Wgu d050 history of healthcare in america final exam quizlet
Wgu d050 history of healthcare in america final exam answers
When was healthcare first created in the United States?
1798 Act for Relief of the Sick and Disabled Seaman
What was created in 1915?
American Association for Labor Legislation… created in the model bill
What was the precursor of Medicare and Medicaid?
Social security passed in 1935
What are the three main goals of ACA?
expand access to health insurance, reduce healthcare costs, support innovative delivery methods
What area medicare or medicaid was improved by the ACA?
medicare
How many children were on CHIP as of Feb 2020?
6 million
What year was medicare and medicaid formed?
1965
What areas can Mezzo interactions influence?
organizations, schools, buisnesses and political relms
What areas do Macro interactions influence?
interactions between healthcare workers and patients/support systems of patients
What do macro indentify and influence?
systemic cause of health disparities (not the indiviual)
What is the foundational reimbursement model used during the establishment of the Medicare and Medicaid programs.
Fee for service
if a patient is readmitted to the hospital within 30 days for the same diagnosis, the hospital will receive a reduced payment
30 day policy under value based healthcare
Which fee-for-service model are lump-sum payments paid by nonprofit, for profit, and medical organizations?
membership fees
What is an advantage of FFS?
being able to have a flexible schedule
How many conditions do DRG classify?
450
Which provision of value-based care is important when coordinating care for a patient with end-stage renal disease?
provide the best care at the lowest cost
Which action could a healthcare coordinator take when providing value-based care to an obese patient?
provide follow up communication to support adoption of healthy behaviors
A care coordinator is explaining value-based care to a patient with cancer. Which statement should be included in the teaching?
This model provides incentives to providers based on positive outcomes
What are the four types of value based models?
share risks, bundles, global capitation, and shared savings
environment consists of trends and changes in various areas, including inflation, employment, economics, and GDP.
macro trend
enacted, administered, and enforced by the government (federal, state, and local)
laws and rules
Centers for Medicare and Medicaid Services (CMS) sets quality standards for what areas?
standards for nursing homes and hospitals, diagnostic standards and billing codes
How does CMS evaluate nursing homes?
rates the quality of US nursing homes through the Star rating program
What standards are established (Medicaid) through CMS?
billing, diagnostic, and national policy standards
What does the state level do with these standards?
implementation, provision, and day-to-day administration
What is the CDC part of?
US public health service
What is the main goal of the CDC?
standards surrounding control, detection, and prevention of communicable diseases while responding to public health emergencies
Office for Civil Rights ensures what?
all individuals receiving services from HHS administered systems or programs are not subject to unlawful discrimination; privacy violations, enforces laws/regulations regarding sex, religion and race
This agency not only detects waste, fraud, and abuse; it also works with federal and state law enforcement agencies to prosecute individuals or organizations that have violated federal health regulations and misappropriated healthcare dollars.
Office of Inspector General
What is a nonprofit organization that oversees hospitals and other institutions that provide inpatient and outpatient care?
joint commission
When was the national mental health act created?
1946 at the end of WW2…. importance placed on PTSD
What was the AMA created?
1846; set national practice standards and overseeing licensing of doctors and physicians
What was the first government run healthcare program?
UD Department of War Freedmans’ Bureau
Established Medicare Part A and Part B, which covered hospitalization and doctors’ visits for persons age 65 and older, with some limited coverage for post-hospitalization skilled nursing care.
Title XVIII of the Social Security Act. E
Established Medicaid, which provided public health coverage to poor families receiving Aid to Families with Dependent Children (AFDC)
Title XIX of the Social Security Act
Under what president, did the amendment to social security act provide coverage to disabled individuals
nixon; added chronic kidney disease
In the health maintenance act of 1973, what type of health insurance was promoted?
prepaid private group, HMO (in addition to fee for service plans)
Health Information stored electronically which could be used to identify a patient is required to retain the utmost confidentiality, and providers are legally responsible for protecting this information.
security rule
Patients retain full access to their health records and can restrict their disclosure and use.
privacy rule
What is one of the most important court cases impacting healthcare delivery?
Tarasoff V Regents of University of California (duty to warn)
What year was health maintenance organization act passed?
1973
What year was Consolidated Omnibus Budget Reconciliation Act PASSED?
1985
What was the main focus of COBRA?
allowing former employees to keep health insurance for a period after termination from job
When was the balanced budget act passed?
1997
When was medicare part D passed?
2003
What is the duty to warn?
doctors can break confidentiality to warn person threated and law enforcement
Who was the first social worker to challenge the mental health stigma?
Dorthia dix
What was a major accomplishment for Dorthia Dix?
32 state hospitals; creating a institution where mental health individuals can be treated by professionals
In the 1940s and 1950s, what was a common treatment of hysteria?
lobotomy; destroying the frontal lobe and leaving individuals severely impacted and unable to function without assistance
When did abuse in mental institutions become known to the public ?
1960s during the civil rights movement
Welsh v Likins year?`
1972
Where was Welsch v Likins located?
Minnesota
What was argued in Welsch V Likins?
confining people was cruel and unusual punishment and unlawful prisonment
Rogers V Okin year?
1975
Where did Rogers V Okin occur?
Boston State Hospital
What did this case argue?
patients argued not to be involuntarily medicated in non/violent situations
Olmested V LC?
1990
What does this case argue?
mental illness is now defined as a disability by the Americans with Disabilites Act
Olmested V LC results?
just because someone is mentally ill they do not have to be in a mental institution
What reviews the design of scientific studies using human study subjects to ensure the safety and ethical responsibility of research proposals?
institutional review board
Who makes up the IRB?
individuals in science, medicine, law and ethics
Who signed in the National Research Act?
Nixon
What are the three main principles of National Research Act?
respect for persons, beneficence, justice
which disabled children were injected with radioactive minerals to study the effects of radiation sickness
Fernald State School Experiment
Which act was created to offer provisions to protect the healthcare coordinator and other whistleblowers?
Health Information Technology for Economic and Clinical Health Act
protect medical professionals from peer review-related lawsuits and encourage them to file official complaints after encountering unprofessional or dangerous peer conduct.
Healthcare Quality Improvement Act
Where was the term death with dignity originate?
Oregon
Active Voluntary Euthanasia
person A consents to Person B actively bringing death
Active nonvoluntary euthanasia
Person B actively bringing person A deaTH. person A cannot consent
Active involuntary euthanasia
person B brings death against person As wishes
passive voluntary euthanasia
person A consents to person B withdrawing treatment
Passive nonvoluntary euthanasia
person B withdraws treatment from person A (cannot consent_
Passive involuntary euthanasia
person B withdraws life saving treatment against Person A wishes
Advocating for the right of terminal patients to refuse treatment.
right to die
What is the legal document that sometimes is called a living will; that provides instruction on patients medical treatment wishes?
advanced directive
What act created in 1990 requires health care providers to provide patients with the opportunity to have an advanced directive?
patient self-determination act
When is a living will enacted?
when the patient cannot think/care for themselves
What year was the first living will introduced to the house?
1968
Karen Ann Quinlan case year?`
1976
What did the Karen Ann Quinlan case encounter?
battle between medical professionals and the patients family to remove patient from breathing tube after a drug overdose. patients family wanted her off breathing tube and the medical professionals wouldn’t remove it
When did the Nancy Beth Cruzan case occur?
