Drivers and Regulation of Healthcare in the United States, Exams of Community Health

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IAHCSMM Healthcare Regulations Final

Exam Review Questions and Answers

100% Pass | Graded A+

David Mungai [Date] [Course title]

IAHCSMM Healthcare Regulations Final

Exam Review Questions and Answers

100% Pass | Graded A+

What are the drives of health care regulation? - Answer>> cost, quality, access What is the most important driver of health care regulation? - Answer>> cost Why do markets fail? - Answer>> unseen externalities and inadequate information What are some ways to regulate? - Answer>> costs, taxes, fines, suspension of license, etc. What is regulation? - Answer>> Controlling human or societal behaviors by rules or restrictions What is quality assurance? - Answer>> inspection or culling, throw out defective products or "bad apples" Focus on the "tail" of distribution Find the source of the mistake What is quality assurance's main focus? - Answer>> the performance of the medical provider What is quality improvement? - Answer>> Analyze and fix the production system; prevention What is quality improvement's main focus? - Answer>> patient care

Who benefits when you repeal community rating? - Answer>> Healthy people Who benefits when you repeal health benefits? - Answer>> Healthy People What are the typical measures of process? - Answer>> claims database medical records What are the most accepted quality measures? - Answer>> measures of technical processes What is technical care? - Answer>> did you go through all the proper procedures When premiums fall for other people, they go __for others in the pool. - Answer>> up What is regulated by the federal government? - Answer>> Physician: Coordination of discipline (NPDB) Hospitals: Medicare and EMTALA Hill-Burton funding Managed Care: HMO Act of 1973 (stimulated growth of HMO's) What is regulated privately? - Answer>> Physician: Private entities Hospitals: Private JCAHO commissions NCQA What is ERISA? - Answer>> Employee Retirement Income Security Act exempts self insured employers from state regulation

What is the NCQA? - Answer>> National Committee on Quality Assurance reviews measurement tools What is the NQF - Answer>> National quality foundation review measurement tools What is NQMC? - Answer>> quality measures What are the market forces used to drive quality improvement? - Answer>> public reporting and pay for performance What is public reporting? - Answer>> reporting of data related to the hospital provider or insurer have the rates of un-insurnace risen or dropped? - Answer>> dropped Who's uninsurnace rate has dropped the most? - Answer>> 18- 29 year olds (young adults) What is the Hill Burton Act? - Answer>> hospital reconstruction What is EMTALA? - Answer>> Emergency Medical Treatment and Labor Act made it so hospitals couldn't turn people away int he event of an emergency What happened with Medigap in 1980? - Answer>> medigap, a private plan was brought under federal oversight What is the HMO Act of 1973? - Answer>> created a more friendly regulatory environment for HMOs

Substance abuse treatment/services Financial assistance most programs are entitlement programs and thus are mandatory What is CMS? - Answer>> Centers for Medicare and Medicaid services and SCHIP Responsible for administering Medicare and Medicaid Regulates all laboratory testing for humans CMS is 88% of HHS budget What is NIH? - Answer>> National institutes of Health Knowledge about nature and behavior of living systems Causes, diagnoses of disease Private science funded, but broadly Research infrastructure What is the AHRQ? - Answer>> Agency for healthcare and research quality 29 million dollar increase since 2012 support and conduct research and improve access to care What is the FDA? - Answer>> Food and Drug Administration Makes medicines more effective and food affordable Drugs/healthcare products as tools for modern care, managed through FDA (ex. Thalidomide prohibited) Pure Food and Drug Act of 1906 Issues include herbal/dietary supplements, cost of drug development, off-label prescribing Drug development costly, also trusted because of FDA What is the Pure Food and Drug Act of 1906? - Answer>> prohibitions of the adulterating and misbranding of foods and drugs in interstate commerce

