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Healthcare managers must consider the multifactorial determinants of health. Medical care is but one subset of the contributing factors to a patient's health and well-being.

Private health insurance, the primary vehicle for the delivery of healthcare in the U.S., has become a firmly entrenched method for paying for costly healthcare.

Perhaps the two most singularly transformative events in U.S. healthcare have been the creation of Medicare andMedicaid in 1965 and the Affordable Care Act of 2010.

Healthcare managers must remember that compliance with federal statutes is essential to providing quality patient-centered care.

Frequent internal evaluations of compliance with licensure, certification, and accreditation standards can help a healthcare organization maintain a patient-first perspective.

Healthcare managers should institute consumer protection practices to build consumer confidence in their organization.

Competition with healthcare markets can encourage healthcare organizations to deliver higher quality care to attract more patients while containing costs.

In addition to abiding to federal regulations, healthcare managers must be aware of the particular compliance processes within their state.

The explosive growth in outpatient services has revolutionized the ability to treat patients. Surgeries that could previously have only been performed in hospitals can now be performed in outpatient settings, causing hospital occupancy rates to decline.

Primary care is the most common route of entry into the healthcare system and can provide continuity of care throughout a patient's entire life span.

Ideally, hospitals can enhance the health status of a community as a whole by providing benefits like education and charity care to the community. Regardless of whether a hospital is investor-owned or nonprofit, their main mission is to serve the community.

Managed care has improved the overall quality of healthcare delivery, partially because early detection and treatment are more likely to occur in a managed care plan versus a traditional fee-for-service plan, all while maintaining cost containment.

Due to pressure from managed care to reduce the cost of healthcare, integrated delivery systems emerged, allowing several organizations under the same ownership to provide a variety of healthcare services to large communities.

Long-term care provides a holistic approach to maximizing the quality of a patient's life through coordinated services that attempt to providethe maximum amount of independence for those with functional limitations.

Though there are many different stakeholders involved in the delivery of care, the most important stakeholder is, unconditionally, the patient.

Improved health literacy is not limited to health comprehension, but health communication—providers must engage in more meaningful dialogue amongst themselves and with patients.

As the most important stakeholders, patients must be educated about their health. It is the responsibility of providers to offer information and directives regarding patient education.

Although clinicians make many of the important medical decisions regarding patient health, unbeknownst to the patient, many healthcare decisions are determined by larger institutions, such as insurers, the government, and professional organizations.

Patient-centered healthcare is contingent upon stakeholders' ability to not only fulfill their defined role, but to coordinate care among each other.

The convergence of predisposing, enabling, and need characteristics not only determine an individual's access to healthcare, but influence their risk for contracting and recovering from illness.

Public health goes beyond merely addressing symptoms—healthcare managers must promote wellness in the community at large.

Healthcare managers have a responsibility not only to current patients, butpotentialpatients as well: the populations that desperately need healthcare, but cannot readily obtain it due to cultural, economic, or other barriers.

Proactive strategies for engaging the community can help prevent healthcare crises and increase the utilization of medical services desperately needed by vulnerable populations.

Due to the increasing complexity of the healthcare system and medicalservices, all population groups can suffer from limited health literacy, regardless of education, income, and socioeconomic status.

Improved health literacy reduces barriers to access, improves outcomes, and raises utilization rates.

Technological and evidence-based changes to clinical and organizational practices will drive greater efficiency and quality in healthcare.

The U.S. healthcare market is increasingly influenced by and modeled after systems and practices in other developed countries.

Economic trends influence the resources available to pay for healthcare and the sources of those funds, which may influence service and provider choices.

Increase access through technology for in-home or virtual care

Standarized practice guidelines for increased quality of care

manufacture of generic and other drugs by Asian countries for export to Europe, Canada, and the United States helps the economies of both the manufacturing and importing countries

political parties and legislation has also resulted in rising health insurance premiums for many Americans while still leaving a large number of people uninsured.

Integration of a racially and culturally diverse workforce is also a growing necessity. A shortage of health care professionals trained in geriatrics is a critical challenge with serious implications, given the anticipated growth in the U.S. elderly population. Primary care physicians need training so they can adequately function as "comprehensivists" to address the needs of a growing number of people with complex chronic conditions.

technology affects many aspects of medical practice, to the point that it currently drives much of the growth in the health services industry. genetic mapping and molecular medicine this technique is expected to replace treatment with medications or surgeries

clinical practice guidelines are designed to provide evidence-based or well-researched protocols to guide physicians' clinical decisions and to promote lower costs of care and better health outcomes

Neither the United States nor the United Nations has the authority to enforce compliance—yet, when threats to public health arise anywhere in the world, the affected nations look to the United States and other developed countries to come to their aid.