1983
What did the Cruzan case consist of?
patient dependent on feeding tubes in which they were removed and it took 11 days for patient to pass by starving to death
When did the Michelle Martin case occur?
1987
What was the point of Martin case?
patient was not in a comatose state but could not function on his own. wife and friends wanted patient to be removed from feeding tubes and parents and family did not; court denied the wife and friends because the advanced directive was not in writing
Theresa (Terri) Maria Schiavo case year?
1990
What happened in the Schiavo case?
could not function and needed feeding tubes; Terri’s parents wanted her on life support and husband did not want to continue this way; feeding tubes were removed 15 years after the accident
What was the result of Karen Ann Quinlan’s drug and alcohol overdose?
persistent veg state
patient must be able to self-administer the life-ending medication, without assistance, prior to obtaining treatment.
physician assisted suicide
Euthanasia occurs during a physician-assisted suicide and the patient must be fully
competent
worked with government officials and jail staff to divert mental health offenders from jail systems to community-based treatment facilities.
Dorthea Dix
work led to the creation of the National Mental Health Association and started the mental hygiene movement, which aimed to improve the treatment of patients in psychiatric institutions.
Clifford Beers
What act introduced civil rights for patients and significantly reduced experiments?
National Mental Health Act
What states allow physician assisted suicide?
CAlifornia, colorado, DC, Hawaii, Oregon, vermont, montana and washington and maine
HIPAA Title I coverage?
health care access, protability, and renewability **same premium for all members
HIPAA Title II coverage>
administration simplification
When was the transaction and code sets rule?
2000; under HIPAA Title II
What did the transaction and code sets rule allow?
standardizes how healthcare transitions and related diagnosis are classified and billed (ICD CODES)
When was the NPI rule enacted?
2006; helped stimulate wider adoption of EMR by assigning identifying numbers to providers
Health Information Technology for Economic and Clinical Health (HITECH) Act:
2009; determines what a breach is and how to notify who is impacted
HIPAA Omnibus Rules:
Enacted which expanded the definition of “covered entity” under HIPAA.
Who are the covered entities under the HIPAA omnibus rule?
healthcare providers, hospitals and insurance
What do covered entities do?
assess risk and compliance gaps and maintain appropriate administrative, technical, and physical safeguards and a formal complaint process
When was Medicare and Medicaid established?
1965 by pres johnson as an amendment to the social security act
What is unique about Medicaid?
federal matches funds given by state gov
audit post-payments procedures and claims.
medicaid recovery audits
To avoid fraud, providers are required to submit all claims within
one year of service; bundle billing
identifies diagnosing and treatment errors and recoups funds when errors are identified.
comprehensive error rate testing
The insured person—the individual who purchases insurance from the insurance company
Layer I
The insurance company and providers—the organization that manages the insurance policy
Layer II
The insurance policy—the policy that is purchased by the first party and managed by the second party
Layer III
Establishes new protocols for service and payment structures.
office of attorney general
Represents the legality of third-party payments and offers legal enforcement of established practices.
department of justifce
Regulates the accuracy of services rendered vs. services paid.
dept of health and human services
What are third party audits regulated by?
2005 deficit reduction act
In substance abuse case planning, what should the care coordinator do?
chief gatekeeper and main support system for pt, facilitate services/resources, involve the client, be community based and be flexible
What is the goal outcome for intensive case management?
employability, housing, mental health stability, and social status, education, food
When did intensive based care originate?
inception of mass deinstitutionalization
ICM has 5 main principles. what are they?
family based, individually tailored, strengths-based, sustanibility and goal focused
What are the three main concepts of strength based care plans?
self-worth, self-determination, and self-regulation
Where did the strength based care plan originate?
University of Kansas due to failing health system
What are the six main strengths of the strength based care plan?
focus on patient not pathology, self-determination, community based resources, intervention should be aggressive, patients can learn/grown/change
What is the goal of the brokerage case model?
assess client immediate needs and link them to community resources (broker a deal)
What is the brokerage case model also known as?
generalist case management model
What did the brokerage case model stem from?
substance and mental abuse (mandated treatment programs AA)
What is the clinical case management model also known as?
rehabailitive model
What is unique about the clinical case management model/
highly unique per patient
What are the four common care models?
patient centered medical home, population health management, guided care model, and accountable care organizations
This care delivery model was developed and promoted by the Agency for Healthcare Research and Quality.
PCMH
goal of PCMH
create a team of care providers who work together to provide comprehensive, coordinated care to patients via a dedicated primary-care team and connected specialists.
Developed and licensed by Johns Hopkins University School of Medicine, this unique model of care delivery uses a proprietary set of tools, training, and methods for certified nurses to help manage and guide care for complex patients with multiple chronic conditions.
guided care model
comprehensive health and clinical health outcomes of specific groups are studied, and this information is used to help understand why some populations are healthier/sicker than others.
population health management
Accompanies a patient to meetings and appointments
intensive case management model
clinical case manager may visit at-risk communities of substance abusers
clinical case management model
originated due to a flooding of deinstitutionalized patients into the community who realized their right to refuse treatment.
strengths based case management
Why did Public Law 92-603 expand the initial Medicare and Medicaid requirements for utilization review?
develop a professional standards review
What is a benefit for providers using a fee for service system?
rewards provider based on volume of services provided
What body is responsible for approving/disapproving human subject related activities?
institutional review board review
Which law lowers the cost of healthcare for households under the poverty level?
patient protection and affordable care act
Which legislation prohibits the transfer of a patient due to inability to pay>
emergency medical treatment and active labor acgt
Why did Public Law 92-603 expand the initial Medicare and Medicaid requirements for utilization review?
Medicare hospice benefit
Why was the prospective payment system established?
slow down the rate of spending in healthcare
Which case management technique emerged with the advent of DRGS?
critical pathways
D050 Course of Study Worksheet- History of Healthcare in America
Unit 2- Historical Impact of Sociopolitical Drivers
Module 1- History of Healthcare in the United States
1. What are the differences between fee-for-service and value-based healthcare models?
Fee for service is based on quantity of services, while value based focuses on quality
2. When did healthcare start in the United States and which act required sailors to
purchase health insurance?
In 1798, Act for relief of sick and disabled seamen
3. What year did the workers’ compensation law pass and in what state?
1911, Wisconsin
4. What is the Model Bill?
This bill provided comprehensive benefits for low-income workers, coordination of
insurance companies, and the concept of premium contributions by employers,
employees, and the state.
5. What two reasons were commercial insurance companies initially reluctant to provide
health insurance policies?
Fear that the people sick would delete the funds, concern of how to appropriately ration
care in an equitable way that generates profit
6. Why was the Social Security Act enacted and in what year?
Congress Enacted the Social Security Act in 1935 to provide benefits to older adults, along with
funds for unemployed, disabled and Children.
7. Why was the Social Security Act important?
Lead to Medicare & Medicaid in 1965 , Public Law 92-603 was enacted in October 1972
considerable progress has been made in the establishment of Professional Standards Review
Organizations (PSROs) for the purpose of determining the necessity, appropriateness, and quality
of medical care provided beneficiaries of the major programs authorized in the Social Security
Act.
