per month rate).
What is capitation?
This is the largest group of health professionals.
Who are nurses?
A concept, not a place, that uses team-based care led by a physician.
What is a medical home (aka patient-centered medical home)?
Availability of private insurance, the Hill-Burton Act, and the start of Medicare & Medicaid.
What are factors contributing to growth of hospitals?
Type of integration in which different types of health care orgs come together to diversify and increase comprehensiveness & continuity of care delivered.
What is vertical integration?
This domain of quality refers to the end result of care and is often measured by patient satisfaction and health status.
What is outcome?
Used by Medicare to pay for hospital inpatient services (often goes by an acronym)
What are Diagnosis-Related Groups (DRGs)? Will also accept Prospective Payment System (PPS).
These health professionals focus on the health of communities rather than individuals.
What are public health professionals?
Point of entry, coordination of care, essential care, integrated care, accountability
What are the key domains of primary care?
A Medicare designation for a rural hospital with 25 beds or less beds. Reimbursed according to cost-plus not DRGs.
What is a critical access hospital?
Name of the organization that accredits MCOs and develops MCO performance measures.
What is the National Committee for Quality Assurance (NCQA)?
This domain of quality refers to resource inputs and how care is organized. It includes things like staffing levels and staff qualifications.
What is structure?
General term for any payment system where criteria for how much to be paid is set in advance. Payment amount is not dependent on services actually provided.
What is prospective?
Better incomes and hours, chance to use cutting edge technology, and the prestige of certain medical fields contributes to this.
What are factors contributing to specialty/primary care maldistribution?