US Healthcare Systems, Exam 3 (Ch 12-14)questions and answers 100% correct

US Healthcare Systems, Exam 3 (Ch 12-14)questions and answers 100% correctaccess The ability of persons needing health services to obtain appropriate care in a timely manner. Can you get medical care when you need it? If yes, you have access to medical care. Access is not the same as health insurance coverage, although insurance coverage is a strong predictor of access for primary care services. administrative costs Costs that are incidental to the delivery of health services. These costs are not only associated with the billing and collection of claims for services delivered but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, costs incurred by insurance and managed care organizations to market their products, and time and effort involved in the negotiation of rates. certificate-of-need or CON Control exercised by a government planning agency over expansion of medical facilities, for example, determination of whether a new facility should be opened in a certain location, whether an existing facility should be expanded, or whether a hospital should be allowed to purchase major equipment. clinical practice guidelines Standardized guidelines in the form of scientifically established protocols, representing preferred processes in medical practice. competition Rivalry among sellers for the purpose of attracting customers. cost efficiency A service is cost efficient when the benefit received is greater than the cost incurred to provide the service. critical pathways Outcome-based, patient-centered case management tools that are interdisciplinary, facilitating coordination of care among multiple clinical departments and caregivers. A critical pathway identifies planned medical interventions in a given case, along with expected outcomes. defensive medicine Excessive medical tests and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnecessary. fraud Intentional filing of false billing claims or cost reports and provision of services that are not medically necessary. health planning Decisions made by governments to limit health care resources, such as hospital beds and diffusion of costly technology. Health-realated quality of life or HRQL 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 disease experience. institution-related quality of life 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 temperatures and factors related to emotional wellbeing such as 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. 00:02 01:08 outcomes The end result of health care delivery; often viewed as the bottom-line measure of the effectiveness of the health care delivery system. over-utilization Utilization of medical services, the cost of which exceeds the benefit to consumers or the risks of which outweigh potential benefits. peer review Refers to the general process of medical review of utilization and quality when it is carried out directly or under the supervision of physicians. Quality Improvement Organization or QIO A private organization composed of practicing physicians and other health care professionals in each state that is paid by the Centers for Medicare & Medicaid Services under contract to review the care provided to Medicare beneficiaries. quality 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. quality assessment Process of defining quality and deciding how quality is to be measured according to established standards. quality assurance The process of ongoing quality measurement and using the results of assessment for ongoing quality improvement. risk management Limiting risks against lawsuits or unexpected events. small area variations Unexplained variations in the treatment patterns for similar patients and medical conditions. top-down control It 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 pre-established budget limits. The downside to this approach is that, under fixed budgets, providers are not as responsive to patients 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. Total Quality Management or TQM Creates an environment in which all aspects of health services within an organization are oriented to patient-related objectives and the production of desirable health outcomes. It holds the promise of not only improving quality but also increasing efficiency and productivity by identifying and implementing less costly ways to provide services. This system is viewed as an ongoing effort to improve quality. Hence, it is also referred to as continuous quality improvement or CQI. underutilization Occurs when medically needed health care services are withheld. This is especially true when potential benefits are likely to exceed the cost or risks. upcoding A fraudulent practice in which a higher priced service is billed when a lower priced service is actually delivered. allocative tools Designates a use of health policy in which there is a direct provision of income, services, or goods to groups of individuals who usually reap benefits in receiving them. distributive policies Spread benefits throughout society. Examples are funding of medical research through the NIH, the training of medical personnel through the National Health Services Corps, the construction of health facilities under the Hill-Burton program, and the initiation of new institutions, for example, HMOs. health policy Refers to public policy that pertains to or influences the pursuit of health. public policies Authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others. redistributive policies Take money or power from one group and give it to another. Examples are the Medicaid program, which takes tax revenue and spends it on the poor in the form of health insurance. regulatory tools Designate a use of health policy in which the government prescribes and controls the behavior of a particular target group by monitoring the group and posing sanctions if it fails to comply. comparative effectiveness research or CER A concept in which a chosen medical intervention is guided by scientific evidence on how well it would work compared to other available treatments. genometrics The association of genes with specific disease traits. high-risk pools State-based pools, before 2014, to make health insurance available to people who otherwise would have been uninsurable because of pre-existing health conditions. molecular medicine A branch of medicine that deals with the understanding of the role that genes play in disease process and treatment of diseases through gene therapy. patient activation A person's ability to manage his or her own health and utilization of healthcare. patient-centered care Delivery of health care that respects and response to patients' wants, needs, and preferences so that they can make choices in their care that best fit their individual circumstances. single-payer system A national health care program in which the financing and insurance functions are taken over by the federal government. universal access The ability of all citizens to obtain health care when needed. It is a misnomer because timely access to certain services may still be a problem because of supply-side rationing. xenotransplantation Also called "xenografting." Transplanting of animal tissue into humans. zoonoses Any disease or infection that is naturally transmittable from vertebrate animals to humans.