8. What are the two main differences between Medicare and Medicaid?
Medicare- 65 and older, disabled, and dialysis
Medicaid- low income, pregnant, disabled, federally funded and varies from state to
state
9. What is COBRA and when was it enacted?
Consolidated Omnibus Budget Reconciliation Act -Enacted in 1986. Helped employees keep
employer-based health insurance for a period of 18-36 months after losing employment.
10. When was the Emergency Medical Treatment and Active Labor Act (EMTALA) added to
COBRA and what did it require?
This act requires that all emergency departments that accept Medicare patients, also
provide medical care to any person seeking care, regardless of their payer source, legal
status, or citizenship. This act requires the hospital to examine the patient, provide
emergency care, and to care for any woman that is in labor.
11. What is the Health Insurance Portability and Accountability Act (HIPAA) and when was it
started?
1996- It allowed for more privacy standards and changed how group health plans handle
pre-existing conditions
12. What is the Children’s health Insurance Program (CHIP)?
Helps uninsured children up to age 19. CHIP is a state administered program that follows
federal regulations. In 2018, there were more than nine million children covered under
this program.
13. What is the Mental health Parity Act and when was it signed into law?
In 1996, the Mental Health Parity Act was signed into law and ensure that insurers
provide adequate coverage for mental health benefits. Law requires insurance groups to
offer coverage for behavioral health disorders and ensure these benefits are comparable
to general medical coverage
14. What were the three primary goals of the Affordable Care Act (ACA) and when was it
enacted?
Goals were to expand access to health insurance, reduce health care costs, and support
innovative delivery method.
15. Whose Contribution to public health helped reshape the way individuals and
organization create interventions to solve health concerns and promoted the idea of
addressing health needs in a holistic way?
Urie Bronfenbrenner proposed the ecological system theory in 1979. It recognized the
important effects of social determinants of health, have in relation to healthy behaviors
and finding solutions to address these powerful effects limiting health promotion
behavior. So he promoted the idea of addressing health needs in a holistic way,
addressing all needs of the person-in-environment. His contribution to public health
helped reshape the way individuals and organizations create interventions to solve
health concerns.
16. What concepts are Mezzo Concepts most helpful for addressing?
withafocus onsmallergroupsandinstitutions.Mezzoconceptsaremosthelpfulinaddressing
problems and organizations, schools, businesses, and political realms. Mezzo involves
implementingsocialserviceinitiativestosupporthealth care,accessonthecommunityand
institutional levels.
17. What must be addressed for mezzo scaled interventions to be effective?
To be effective, Mezzo scale interventions must address individual culture of the
organization, group, or family
18. Macro solutions are most often implemented by what?
Macro solutionsare most often implemented bypublichealth organizations- economic factors –
inflation, employment, economics, and GDP
19. Macro factors involve direct interactions between who?
Direct interaction between health care providers like doctors, patients, staff, nurses and patients
and their patients, support systems, families, other providers, and loved ones
20. What are some advantages of FFS?
A positive thing is really unlimited choices of medical providers, no delays in receiving treatment.
ownership of the amount of doctors visits, and flexible appointments are all strengths of fee-for-
service.
21. What are some disadvantages of FFS?
Itincreasedtheoverallcostofhealthcare-Thedisadvantagesaretheexpense,thepaperwork,
denial of services, limited focus on preventative treatment, and lack of medical provider
accountability
22. What are the four value-based systems?
DRG- hospitals are paid a flat rate. Bundled payments – shared savings are incorporated in value-
based reimbursement models, providers are paid a fixed amount for all the services.Shared risk
models-also known as downside risk models, payers and providers are agree upon a set budget
andqualityperformancethresholds.Global capitation- arrangements reimburse providers with
asinglefixedpaymentforallhealthcareservicesgiventothepatient.Sothatincludestheir
primarycare,theirhospitalization,theirspecialistcare.It’sallasinglefixedpayment. Shared
Saving arrangements- They offer providers a higher level of financial reward than pay- for-
performance model. Providers are reimbursed under the fee-for-service model. But if a provider
can reduce healthcare spending below and established benchmark set by the payer, then he can
retain a portion of those savings produced.
Unit 3- Legal History
Module 2- Regulatory ComplianceDocument continues below
Discover more from:
History of Healthcare in America (D050)(D050)
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1. What are the eight key healthcare regulatory bodies in the United State governing
nearly all jurisdictions across the country and what does each do? Note Cards work great
to help remember these.
Centers for Medicare and Medicaid Services (CMS) regulations- federal insurance standards,
reimbursement rules Occupational Safety and Health Administration (OSHA) standards –
requires employers to provide safety equipment protect from bloodborne pathogens, and
needlestick safety. Centers for Disease Control and Prevention – CDC. That is the chief public
health agency for the nation. Control, detection, and prevention of communicable diseases,
health promotion, monitor disease activity and prevention and preparedness. State and local
public health departments model themselves on the CDC standards. FDA- regulate food, drugs,
and medical devices- regulate ads and product labeling Agency for Healthcare Research and
Quality- (AHRQ aka ark) – Governs, the regulation of the safety, quality and efficacy of healthcare
provided in the United States. It has helped to reduce the incidence of medical mistakes such as
wrong side surgery and reduced hospital acquired conditions. Office of Civil Rights (OCR) –
ensure services from HHS are not subject to unlawful discrimination. Ensuring Civil right acts are
properly enforced of 1964, Americans with Disabilities Act, American Equal Access Act and the
Age of Discrimination Act in 1975. They enforce laws, rules, and regulations that protect
individuals with including right to refuse care and right to personal and religious freedoms.
Office of the Inspector General (OIG) – They detect waste, fraud, and abuse and prosecute
individuals or organizations who violate health regulations & misappropriate healthcare funds.
Joint Commission- Oversee hospitals, healthcare organizations, and other institutions, to ensure
they are safe and effective care meets the national accepted performance standards &
accreditations. Hospitals cannot operate if they don’t meet accreditation standards. American
Medical Association 1846- set national standards for licensing physicians Freedmen’s Bureau
-1865, which is the first U.S. government healthcare program for the public. At the end of the
civil war. Build & administer hospitals to help care for freed slaves to transition to self-sufficient
lives, also established schools, social services, and other support programs. Patient Safety and
Quality Improvement Act protects healthcare workers who report unsafe conditions, such as
medical errors while maintaining patient privacy. The Healthcare Quality Improvement Act
protect medical professionals from peer review-related lawsuits and encourage them to file
official complaints after encountering unprofessional or dangerous peer conduct. This act only
protects physicians and dentists—not healthcare coordinators. Inspector General Act of 1978-
focused on combating waste, fraud, and abuse within governmental agencies Consolidated
Omnibus Budget Reconciliation Act of 1985- COBRA Health Information Technology for Economic
and Clinical Health Act (HITECH)- The Health Information Technology for Economic and Clinical
Health Act offers provisions to protect whistleblowers that report healthcare fraud
2. This program was created to address the concerns of military personnel and their
dependents?
Tricare
3. Its goal was to remove people from mental health institutions and create a strong
network of centers to address mental health concerns without institutionalization?