Addressing workforce diversity and training are other looming challenges that could threaten the adequacy of the health care workforce in a changing demographic landscape

gradual reforms in Medicaid, access expansion expanding insurance coverage, outreach programs in rural areas, reducing the cost of care with the use of PPS and RBRVs, Creating AHRQ to monitor and increase quality care and calling for clinical practice guidelines

increase in public financing for Medicare/ medicaid/ VA / Indian Health service

often referred to as IDS/ IDN. Goal is to provide seamless services more accessibley that will lead to better overall care of the patient.

may be referred to as underserved populations, medically underserved, medically disadvantaged, underprivileged, or vulnerable populations; marginalized groups; or American underclasses. The causes of their vulnerability are largely attributable to inequalities in social, economic, health, and geographic conditions

policies to encourage professional education programs that are sensitive to the unique needs of minorities as well as programs to expand the delivery of services to areas populated by minorities.

CHIP, created in 1997, has given states some flexibility in how they spend federal funds allocated for investment in children's health coverage

Funding the National Health Service Corps is one step toward addressing the problem of personnel shortages in rural areas. Additional programs are needed to increase the total supply of physicians and create incentives for permanent practice in rural areas.

uninsured individuals are likely to be poorer and less educated than insured individuals, and tend to work in part-time jobs and/or be employed by small firms. The uninsured also tend to be younger (age 25 to 40 years), because most of the elderly (age 65 and older) are covered by Medicare. Ethnic minorities are also more likely to lack health insurance.

financial challenges and problems in satisfying eligibility requirements for health insurance. Accessible transportation to medical facilities is often unavailable to them. The homeless usually suffer from a lack of proper sanitation, do not have a stable place to store medications safely, and are unable to obtain the proper food for the medically indicated diet necessary to treat conditions such as diabetes or hypertension.

Congress passed the Americans with Disabilities Act (ADA). Title I of this civil rights law protects individuals with depression, posttraumatic stress disorder (PTSD), and other mental health conditions from discrimination in the workplace

people with lower education or income, of specific races or ethnic backgrounds, and in specific geographical locations, among other factors, are disproportionately affected by chronic diseases, often as a result of social disadvantages and vulnerability

low socioeconomic status and minority group membership are associated with lower overall health care access and utilization

primarily to extend health care services to medically underserved regions of the United States.

Geographical, socioeconomical barriers special needs are all access and cost barriers to healthcare. reduced Public / government funding to support programs to increase the quality and access of care

Someone practicing a skilled profession where education or licensing is required

licensed healthcare provider who has been awards an MD or DO degree

midlevel provider, and physician extender—refers to clinical professionals who practice in many areas in which physicians practice but who do not possess an MD or a DO degree

a person who has received a certificate or associate's, bachelor's, or master's degree; doctoral-level training; or post-baccalaureate training in a health care-related science and who has responsibility for the delivery of health or related services

to dispense medicines prescribed by physicians, dentists, and podiatrists and to provide consultation on the proper selection and use of medicines. All states require a license to practice pharmacy.

aka. medical scientist, studies diseases and conditions to heal improve and protect public health

Diagnostic tests play a crucial role at every step of disease management - Diagnosis, Monitoring, Screening and Prognosis

Health services administrators are employed at the top, middle, and entry levels of various organizations that deliver health services to assist in strategic direction, involved in major planning and coordinating functions, overseeing and assisting in operations.

follow the orders they receive and participate in their own healthcare

receives health insurance and uses it

Direct efforts to institute system change, their negotiations with health plans, and their decisions concerning the structure of health benefits for their employees

improve companies decision-making, legitimacy and competitiveness

a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity

increased the need for afforable univarsal cost efficient integrated healthcare

Because spiritual beliefs and practices positively influence physical, mental, and social well-being and may affect the incidences, experiences, and outcomes of many medical problems

Medicare, Medicaid, Workers compensation, Private

"Medicare - provided publicly financed health insurance to all elderly individuals, regardless of their incomes. Part A and Part B of Medicare Medicaid / CHIP - covered the eligible poor and was based on the earlier Kerr-Mills Act program. It would be financed through federal matching funds to the states in accordance with each state's per capita income. Workers comp- covered the eligible poor and was based on the earlier Kerr-Mills Act program. It would be financed through federal matching funds to the states in accordance with each state's per capita income. Private - not available to all

Sharing all risk amoung a group of insurance companies. companies reduce their own risk because the high cost of the unhealthy is offset by the realitely low cost of the healthier.

Fee for service - Each service is reimburse Bundled payments - a group of services (dentist, xrays, frams) Capitation - monthly payment to physician cover visits Prospective reimbursement (PPS) - uses certain pre established criteria to determine in advance the amount of reimbursement.

Diagnosis Related Groups - DRGs prospectively sets a bundled price according to the principal diagnosis at the time of admission. The hospital receives the predetermined fixed rate for that particular DRG classification. Ambulatory Payment Classifications (APCS) - divides all outpatient services into more than 300 procedural groups, with specific reimbursement rates being associated with each APC group. The rates are also adjusted for geographic variations in wages. APC reimbursement includes services such as anesthesia, certain drugs, supplies, and recovery room charges in a package price established by Medicare. Resource Utilization Groups (RUGS) - categories are used for determining an SNF's overall severity of health conditions requiring medical and nursing intervention. The aggregate of clinical severity in a facility is referred to as its case mix. It is determined by first evaluating each patient's medical and nursing care needs. Based on this evaluation, each patient is classified into one of 66 RUGs (according to RUG-IV classifications). Home Health Resource Groups - home health care pays a fixed, predetermined rate for each 60-day episode of care, regardless of the specific services delivered. Thus all services provided by a home health agency are bundled under one payment made on a per-patient basis.

