Healthcare Delivery System

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  1. Private system Funding = private health ins., personal out of pocket, industrial health related services, philanthropy
  2. Public Healthcare funding = federal, state & local funding (medicare/medicaid); department of defense healthcare; department of veteran affairs
  3. TJC, the Joint Commission, accreditation for acute care hospitals, home health agencies, long-term care, ambulatory care, and psychiatric facilities
  4. Allied Health = professions that function to assist physicians and specialists
    • physical therapy
    • Health Information management
    • emergency medical technology,
    • etc
  5. Hospital =
    1) organized medical staff
    2) permanent inpatient beds
    3) 24hr nursing services
    4) diagnostic and therapeutic services
  6. Managed Care Plans = healthcare reimbursement systems
  7. Medicine= the science of disease prevention, diagnosis, alleviation, and cure
  8. Greek "pharmakos" = remedy and poison
  9. In 1885 Louis Pasteur invented vaccine for rabies

  10. 1865 Lister used carbolic acid to prevent infection in wounds
  11. 1895 Wilhelm Roentgen xray technology
  12. AMA established in 1847
  13. 1876 Amercian Association of Medical Colleges (AAMC)
  14. There are 24 medical specialties.
  15. Ambulatory Care:
    Preventative/corrective healthcare provided in practitioner's office, clinic, freestanding diagnostic or surgical center, or a hospital on an outpatient basis.
  16. Community based ambulatory care services not affiliated with a hospital include:
    flu vaccination clinic, health fairs, mammography programs, cancer screening programs, neonatal classes
  17. Subacute care (Home Health & Adult Daycare):
    - nursing homes
    - home care providers
    - rehab facilities
    The level of skilled care needed by complex conditions, typically elderly patients with multiple problems.
  18. Home Healthcare is the fastest growing sector of medicare, because of economic pressure from third party payers
  19. Primary Care: First point of contact in outpatient (ambulatory) setting
  20. 5 definitions of primary care:
    • 1) Primary Care
    • 2) Primary Care Practice
    • 3) Primary Care Physician
    • 4) Non Primary Care Physicians providing primary care services
    • 5) Non physician primary care providers
  21. Managed Care:
    Generic term for system that manages cost, quality, and access to services. Manages cost by restricting services, preauthorization, presetting amounts
  22. How managed care delivery systems manage costs:
    • -implementing financial incentives for providers
    • - promoting healthy lifestyles
    • - identifying risk factors and illnesses early in disease processes
    • - providing patient education
    • - preauthorization/utilization review
  23. Average patients may are well under managed care, but chronically ill elderly and poor patients show worse outcomes
  24. Purpose of manage care:  To provide affordable high quality healthcare
    Managed care merges clinical, financial and administration to manage access, cost, and quality of care
  25. Managed Care Organizations (MCOs) benefits and characteristics:

    MCO= healthcare plans that attempt to manage care

    Balanced Budget Act 1997= "coordinated care plans"
    • - physician services (in & out patient)
    • - inpatient care
    • - preventative wellness, immunization, well check, adult exams, pap smears
    • - prenatal care
    • - emergency services
    • - diagnostic/laboratory tests
    • - certain home health care
  26. Types of Managed Care Organizations:
    - HMO: health maintenance organization
    - PPO: preferred provider organization
    - POS: point of service plan (open ended HMO)
    - EPO: exclusive provider organization
    - Medicare Advantage/Medicare part C
  27. Medical Home Model as defined by AAMC:
    • - round the clock access to consultation
    • - cultural and religious beliefs
    • - comprehensive/coordinated approach to care through providers and and community services
  28. EHR Collaborative: joint collaboration involving AHIMA, AMA, American Medical Informatics Association (AMIA), College of Healthcare Information Management Executives (CHIME), HIMSS, NAHIT
  29. IHE: an initiative to improve how computer systems share information.

    - Promotes DICOM and HL7
  30. ACHE: American College of Health Executives
    • International society whose goal is to improve health status by advancing leadership and management.
    • - Health information confidentiality
    • - organ donation
  31. AHIMA - American Health Information Management Association
    • - For managers of health record services and healthcare information
    • - coding professionals are members
    • - "quality healthcare through quality information"
    • - RHITs (2yrs)
    • - RHIA (bachelor)
  32. AHA - American Hospital Association

    * Originally Association of Hospital Superintendents
    • - Today's mission is to advance the health of individuals and communities
    • - Houses central office on ICD9 coding
  33. AMA - American Medical Association

    * largest medical professional association
    * to promote art and science of medicine and better health
    • - accreditation body for medical schools and residency programs
    • - CPT, current procedural terminology coding system
    • - Journal of American Medical Association
    • - Code of Medical Ethics
    • - CPT Assistant, monthly newsletter
  34. IOM - Institute of Medicine

    * works outside government to ensure scientific analysis and independent guidance
    - serves as adviser to the nation to improve health
  35. NCQA - National Committee for Quality Assurance

    * provides report cards and accreditation to healthcare plans
  36. HIPPA coding systems:
    • - HCPCS (ancillary services)
    • - CPT4 (physicians procedures)
    • - CDT (dental terminology)
    • - ICD9 (diagnosis and hospital inpatient)
    • - ICD10
    • - NDC (national drug codes)
  37. Components of QUALITY care:
    • - appropriateness (right care is provided at right time)
    • - technical excellence (right care is provided in the right manner)
    • - accessibility (right care can be obtained when needed)
    • - acceptability (patients are satisfied)
  38. Evaluating quality of care by IOM (institute of medicine) National Roundtable on Healthcare Quality:
    • - Professional accountability: self regulated relationships among physicians, etc
    • - Market accountability: rests on informed choices by employers and consumers
    • - Regulatory accountability: relies on government remedy to correct any of these failures
  39. Professional Accountability:
    • -Continuous Quality Improvement (CQI) processes
    • -Emphasis on Patient Focused Care
    • - Peer Review
    • - Quality Management Programs
  40. Market Accountability:
    • - Collection of Information and Date on Quality of Healthcare
    • - Nationa Business Coalition on Health (NBCH)
    • - Employer Coalitions and Market Accountability
  41. Regulatory Accountability: (Federal Govt)
    • - quality of care/malpractice issue
    • - National Practitioner Data Bank (NPDB)
    •  -- Moderate incidence of malpractice
    •  -- weed out incompetents
    •  -- improve timeliness on malpractice
    • - HHS, through OIG, created Healthcare Integrity and Protection data Bank (HIPDB) to combat fraud and abuse of insurance
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Healthcare Delivery System
Healthcare Delivery System course
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