What is HRSA? - Answer>> Health Resources and Services Administration Focuses on uninsured, underserved populations Budget: 6,022 million CARE ACT: AIDS Resource Emergency Act to provide support Which agency takes up the most of the HHS budget? - Answer>> CMS because of entitlement programs What is quality? - Answer>> how health care improves patient outcome, dollars per quality What are the three perspectives of quality? - Answer>> patient, provider, payer What is the Donabedian model? - Answer>> Structure, process, outcomes Which pillar of donabedian's model is most used to measure quality? - Answer>> process Why aren't outcomes the best way to measure quality? - Answer>> things like death rates are often irrelevant; risk adjustment is necessary What is risk adjustment? - Answer>> statistically account for differences in two entities when comparing them What is evidence based medicine? - Answer>> Ranking quality and generalizability of evidence Spectrum of scientific rigor: strong to weak (Meta-analysis best) What is the NQF? - Answer>> National Quality Form reviews measurement outcomes

What is Supply Sensitive Care? - Answer>> care whose frequency is not determined by scientific evidence overuse of acute care settings patients who should be outpatients are admitted as inpatients patient overuse actue care because we don't have a PCP focused system What is Preference Sensitive Care? - Answer>> comprises care that has significant trade offs when it comes to quality or length of life should be patient preference but the issue is that physicians in certain communities How do we solve quality problems? - Answer>> accountable care organizations Pay for Performance What is the number one contributor to sickness in the U.S.? - Answer>> the health cars system What is Pay for Performance? - Answer>> incentive for high value low cost find process you want to create incentives around and then develop reimbursement system that aligns with those goals What are Accountable Care Organizations? - Answer>> Groups of doctors, hospitals and providers who come together voluntarily to provide coordinated high quality care to the Medicare patients they serve What is the triple aim? - Answer>> improving quality care, improving patient experience, and reducing cost

What are the drivers of change in medical tech.? - Answer>> Triple Aim (improve patient expeirence, improve health of populations , lower per capita cost) Electronic Medical Records Alternative Payment Models What are Alternative Payment Models? - Answer>> payments linked to quality and value pay for performance, capitation , and bundled payments What is the fundamental problem? - Answer>> fragmented patient data results because doctors interact with a whole bunch of patients in a whole bunch of different practices What s required for health care transformation? - Answer>> adoption and use of electronic health records, health information exchange with other providers, and knowledge and data driven learning system What is federalism? - Answer>> system of government with power between state and nation What are the two regulatory powers for health care? - Answer>> regulation of commerce between states (FDA), and funding for general welfare (Hill-Burton Act, HHS) What is the state regulation of insurance markets? - Answer>> health insurance exempt from federal antitrust laws What are the federal insurance regulations? - Answer>> ERISA, COBRA, HIPAA, What is HIPAA? - Answer>> Health Insurance Portability and Accountability Act

What do disparities lead to? - Answer>> worse outcomes for those affected (higher death rates for minorities) Who lives longer? - Answer>> blacks live 4.3 years less than whites native Americans live 4.6 years less than whites What trends do black and whites have? - Answer>> long term trends follow the same trend as whites but life expectancy is always fewer How are disparities researched? - Answer>> Documenting disparities→ understanding mediators → developing interventions What does the patient's race affect? - Answer>> clinical decision making black female less likely to get cardiac treatment Who is more likely to visit their medicare PCP? - Answer>> white patient over black patients Who has a higher risk adjusted mortality rate? - Answer>> black patients over white patients Who's nursing homes are more frequently terminated? - Answer>> 10.7% of nursing homes with 30 or more % black patients terminated by medical/ medicaid 4.9% of NHs terminated that have less than 30% black population What impact do disparities have on quality improvement? - Answer>> variations in appropriate care =sub optimal quality. disparities are a quality failure

Has health care improved since 1977? - Answer>> yes Have disparities improved since 1977? - Answer>> ins some measures but not others what country spends the most on healthcare? - Answer>> the united states Why are do we spend so much? - Answer>> lower than average, physicians, physician visits, and hospitals discharges high than average technology THE US DOES NOT HAVE MORE SERVICES THEY ARE JUST MORE EXPENSIVE AND ARE DONE WITH EXPENSIVE TECH. If utilization isn't higher than why do we spend so much? - Answer>> our price per unit is higher How does the US do in system performance? - Answer>> we underperform, we have higher rates of Adverse birth outcomes Injuries and homicides Adolescent pregnancy and STIs HIV & AIDS Drug related mortality Obesity and diabetes Heart disease Chronic lung disease Disability What is the problem Balanced Budget Act of 1997? - Answer>> Set a ceiling on aggregate payments for MD services based on GDP growth and a few other factors