Demand side rationing create obstacles with prices and ability to pay limit or ration the quantity and type of services consumed. current changes with ACA is that we bome more social market rather than martet just. This will remove ability to pay, but will most likely incrase rationing tech / supply.

It established Medicare, a health insurance program for the elderly, and Medicaid, a health insurance program for people with limited income.

decreased disparities increased initiatives to Offord move coverage

Obtain a certification to gain compliance- enforced and maintained by survey inspections

The Affordable Care Act (ACA) is a comprehensive reform law, enacted in 2010, that increases health insurance coverage for the uninsured and implements reforms to the health insurance market. This includes many provisions that are consistent with AMA policy and holds the potential for a better health care system.

The HITECH Act was created to promote and expand the adoption of health information technology, specifically, the use of electronic health records (EHRs) by healthcare providers.

physician self-referral

The Employee Retirement Income Security Act of 1974 (ERISA), a federal statute, delineates minimum standards for the administration of private industry's pension plans and establishes the impact that federal income taxes will have on transactions associated with management of such pension plans.

A federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge

A. To protect the health and well-being of millions of american families- improving economic security of the nation

B. Health administration "IT", the regulatory force for the entire health system to support the adoption of health information technology. Developed stands-based health information exchange

C. Manages a wide array of health and welfare programs. HHS is responsible for regulating food products and new pharmaceutical drugs (Food and Drug Administration), implementing the nation's biggest health care programs (Medicare and Medicaid), preventing the outbreak and spread of diseases (Centers for Disease Control and Prevention) and funding some of the most important medical research in the world (National Institutes of Health), among other programs.

D. The medical research agency- part of HHS - regulates and provides med research

E. HHS governed office responsible for elimination discrimination on the basis of disability

F. Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. They accredit and certify HCOs and programs

G. The Food and Drug Administration is responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices; and by ensuring the safety of our nation's food supply, cosmetics, and products that emit radiation.

H. operates and maintains systems that are critical to the nation's financial infrastructure, such as the production of coin and currency, the disbursement of payments to the American public, revenue collection, and the borrowing of funds necessary to run the federal government.

A. Conducts targeted market conducts exams, as necessary and responds to consumer inquires and complaints

B. issues guidance and interpretations on HIPAA Privacy and Security rules, including how these rules apply to electronic health records, personal health records, and health information technology. OCR has enforcement authority to ensure compliance with the HIPAA Privacy and Security Rules through investigation and the ability to impose civil monetary penalties. The HITECH Act of 2009 enhanced many of the Privacy Rule provisions, including extending certain requirement to business associates; limiting uses and disclosure of protected health information for marketing; prohibiting the sale of protected health information (PHI) without patient authorization; expanding individuals' rights to access their information and restrict certain PHI disclosures to health plans; and providing greater enforcement authority to OCR.

C. Through its programs/ OCR - NIH

D. Through policies , auditing and compliance certifications

E. Through compliance reviews and complaint investigation

F. Surveyor visits

G. Monitor the quality of human drugs through facility inspections, product testing, and other pre- and post market compliance activities. Ensure drugs in FDA approval system have reliable evidence of safety and effectiveness, human subjects in clinical trials are protected, and drugs meet postmarket safety requirements.

H. Tax regulations

permanent or semi-permanent organization in the machinery of government that is responsible for the oversight and administration of specific functions, such as an administration

Accreditation is formal recognition on the competency towards a specified standard - in healthcare an accreditation legitimizes an organization within an industry Certification is a written assurance by a 3rd party on the product or service directly to the individual / service provider.

A. Individual Mandatory credentialing process established by law-at a state level-based on the national code for ethical medical practice- AMA

B. JC Accreditation and certification means your organization complies with the highest national standards for safety and quality

Outpatient is used interchangeably with the word ambulatory because a patient can typically ambulate(Walk to the service). Outpatient or ambulatory care refers to any health care service that does not require an overnight stay in a health care institution. This also includes more that primary care, which would be a visit buy your primary provider. Outpatient service can also be tests at labs, imaging or same day procedures.

a level of care for patients who require more assistance than custodial care, and may require nursing supervision, but do not have a true skilled need

specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home

provides intermittent skilled care to patients in their home. Skilled nursing, physical therapy, occupational therapy, speech therapy and medical social worker visits are services that home health agencies provide.

Managed care and integrated are synonymous, it is the healthcare coverage that organizes providers into groups in order to enhance the quality and cost effectiveness of the medical treatment.

often referred to as IDS/ IDN. Goal is to provide seamless services more accessibly that will lead to better overall care of the patient.

most non PHO's rely on an MCO delivery process. There are multiple facilities where care can be delivered.

Hospitals typically use an IDN delivery process and tend to ACO requirements for level of care