Community Mental Health Centers Construction Act 1963
4. Discuss the National Mental Health Act, when it was created, and what it did.
National Mental Health Act of 1946- Awareness of mental illness resulted from World War I
when soldiers returned home from suffering neurosis and were treated with drug-induced
convulsions and electroconvulsive therapy. However, the U.S. government was not active in the
treatment of mental health until the federal government later took action. Helped addresses
PTSD, addresses medication management rather than institutionalization addressing issues from
depression and anxiety to PTSD.
5. The Pure Food and Drug Act of 1906 did what?
Illegalized manufacturing and mislabeling of dangerous and spoiled foods, labeling and ads. It
regulated the manufacturer and sale of drugs by defining standards of quality and safety and
strength and purity. FDA- Regulates also the use of medical devices, such as pacemakers and
surgical instruments
6. What was the first US government healthcare program for the public? And what did it
do?
1798- Health Insurance for sailors
7. Know the Social Security Act and the amendments.
Social Security Act was passed in 1935, amended 1965
Title XVIII – 18 covered Medicare A& B covering hospitalization and doctors visits 65 and older
Title XIX – 19 provided coverage for Medicaid- st 1972- provided coverage for disabled people
under 65 in Medicare Program
8. What provisions were accomplished by the Health Maintenance Organization (HMO) Act
of 1973?
health insurance, prepaid private group practice service plans, required employers to offer HMO
plan when available, required PCP’s to act as gatekeepers- referrals needed.
9. What act helped employees keep employer-based health insurance for a period of 18-36
months after losing employment?
COBRA- pay out of pocket
10. What is HIPAA?
Health Insurance Portability and Accountability Act 1996- covers Privacy & Security rule as well
as limited extent that insurance companies could exclude people for pre-existing conditions,
including pregnancy. & extends CORBA coverage
11. Know what the security and privacy rule of HIPAA is.
Privacy – patient could retain full access to their health records, can restrict disclosure and use
Security – PHI must be protected, confidentially maintained. – access control
12. What did the Balanced Budget Act of 1997 establish?
Created Title XXI SS Act amendment Established the state CHIP program under Medicaid
Changes to Medicare with adding expanding options for privet Medicare HMO/PPO plans
(Medicare Advantage) Encouraged stated to offer HMO plans to Medicaid recipients.
13. Discuss the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(Medicare Part D).
Voluntary Program – enables Medicare to cover Px drug cost. B -Also introduced higher
premiums to higher–income beneficiaries, singles over 85,000K couples over 170,000K
14. What are some of the key aspects of the Health Information Technology and Economic
and Clinical Health Act (HITECH)?
Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as
part of the American Recovery and Reinvestment Act (ARRA)-2009 It tightened regulations
around HIPPA healthcare privacy enforcement. It mandated the use of electronic medical
records by all U.S. healthcare providers by 2015. Increases penalties and fines for healthcare
providers who repeatedly violated HIPPA privacy protections, and offered previsions to protect
whistleblowers who reported healthcare fraud. The Health Information Technology for Economic
and Clinical Health Act offers provisions to protect whistleblowers that report healthcare fraud
15. What did the Patient Protection and Affordable Care Act of 2010 (ACA, “Obamacare”
accomplish?
It provided an expansion of health insurance coverage for Americans through both individual
health insurance exchanges and it increased access to employer provided plans. Minimum
requirements of coverage were established with individual and employer mandates, which were
enforced by tax penalties. Those tax penalties have been removed now, but that was part of the
act. Expanded Medicaid to cover low-income childless adults, states optional
16. What are the ten essential benefits of the ACA?
Mandated that insurance plans cover certain essential benefits across all health plans.
Ambulatory outpatient patient services, emergency services, hospitalization, maternity and
newborn care, mental health and substance abuse disorders services, prescription drugs,
rehabilitation services, laboratory services, preventive and wellness services, and then pediatric
services, including oral and vision care.
17. What is duty to warn?
Duty to break patient to warn the person threatened, and law enforcement when they suspect a
client may become violent toward that individual. Will be held liable if they didn’t warn to
person. Obligation to warn subject when there’s a treat against to person
18. What is duty to report?
Mandated reporting laws legally required to tell of abuse, neglect, or financial exploitation of a
individual.
19. Know the following key judicial decisions
a. Olmstead v. L.C.
1990 This legal case determined that mental illness is a disability condition. The United
States Supreme Court actually ruled mentally ill persons are disabled, and as such, they have
a guaranteed legal right under the Americans with Disabilities Act to reside in the
community rather than a mental health institution.
b. Rogers v. Okin
1975 An individual was involuntarily admitted to a psychiatric hospital. The psychiatrist
diagnosed the patient with paranoid schizophrenia and prescribed an anti-psychotic
medication. The individual, however, is refusing to take the antipsychotic because of the
medication’s side effect. Court ruling establish individual to take this action, not to be
forcibly medicated in non-emergency situations.
c. Welsch v. Likins
1972- state hospitals for mentally disabled were heavily medicated, forcibly restrained,
cruelly treated. The plaintiffs argued that forcefully confining these mentally disabled
unlawful imprisonments w/out appropriate due process. Required care for the mentally
incompetent and disabled be humane without unlawful imprisonment.
20. Who is Dorthea Dix?
In 1830 social worker challenged public perception of mental illness, advocated better living
conditions, created 32 psychiatric hospitals. Hospitals turned into long term care facilities.
21. What is the IRB and what does it do?
Institutional review board review- Code of Regulations (45CFR part 50) is involved with
approving or disapproving all human subject research activities. To ensure the safety and ethical
acceptability of the research, doesn’t cause human harm
22. Discuss 3 questionable studies.
Tuskegee Syphilis Experiment
Fernald State School Experiment
Henrietta Lacks
Unit 3- Legal History
Module 3- Ethical and Legal End of Life Concepts
1. What are advanced directives and do-not-resuscitate orders?
Written out end of life wishes, Patient Self-Determination Act (PSDA) of 1990 Physician Orders
for Life-Sustaining Treatment – transfer across treatment setting
2. Know the timeline of Chronology of Assisted Dying in the US.
1870- Samuel Williams proposed using strong pain medication and sedatives to ease pain at the
end of life. In 1906, the Ohio legislature introduced a bill to legalize euthanasia, but it was
defeated 1960s and 1970s, society began to consider the idea of patients having a “right to die.”
The idea of advance directives and do-not-resuscitate orders became more common. As the
acceptance of advance directives and do-not-resuscitate orders became more prevalent, a
movement called Death with Dignity that started in the early 1990s emerged, allowing
terminally ill patients the right to medical supervision and support to end their lives assisted
suicide legalized in Oregon. California, Colorado, District of Columbia, Hawaii, Oregon, Vermont,
and Washington, New Jersey & Montana
3. What placed requirements on medical providers and healthcare organizations to provide
patients with the opportunity to complete advance directives?
The Patient Self-Determination Act was enacted, which stipulated that all hospitals obtaining
medical funding from Medicaid or Medicare must ascertain if patients have or wish to complete
an advance directive. Right to die: Advocating for the right of terminal patients to refuse
treatment.
4. What are the principles of self-determination?
Freedom- meaningful life in community, authority- over funds, support, responsibility, and
confirmation- get involved and make sure the principles are carried out.
5. Identify the four advance directive cases as notable cases that spearheaded the
movement on effective execution of patient wishes
Karen Ann Quinlan: A 1976 case involving a 22-year-old female who became comatose following
a drug and alcohol overdose. Flight was to remove her off life support, She did begin breathing
on her own. She was moved to a nursing home where she lived until her death in 1985.
