US Healthcare System Chapter 12 – Flashcards

May be defined as the timely use of needed, affordable, convenient, acceptable, and effective personal health services.

Costs associated with the management of the financing, insurance, delivery, and payment functions. These costs include management of the enrollment process, setting up contracts with providers, claims processing, utilization monitoring, denials and appeals, and marketing and promotional expenses.

Statutes were state-enacted legislation whose primary purpose was to control capital expenditures by health facilities. The CON process required prior approval from a state government agency for new construction of facilities, expansion of existing facilities, and purchase of expensive equipment. Approvals were based on the demonstration of a need for additional services by the community.

Explicit descriptions representing preferred clinical processes. They are standardized guidelines in the form of scientifically established protocols designed to guide physicians' clinical decisions.

Refers to rivalry among sellers for customers. In health care delivery, it means that providers of health care services would try to attract patients who have the ability to choose from several different providers. Although competition more commonly refers to price competition, it may also be based on technical quality, amenities, access, or other factors.

Evaluates the relationship between increasing medical expenditures/risks and improvements in health levels. A service is cost-efficient when the benefit received is greater than the cost incurred in providing the service or the potential health risks from additional services.

Case-specific plans of medical care that identify, along a time line, who will provide what interventions and what the expected outcomes would be.

The practice of medicine that involves prescribing tests and services that are not medically justified but are likely to protect physicians against possible malpractice lawsuits.

Involves a knowing disregard for the truth. It generally occurs when billing claims or cost reports are intentionally falsified. It includes provision of services that are not medically necessary and billing for services that were not provided.

government undertaking to align and distribute health care resources so that the system will achieve desired health outcomes for all people.

Stands for health-related quality of life. In a composite sense, HRQL includes a person's own perception of health, ability to function, role limitations stemming from physical or emotional problems, and personal happiness during or subsequent to the disease experience.

Refers to a patient's quality of life while confined in an institution as an inpatient. Examples include comfort factors (such as cleanliness, safety, noise levels, and environmental temperature) and factors related to emotional well-being (autonomy to make decisions, freedom to air grievances without fear of reprisal, reasonable accommodation of personal likes and dislikes, privacy and confidentiality, treatment from staff in a manner that maintains respect and dignity, and freedom from physical and/or emotional abuse).

The end result obtained from utilizing the structure and processes of health care delivery. Outcomes are often viewed as the bottom-line measure of the effectiveness of the health care delivery system.

Occurs when the costs or risks of treatment outweigh the benefits, and yet additional care is delivered.

Refers to the general process of medical review of utilization and quality when it is carried out directly or under the supervision of physicians.

Also referred to as PROs (see PROs).

Defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Refers to the measurement of quality against an established standard.

A step beyond quality assessment and is synonymous with quality improvement. It is the process of institutionalizing quality through ongoing assessment and using the results of assessment for continuous quality improvement (CQI).

Reflects the extent to which the same results occur from repeated applications of a measure.

Consists of proactive efforts to prevent adverse events related to clinical care and facilities operations, and is especially focused on avoiding medical malpractice.

Refer to a type of health care financing system in which one entity, typically a government run organization, would collect all health care fees and pay out all health care costs. The main benefit is to reduce the amount of administrative waste associated with collecting and dispensing fees.

Refer to the unexplained variations in the treatment patterns for similar patients and health conditions in different parts of the country.

down controlover total health expenditures establishes budgets for entire sectors of the health care delivery system. Funds are distributed to providers in accordance with these global budgets. Thus, total spending remains within preestablished budget limits. The downside to this approach is that, under fixed budgets, providers are not as responsive to patient needs, and the system provides little incentive to be efficient in the delivery of services. Once budgets are expended, providers are forced to cut back services, particularly for illnesses that are not life- threatening or do not represent an emergency.

Stands for total quality management and is synonymous with continuous quality improvement (CQI). It is an integrative management concept of continuously improving the quality of delivered goods and services through the participation of all levels and functions of the organization to meet the needs and expectations of the customer.

Occurs when the benefits of an intervention outweigh the risks or costs, yet the intervention is not used.

A fraudulent practice in which a higher priced service is billed when a lower priced service is actually delivered. It is illegal under the False Claims Act.

of a scale is the extent to which it actually assesses what it purports to measure.