What is the Ryan White Comprehensive Aids Resource Emergency Act? - Answer>> CARE Act provides support for people who have HIV/AIDS What is NCI? - Answer>> National Cancer Institution this is where the NIH is located today What is the public health service act of 1944? - Answer>> funded private scientists more broadly How does pay for performance work? - Answer>> Identify outcomes you want to create incentives around Develop reimbursement system that aligns with those goals Focus → inpatient and outpatient, others Does pay for performance work? - Answer>> The jury is still out some facilities increased a little in quality while some stayed the same What do ACOs want to address? - Answer>> Move away from FFS Improve quality, decrease costs What are the three core principles of ACOs? - Answer>> Provider led group with strong primary care base, collectively responsible for quality and costs across the continuum of care for a population Payments linked to quality improvements that also reduce costs Measurement that supports quality improvement and shows that cost improvements are not from skimping on necessary care What is horizontal consolidation? - Answer>> smaller practices become bigger practices, consolidation within the same sector

What is vertical consolidation? - Answer>> consolidation across different industries; What is biomedical informatics? - Answer>> The interdisciplinary field that studies and pursues the effective uses of biomedical information and knowledge for scientific inquiry, problem solving and decision making, motivated by efforts to improve human health. wat are electronic health records? - Answer>> longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. data included: demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, lab data, radiology reports, careplans, MAR. no standardized, too many ways to say the same thing What are community health workers? - Answer>> frontline public health workers who are trusted members of the communities served - is a nationally recognized model for improving community health; No previous health professional license What are health equity zones? - Answer>> Geographic areas with measurable health disparities and social and environmental conditions that can be improved. pop of at least 5,000 or more What are health disparities? - Answer>> higher burden of illness, injury, disability, mortality experienced by one population group relative to another group What are healthcare disparities? - Answer>> differences between groups in health insurance access and coverage

if health care in a certain ares is not equitable than the care is _____________ - Answer>> sub-optimable What is the patient safety movement? - Answer>> Origins of errors: Human factors, Medical, Complexity, System failures A new patient safety discipline has developed Role of technology such as electronic medical records and computerized physician order entry Tremendous opportunities in these areas What are claims databases? - Answer>> when someone has something done, the provider fills a bill with the payer, which then creates a claim; provide proof that it happened and that it was charged for what did the porter paper say? - Answer>> Nicely makes the argument against process measures, and for outcome measures Argues that risk adjustment methods are mature and ready for prime time ... some would debate this Basic premise - that assessing value requires a focus on outcomes - is correct Debate is about technical problems of measuring and risk adjusting the outcomes What are pioneer ACOs? - Answer>> funded and started 32 in 2013 after 3 years there were only 9 left they couldn't make money sot hey dropped out What are Shared Savings ACOs (Medicare Savings Programs)? - Answer>> less risk but also less return What is surgical marking? - Answer>> marking the body part that needs the operation the night before

what is wrong sided surgery? - Answer>> doing the surgery on the wrong patient or doing the wrong surgery what are "time out" protocols? - Answer>> check if the right procedure is being done on the right patient the night before What is a certificate of participation (COP)? - Answer>> certificate that hospitals need to have to receive billing from Medicare What are Quality improvement Organizations? - Answer>> improve all acre of patients and replace PROs Malcolm Baldwin Quality Improvement Awards What is community rating? - Answer>> everyone gets the same rate of premiums, healthy and sick How do you measure interpersonal care? - Answer>> you have to ask the patient how they were communicated with, how they felt after, service quality, trust, respect done through surveys how well does the patient understand what is happening to them What is risk adjustment? - Answer>> statistically adjusting for fair comparisons when things being compared are different What was said in the Cost Conundrum and Overkill - Answer>> Mcallen TX had highest rate of utilization for Medicare services because people got things they didn't need What was said in The Quality if Health Care Delivered to Adults in the United States - Answer>> random sample of 12 adults, got permission o look at their medical records, review med records for adherence to standards of care for multiple conditions