Beginning the living will right.
Nancy Beth Cruzan: A 1983 case involving a 33-year-old female who sustained major brain
injuries following a car accident. Nancy’s family request removal of her feeding tubes after
doctors ruled that consciousness was not possible. Following seven years of legal battles,
Nancy’s life support was disconnected. However, another controversy arose when it took 11 days
for Nancy to pass—her feeding tubes were removed on December 15, and she died on
December 27. This case introduced the argument of the ethics involved in removing tube
feedings and effectively starving the individual.
Michael Martin: This 1987 case involved a 35-year-old male who suffered a major brain injury
following a car-train accident. Following the accident Michael was unable to walk or talk, was
severely mentally impaired, and was dependent on feeding tubes. Michael’s condition was
severe, but he was not in a vegetative state. Michael regained some movement and had the
ability to recognize faces. Five years following the accident, Michael’s condition did not improve,
and his wife requested the removal of the feeding tubes. However, Michael’s sister and mother
filed a lawsuit to maintain treatment. Michael’s wife and colleagues reported that he verbally
acknowledged no interest in being on life support. The court denied the wife’s request since
Michael did not have a written advance directive.
Theresa (Terri) Maria Schiavo: In 1990, 26-year-old Terri Schiavo collapsed at home and went into
cardiac arrest caused by a potassium imbalance. The incident left Terri without the ability to
function (walk, talk, sit, or eat) and with the requirement of a feeding tube. Terri’s husband and
parents became involved in a long battle regarding the goals of care for her. Terri’s parents
wanted her to continue life support, but after 10 years her husband pursued removal. The case
went through several appeals and was followed closely in the media. Eventually, the husband
won the case, and Terri’s feeding tubes were removed on March 18, 2005, almost 15 years after
her original injury. She died 13 days later.
Cruzan v. Director, Missouri Department of Health- An individual has been in a vegetative state
for several years, and the patient’s mother, the proxy, wishes to discontinue providing nutrition
via a feeding tube.
Unit 3- Legal History
Module 4- Ethical and Legal Behavioral Concepts
1. Who were the two key individuals, noted in module 4, who helped the broader public
understand the issues facing those who may struggle with mental health?
Dorothea Dix, a jail nurse and social worker in the 1870’s, noted that many incarcerated
offenders were diagnosed with mental illness. These offenders were often mistreated and
suffered from malnutrition. She noticed that there was a lack of mental healthcare. Dix worked
with government officials and jail staff to divert mental health offenders from jail systems to
community-based treatment facilities.
Clifford Beers, in the early 1900’s, as a mental health patient and businessman, documented his
experience during an insane asylum placement following a nervous breakdown in his text A
Mind That Found Itself. Beers spoke out about inhumane treatments such as sexual assault,
starvation, and medication overdosing and underdosing, along with violence in state hospital
systems. Beers’ work led to the creation of the National Mental Health Association and started
the mental hygiene movement, which aimed to improve the treatment of patients in psychiatric
institutions
2. What are some examples of behavioral health conditions?
Obesity, mood disorders (depression), anxiety disorders (phobias, obsessive-compulsive, etc.),
selfsabotaging behaviors (self-neglect, low self-esteem, self-harm, etc.), personality disorders,
and psychotic disorders such as schizophrenia.
3. What is the Community Mental Health Act?
Goals was to removes people from institutions and create a strong network of centers Locations
providing mental health services in neighborhood areas had to increase capacity in anticipation
of the release of patients from state hospitals.
Unit 5: Finance and Information Security History
Module 5: Data and Information Governance
1. Know the micro, mezzo, and macro levels of HIPAA Security.
micro (clinical practice), mezzo (community practice), and macro (policy) levels These security
measures impact all levels of healthcare delivery; from the individual patient level (micro) to the
healthcare delivery site level (mezzo) to the broader healthcare system landscape level (macro)
2. Identify key historical events, legal cases, and practical situations that led to the
establishment of HIPAA laws.
Tarasoff v. California Board of Regents and Olmstead v. LC, both of which impacted healthcare
practices surrounding privacy, confidentiality, and disclosure of PHI, either directly or indirectly.
These cases along with others were led by citizens and politicians to seek a more standardized
approach to the privacy, safety, and portability of PHI.
1996 HIPAA-> 2000 transaction & codes set rules-(established title II- ICD codes)> 2003 Security
Rule (push to standardize security processes) –> 2006 Enforcement Rule (Est guidelines for
criminal prosecution of HIPAA violations) -> 2006 NPI # rule (unique ID # for providers)-> 2009
HITECH Rule (established standards for what constitutes a breach of PHI security)-> 2013 HIPAA
Omnibus Rule added “covered entity” new rules, healthcare contractors and subcontractors
(such as records-processing and storage companies, IT providers, marketing companies, and
other service providers) who had access to PHI also became covered entities under HIPAA
3. Watch the video “HIPAA Training” on page 47 in your course.
4. What is HIPAA Title 1?
HIPAA Title I. Covers Health Care Access, Portability, and Renewability. This segment of the original HIPAA
law stipulates that healthcare plans must charge the same premiums for all plan members. Title It also
allows patients to take their healthcare with them when they voluntarily change jobs. Note: Some
portions of Title I were overturned with the passage of the Affordable Care Act of 2010
5. What is HIPAA Title 2 and what are the rules?
HIPAA Title II. This segment of HIPAA includes the Administrative Simplification (AS) provisions,
including the Privacy Rule for “covered entities,” which standardized and established patients’
right to privacy of their PHI, whether those records were on paper or electronic. Title II triggered
a graduated rollout of the following components between 2000 and 2006 These components
were intended to help prevent healthcare fraud and abuse in 2013
6. HIPAA has established administrative rules that serve as guidelines for what all covered
entities must do to comply with the law, what are they?
The Enforcement Rule: Established in 2006 standardized civil penalties and guidelines for
criminal prosecution for HIPAA violations. Prior to the establishment of the Enforcement Rule,
few HIPAA violations were prosecuted. Once the rule was established, however, enforcement of
HIPAA increased considerably, resulting in tens of thousands of civil and criminal enforcement
actions.
Unit 5: Finance and Information Security History
Module 6: Medicare and Medicaid Reimbursement
1. Know the 4 forms of Medicare benefits.
Part A: pays for inpatient hospital coverage.
Part B: pays for outpatient doctor visits.
Part C: Advantage Plan (most contain D as well)- Privet based benefit Covering Vison, Dental, &
some prescriptions – began under Balanced Budget Act of 1996
Part D- Introduced by Clinton in 1999, Passed by President Bush in 2003 part of Medicare
Modernization Act, also introduced higher premiums to higher–income beneficiaries, singles
over 85,000K couples over 170,000K for Part B- Outpatient services.
2. List the four programs that were passed as part of the Medicare Catastrophic Coverage
Act of 1988
The provisions within this law require states to help low-income Medicare beneficiaries pay their
Medicare Part A and B premiums, along with a portion of the coverage costs such as deductibles
and coinsurance costs. The Medicare Catastrophic Coverage Act was passed. This act added, “no
gap” on out of pocket costs for those receiving Medicare Parts A and B. Qualified Medicare
Beneficiary Program (QMB), Specified Low Income Medicare Beneficiary Program (SLMB),
Qualified Individual Program (QI), Qualified Disabled & Working Individuals (QDWI
3. What is the Omnibus Reconciliation Act?
1980- Congress passed the Omnibus Reconciliation Act, which added medical coverage for in-
home healthcare services.
4. What year was services for the terminally ill (hospice services) added. This service shifts
the goal of patient care from curative to palliative, meaning the focus is on patient
comfort.
1982: Services for the terminally ill (hospice services) were added. This service shifts the goal of
patient care from curative to palliative, meaning the focus is on patient comfort.
5. What is The Patient Protection and Affordable Care Act (ACA)?
2010: The Patient Protection and Affordable Care Act was passed, offering improvements in
delivery services and reductions in wait times. The ACA also added value-based care provisions,
which encouraged physicians to have conversations about subjects such as smoking cessation,
weight-loss counseling, and end of life decision-making discussion. In ICD codes, these are
referred to as Z codes, reflecting the location within the ICD manual.
6. What is Medicaid?
Medicaid was signed into law when President Lyndon B. Johnson amended the Social Security
Act in 65
7. What is the difference between Medicare and Medicaid?
8. Know the historical events regarding the inception of Medicaid.
1977: The Health Care Financing Administration was created to manage Medicare and
Medicaid Services. This provided the proper management over the division of services. 1986:
Medicaid began offering healthcare coverage to low-income pregnant women. 1990: The
Medicaid Drug Rebate Program was enacted. This program requires drug manufacturers to
inform state Medicaid programs of the price of a drug before it is sold. Each state must opt-in or
opt-out of providing the drug to Medicaid beneficiaries. 1990: The Health Insurance Premium
Payment program was created. This program allows Medicaid beneficiaries to receive health
insurance through a private insurer, often called commercial insurance, paid for entirely by the
state Medicaid program. 1993: The Medicaid Estate Recovery program was enacted. This
program allows states to recover the medical costs associated with long-term nursing home care
after the individual dies. Estate recovery allows the state to take the proceeds from a decedent’s
property to pay for his or her care. This program is controversial and viewed as unpopular by
many. 1990’s: Children with disabilities, and their parents and caretakers, became eligible for
services, and prescription coverage was expanded under a fee-for-service model. ACA – created
to expend Medicaid to all but supreme court allowed stated to decided, expansion covers
democratic states who opted in
9. What is medical coding? Also, know the history of medical coding.
Medical coding is the process of documenting medical services (diagnosing, evaluations, treatments,
etc.) into codes for billing and documentation purposes. Started in England in seventeenth
century to estimate recurrent death. International Classification of Diseases, or ICD, codes
initially gave epidemiologists and public health officials an effective new way to use data. IDC-
diagnosis, CPT- Procedures
Unit 5: Finance and Information Security History
Module 7: Third-Party Insurance Reimbursement
1. What is third-party insurance?
Third-party insurance is insurance purchased either by an organization, usually the employer of
the insured, or the insured person themselves
2. What are the layers of the three-layer insurance system designed to protect the insured?
Layer I First Party: The insured person—the individual who purchases insurance from the
insurance company Layer II Second Party: The insurance company and providers—the
organization that manages the insurance policy Layer III Third Party: The insurance policy—the
policy that is purchased by the first party and managed by the second party
3. Who regulates third-party healthcare and insurance?
Third-party healthcare and insurance are regulated by state, local, and governmental guidelines
via the Centers for Medicare and Medicaid Services (CMS). The CMS monitors third-party
healthcare insurance and payers based on the legalities associated with the following
organizations. TPAs are generally contracted by health insurers or self-insuring companies, TPAs
administer claims, collect premiums, and process claims along with other processing duties
4. What does the Department of Health and Human Services regulate?
Regulates the accuracy of services rendered vs. services paid.
5. What does the Department of Justice do?
Represents the legality of third-party payments and offers legal enforcement of established
practices
6. What does the Office of the Attorney General establish?
Establishes new protocols for service and payment structures.
7. Third-party audits are regulated by the 2005 Deficit Reduction Act, which is focused on
what?
focused on preventing Medicaid fraud and abuse in the healthcare field. Healthcare providers
should view audits as a regular part of service and should be fully prepared to submit
documentation validating the necessity of the services provided. To identify hospital-acquired
conditions that could have reasonably been prevented through the application of evidence-
based guidelines
Unit 6: Historic Models of Case Management
Module 8: Case Management Models
1. Identify the core principles of case management services in substance-abuse.
Offer a single point of contact between the patient/client and the overall health/social services
system. The case manager serves as the chief gatekeeper and support advocate for the
substance-abuse client.
Provide social and/or clinical support services that are client-driven, whether by need or
otherwise. In this context, all services are initially sought by the patient/client, while the case
manager acts as a facilitator to help the client access the desired services. This model supports
self-actualization in the client.
Involve patient/client advocacy. The case manager’s role is always to promote the client’s best
interests. In the substance-abuse management environment, the case manager may provide
advocacy in the medical, psychosocial, legal, and socioeconomic environments, among others.
Be community-based. Ideal case management in the substance-abuse population should
prioritize the use of services in the community, such as outpatient treatment, self-help groups,
social circles (family, friends, religious groups, others), social welfare organizations, and other
formal/informal treatment and support options. Institutionalized environments should only be
selected when community-based resources are not adequate to safely support the client’s
immediate needs.
Be pragmatic, anticipatory, flexible, and culturally sensitive. The goal of case management is to
provide the patient/client with the services and support that he or she needs, without impeding
substance abuse recovery. For example, a homeless narcotics abuser may be in immediate need
of shelter but placing that client in a housing situation with other active narcotics abusers would
impede that client’s recovery. Case managers should work with clients and their communities to
help provide services that are sensitive to many different, nuanced aspects of each client’s
addiction recovery, the hierarchy of needs, and cultural concerns. Lastly, each case management
approach should be custom-tailored to suit an individual client, rather than using a one-size-fits-
all approach.
2. List 5 historic models of case management.
Amis Model- patient engagement
Wraparound – physical and behavioral need for children
PCMH – patient centered Medical Home- Neighborhood collaborative– medical & social support
community resources
Brokerage – linking community resources, needs, planning strategies like house etc
Clinical Case Management Model- Clinical care provider serves as case manager – Clinician –
counselor, therapist Including mental health services, addiction recovery, treatment of chronic
health condition.
Intensive provides assertive outreach & counseling – homeless & alcohol dependent, mentally
Ill, & substance abuse- to assist patients with employment, housing, mental health stability, and
social status. – Often patients who receive this type of care are institutionalized and provided
with 24/7 care – Accompanies a patient to meetings and appointments
Strength based- Impowering Patent & their families- It encourages the client take the lead in
identifying their own needs, take control over the search of resources and services to address
those needs and view the community as a resource instead of a barrier.
Acute Care Coordination model- emergency care model, continues when emergency passed &
the patient is transferred. Help reduce avoidable readmissions – ensure Prescriptions & meds are
filled, & follow up care established.
Post Acute- Long term care coordination model- manage meds, transfers, & update care plans
3. Complete the table:
Case
Management
Model
Intensive Strengths-
Based
Brokerage Clinical Care Delivery
Models
Focus
Origin
Advantages
Best practices
Shortcomings
Additional
History
4. Discuss the reason / need for a dynamic and ever-evolving model.
5. Describe 4 Care Delivery Models.
Uniform Anatomical Gift Act of 1968
allowed to donate body/specific part upon death and in 1987 no longer had to have consent of nearest kin to do so
Wyatt v. Stickney 1971
Right to treatment decision- established minimum standards of treatment for individuals in mental health facilities
Title IX of the Education Amendments of 1972
A provision of the 1972 Educational Amendments that prohibits sex discrimination in any educational program receiving federal financial assistance.
Section 504 of the Rehabilitation Act of 1973
Is a section of the a federal civil rights law which reads in part, that no “otherwise qualified handicapped individual” shall be excluded from participation in program or activity receiving federal financial assistance (“college, university or other post-secondary institution, or a public system of higher education”) It is much broader in its definition of “handicap” than is the IDEA and it is a much more general law in that it doesn’t not provide specific direction on how to address the needs of individuals with disabilities, referring only to the fact that schools must make “reasonable accommodations.” Because of its broader definition students who do not qualify for special education services under the IDEA may be considered “handicap” under Section 504.
Family Educational Rights and Privacy Act (FERPA) 1974
A federal law that governs student confidentiality in schools. It requires that schools not divulge, reveal or share any personally identifiable information about a student or his/her family, unless it is with another school employee who needs the information to work with the student. An exception is the publishing of student directory information.
Individuals with Disabilities Education Act (IDEA) 1975
U.S. legislation granting educational rights to people with cognitive, emotional, or physical disabilities from birth until age 21; initially passed in 1975, it has been amended and reauthorized in 1997 and again in 2004. IDEA operates under six basic principles: zero reject, nondiscriminatory identification and evaluation, free and appropriate public education, least restrictive environment, due process, and parent and student participation in shared decision making with regard to educational planning.
Education for All Handicapped Children Act of 1975
Landmark legislation that signifies a remarkable change in how the needs of exceptional students were addressed in public school setting
Tarasoff v. Regents of the University of California (1976)
This was a wrongful death suit brought against an outpatient clinic associated with the university hospital. During a counseling session, a client threatened to murder an individual by the name of Ms. Tarasoff. The police determined he was not a threat, and both the supervisor and the supervisor’s supervisor agreed not to involuntarily admit him. Two months later, the client murdered Ms. Tarasoff. The court concluded that the supervisor’s supervisor was liable because he had direct knowledge and ultimate control of the case and because of this direct knowledge, he assumed a duty to warn Ms. Tarasoff of the potential danger just as if he were the primary therapist.
Consolidated Omnibus Budget Reconciliation Act (COBRA) 1985
Federal law that requires employers to permit employees or their dependents to extend their health insurance coverage at group rates for up to 36 months following a qualifying event:
Layoff
Reduction in hours
Employee’s death
Emergency medical treatment and active labor act 1985
It requires hospital Emergency Departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) to anyone seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay.
Health Care Quality Improvement Act of 1986
A federal statute passed to improve the quality of medical care nationwide. One provision established the National Practitioner Data Bank.
Rogers v. Okin 1987
The right of committed patients to refuse psychotropic medications
Stark Law 1989
Prohibits physicians or their family members who own health care facilities from referring patients to those entities if the federal government, under Medicare or Medicaid, will pay for treatment.
Patient Self-Determination Act of 1990
this law requires that patients are provided the opportunity to express their preferences regarding lifesaving or life-sustaining care on entering any health care service, including hospitals, long-term care centers, and home care agencies. The law also requires that adequate information be supplied to the patient so that he or she can make informed decisions regarding self-determination
Americans with Disabilities Act of 1990
A law passed in 1990 that requires employers and public facilities to make “reasonable accommodations” for people with disabilities and prohibits discrimination against these individuals in employment.
Health Insurance Portability and Accountability Act (HIPAA) 1996
Under this federal law employers who provide health insurance are restricted in whom they can exclude for a “preexisting condition.” The collection, use, and disclosure of health information are also regulated, and violations of these provisions are subject to civil and criminal penalties.
Death with Dignity Act
A state statute that allows competent, terminally ill adult patients to obtain a physician’s prescription for drugs to end their life.
Balanced budget act 1997
Federal act of 1997 that made significant cuts in home care budgets on the basis of the enactment of prospective reimbursement
Medicare Prescription Drug Improvement and Modernization Act of 2003
Medicare beneficiaries would be able to get a price reduction on their drugs
Mental health parity and addiction equity act 2008
Requires group health plans to treat mental health benefits the same way they do medical and surgical benefits
The health information technology for economic and clinical health HITECH 2009
The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted as part of the American Recovery and Reinvestment Act of 2009 to promote the adoption and meaningful use of health information technology; amends HIPAA privacy and security rules by introducing additional privacy regulations, breach notification rules, and stiffer civil and criminal penalties for security violations
Patient Protection and Affordable Care Act of 2010
Employers with more than 50 employees must provide health insurance
comprehensive addiction and recovery act 2016
establishes a comprehensive, coordinated, balanced strategy through enhanced grant programs that would expand prevention and education efforts while also promoting treatment and recovery.
Fee-for-service (FFS)
set of fees for services established by a health care provider and paid for by the patient
Value-based care
providers are paid more for better quality of care and improved outcomes
Clinical Case Management
Provide support and intervention to clients with serious illness which significantly limits ability to access or engage in existing community services or therapeutic programs; is you’re the person is able to remain in the community and not be re-hospitalized
Intensive Case Management
An evidence-based practice that includes low staff-to-client ratios; 24-hour coverage; and services and referrals for mental health treatment, housing, living skills, employment, and crisis intervention
patient centered care
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Strengths based case management
focuses on clients’ strengths, self-direction, and the use of informal help networks (as opposed to agency resources). It further stresses the primacy of the client-case manager relationship and applies an active form of outreach.
Brokerage case management
is a very brief approach to case management in which case workers attempt to help clients identify their needs and broker ancillary or supportive services, all in one or two contacts.
Sheppard-Towner Act 1921
U.S. Act of Congress providing federal funding for maternity and child care, a response to the lack of adequate medical care for women and children
Social Security Act of 1935
Created both the Social Security Program and a national assistance program for poor children, usually called AFDC.
Public Health Service act 1944
Containment of illnesses spread from foreign countries
Hospital Survey and Construction Act of 1946
federal legislation that provided substantial funds for hospital construction
National Mental Health Act of 1946
Established the National Institute of Mental Health (NIMH)
Mental health study act 1955
Created Joint Commission on Mental Illness and Health that recommended shift of patient populations from state hospital systems to community health systems
Community mental health centers construction act 1963
Resources for mental health programs instead of institutions
Elementary and Secondary Education Act of 1965
Extended federal aid to private and parochial schools in addition to public schools and based the aid on the economic conditions of students rather than the need of the schools.
HIPAA
The Health Insurance Portability and Accountability Act, a federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed.
The HHS Office of Civil Rights
This federal agency is charged with responsibility for the oversight and enforcement of the HIPAA privacy regulations.
Protected Health Information (PHI)
Any information about health status, provision of health care, or payment for health care that can be linked to an individual. This is interpreted rather broadly and includes any part of a patient’s medical record or payment history.
Office of the Inspector General (OIG)
investigates abuse, fraud, waste, and mismanagement within a government organization
Office of the National Coordinator for Health Information Technology (ONC)
Federal government office introduced to lead and coordinate efforts toward a National Health Information Network
Medicare outpatient observation notice(MOON)
a standardized notice developed to inform Medicare patients that they are an outpatient receiving observation services and are not an inpatient of the hospital
Health Maintenance Organization (HMO)
Alternative means of health care in which people or their employers are charged a set amount and the HMO provides health care and covers hospital costs.
Agency for Healthcare Research and Quality (AHRQ)
a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans
The Joint Commission (TJC)
An organization that accredits health care organizations and programs
ICD-10 Coding
- implementation tentatively set for Oct 2015
- allow greater specificity of codes
- alignment with world wide coding practice
Continued Stay Review
A type of review used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a patient’s hospitalization for care
National Uniform Billing Committee (NUBC)
The national group responsible for identifying data elements and designing the CMS-1500
palliative care
Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.
critical pathways
Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.
HIPAA Privacy Rule
Law that regulates the use and disclosure of patients’ protected health information (PHI).
HIPAA Security Rule
regulations outlining the minimum administrative, technical, and physical safeguards required to prevent unauthorized access to protected health care information
HIPAA Breach Notification Rule
requires covered entities and business associates to provide notification following a breach of unsecured protected health information
Program of Assertive Community Treatment (PACT)
A program of case management that takes a team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness
POLST (Physician Orders for Life-Sustaining Treatment)
A transportable medical document completed and kept by the patient that states the type of life-sustaining treatment(s) they may or may not want. It is signed by both the patient and the patient’s physician
Center for Disease Control and Prevention (CDC)
federal governmental agency that issues guidelines relative to protection and manners to improve health
Food and Drug Administration (FDA)
a federal agency charged with enforcing regulations against selling and distributing adulterated, misbranded, or hazardous food and drug products
Medicare Hospice Benefit
a Medicare entitlement that provides for comprehensive, interdisciplinary palliative care and services for eligible beneficiaries who have a terminal illness and a life expectancy of less than 6 months
Advanced Beneficiary Notice (ABN)
document given to medicare beneficiaries indicating the services medicare is unlikely to pay for
Department of Health and Human Services
Gives services for Americans’ health and basic needs
Center for Medicare and Medicaid Services (CMS)
Administer the Medicare program and funding
Agency for Healthcare Research and Quality (AHRQ)
a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans
TRICARE
U.S. government health insurance plan for all military personnel
Occupational Safety and Health Administration (OSHA)
The federal regulatory compliance agency that develops, publishes, and enforces guidelines concerning safety in the workplace.
living will
A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes.
Advanced Directive (AD)
A legal document in which an individual gives written instructions expressing his or her wishes regarding health care in the event that person can no longer make those decisions.
Duty to warn
Mental health professional’s responsibility to break confidentiality and notify the potential victim whom a client has specifically threatened.
physician assisted suicide
a form of active euthanasia in which a doctor provides the means for someone to end his or her own life
Cruzan v. Director, Missouri Department of Health
1990; competent persons can refuse medical treatment; right to die.
Standard Gamble
the process used to determine utility values
Time trade off
exchanging time in poor health for briefer time in good health.
Health Utility Index
a rating scale used to measure general health status and health-related quality of life
EuroQoL
It has been widely used in population health surveys, clinical studies, economic evaluation and in routine outcome measurement in the delivery of operational healthcare.
Rosser and kind index
Person trade off
macro level
a wide-scale view of the role of social structures within a society
meso level
a term used to analyze the relationships among issues, individuals, and groups as viewed from a community, or local, perspective
micro level
focus on the individual and his or her interactions in specific settings
Medicare Part A (aka Hospital Insurance or HI)
Provides hospital insurance automatically @ age 65 (if FICA qualified) @ no fee but may have deductible & co-pay.
Medicare Part B
The part of the Medicare program that pays for physician services, outpatient hospital services, durable medical equipment, and other services and supplies.
Deficit Reduction Act of 2005
Created Medicaid Integrity Program (MIP), which increased resources available to CMS to combat abuse, fraud, and waste in the Medicaid program. Congress requires annual reporting by CMS about the use and effectiveness of funds appropriated for the MIP.
patient centered medical home
a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand
Population Health Management
The concept that the health of all individuals is improved when the health of the entire population is improved
Guided Care Model
Accountable Care Organization (ACO)
An organization of healthcare providers accountable for the quality, cost, and overall care of Medicare beneficiaries who are assigned and enrolled in the traditional fee-for-service program
In 2018, how many children were covered under the Children’s Health Insurance Program (CHIP)?
What year did Congress pass An Action for Relief of Sick and Disabled Seaman?
In 1932, Blue Cross Networks was established in which American city?
Which statement is true about COBRA?
Allows employees to carry their own health insurance
Determines the value of health/life expectancy by making simple conclusions based on actions
Determines quality-adjusted life-year(QALY) calculations and health outcome values
Evaluates the type of healthcare services most effective for community interventions
Measures general health and quality of life
This instrument measures health on avertical and visual analogue scale
Measures life quality and health status
Is an estimate of social values and healthcare interventions
working less than full time/without regular employment
direct interactions between providers and patients
norms, safety, access to community resources
focus on smaller groups and institutions
working poor, chronic homeless
constantly denied the opportunity to rebuild
ESRD QIP (end stage renal disease quality incentive program)
Promotes the use of outpatient dialysis centers to reduce inpatient treatment fees
HVBP (Hospital value based purchasing)
This program forced hospitals to focus on patient care rather than the quantity of services
HRR (hospital readmission reduction)
When patients are readmitted, hospitals receive fines/lower service costs for duplicate services
Measures service quality and adjusts provide payments based on patient outcomes
HAC (hospital acquired condition)
Incentives are based on the number of admissions that do not contract hospital-based illnesses
Which are the primary fee-for-service (FFS) payment systems?
FFS Health Plans and Medicare FFS
Which is an advantage of fee-for-service?
Patients have the flexibility to schedule appointments with any doctor/provider
Provide the best care at the lowest cost.
Provide follow-up communication to support adoption of healthy behavior changes.
“This model provides incentives to providers based on patient health outcomes.”
Act for the Relief of Sick and Disabled Seamen
established in Sacramento 1932 under the AMA
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Health Insurance Portability and Accountability Act (HIPAA) in 1996
Children’s Health Insurance Program (CHIP)
as the allocation and utilization of resources within healthcare settings as a whole.
Mezzo interactions occur on a larger scale than macro factors with a focus on smaller groups and institutions. Mezzo concepts are used on large-scale problems in organizations, schools, businesses, and political realms. Mezzo involves implementing social service initiatives to support healthcare access on the community and institutional levels.
This cost-cutting type significantly reduces patient expenditure by combining services.
fixed fees for medical services linked to market rates.
funding elements that are generated through small- and large-scale donations and paid to medical providers as services are rendered—to offset medical patient paid expenses. Patients pay a certain percentage for their medical expenses (fee per service) and medical providers request additional funding from donations to offset costs. Potential donors receive messages that their donations halt psychosocial issues associated with medical problems (such as the spread of diseases, unemployment, homelessness, etc.).
