ABPS Administrative Medicine cheat sheet

US delivery is pluralistic: private practices, hospitals, federally qualified health centers (FQHCs), and integrated systems (e.g., staff/group-model HMOs) coexist.

Safety-net providers: FQHCs receive enhanced Medicare/Medicaid prospective payment; critical access hospitals (<=25 beds, rural) get cost-based reimbursement at 101% of cost.

EMTALA requires a Medicare-participating hospital with an emergency department to provide a medical screening exam and stabilizing treatment regardless of ability to pay.

Accountable care organizations accept shared savings/losses for a defined population; the ACO must meet quality benchmarks to share savings.

Levels of care: primary (first contact, continuity), secondary (specialist referral), tertiary (advanced subspecialty), quaternary (rare/complex, often academic).

Vertical integration combines payer/provider or different care levels; horizontal integration combines like entities (hospital systems, physician groups).

Telehealth modalities: synchronous (live video), asynchronous (store-and-forward), remote patient monitoring; licensure generally follows patient location.

Rural Health Clinics and FQHCs differ in payment methodology and staffing rules; both qualify for 340B drug pricing if eligible.

Medicare Part A (hospital insurance, payroll-tax funded), Part B (outpatient, premium + general revenue), Part C (Medicare Advantage), Part D (outpatient drugs).

HIPAA Privacy Rule permits disclosure for treatment, payment, and operations (TPO) without authorization; minimum necessary standard applies to non-TPO uses.

Anti-kickback Statute (federal) criminalizes remuneration for referrals of federally payable items/services; Stark Law (physician self-referral) is strict-liability civil for designated health services.

EMTALA, HIPAA, CLIA, and the False Claims Act are core federal compliance statutes; FCA qui tam relators may receive 15-30% of recovery.

Informed consent requires capacity, disclosure of material risks/benefits/alternatives, and voluntariness; emergency exception applies absent a surrogate.

Licensure is state-based; scope of practice is defined by state statute and board rules, not by federal law or hospital bylaws.

Negligence elements: duty, breach (standard of care), causation (actual and proximate), and damages; res ipsa loquitur shifts burden when the injury is of a type that ordinarily does not occur without negligence.

Certificate of need (CON) laws in some states require regulatory approval before building capacity or adding certain services.

DRG-based inpatient payment (MS-DRG) pays a fixed case rate; outlier payments cover extremely high-cost cases.

Contribution margin = revenue − variable costs; a service line with positive contribution margin can still be dropped if it does not cover fixed costs in the long run.

Cost shifting: when public payers pay below cost, providers charge private payers more; magnitude depends on payer mix and market power.

Moral hazard: insurance lowers the marginal price of care, increasing utilization; deductibles and copays are demand-side cost-sharing tools.

Adverse selection: sicker individuals disproportionately buy generous coverage; risk adjustment and community rating mitigate it.

Break-even volume = fixed costs ÷ (price − variable cost per unit).

Value = quality (outcomes) ÷ cost; value-based payment ties reimbursement to quality metrics and total cost of care.

RVU (relative value unit) components: physician work, practice expense, and malpractice; payment = (RVU × GPCI) × conversion factor.

Donabedian model: structure (resources), process (what is done), outcome (results); structure and process are proxies for outcomes.

PDSA (Plan-Do-Study-Act) is a rapid-cycle improvement method; each cycle tests a small change before scaling.

Six Sigma targets defect reduction (DPMO); Lean targets waste elimination; both are complementary to PDSA.

IOM (now NAM) STEEEP aims: Safe, Timely, Effective, Efficient, Equitable, Patient-centered.

Never events (e.g., wrong-site surgery, retained foreign body) are largely preventable and often non-reimbursable under Medicare policy.

Root cause analysis (RCA) is retrospective for sentinel events; failure mode and effects analysis (FMEA) is prospective, scoring severity × occurrence × detection.

Just culture distinguishes human error (console), at-risk behavior (coach), and reckless behavior (sanction).

Statistical process control: common-cause variation needs system redesign; special-cause variation triggers investigation of a specific event.

Situational leadership: directing (low readiness), coaching, supporting, delegating (high readiness) - match style to follower maturity.

Transformational leadership (idealized influence, inspirational motivation, intellectual stimulation, individualized consideration) vs. transactional (contingent reward, management by exception).

Tuckman stages: forming, storming, norming, performing, adjourning.

Conflict modes (Thomas-Kilmann): competing, collaborating, compromising, avoiding, accommodating; collaborating is best for important, complex issues.

Span of control: narrower spans suit complex, high-uncertainty work; wider spans suit standardized, routine work.

Maslow (physiologic→self-actualization) and Herzberg (hygiene factors prevent dissatisfaction; motivators drive satisfaction) explain motivation.

Kotter's 8-step change model begins with urgency and ends with anchoring change in culture.

Emotional intelligence (Goleman): self-awareness, self-regulation, motivation, empathy, social skill.

SWOT (strengths, weaknesses, opportunities, threats) pairs internal factors with external ones; TOWS converts them into strategies.

Porter's five forces: rivalry, new entrants, substitutes, buyer power, supplier power; used to assess market attractiveness.

PESTLE scans political, economic, social, technological, legal, environmental factors.

Balanced Scorecard perspectives: financial, customer, internal process, learning and growth.

Capacity planning: demand forecast + variability buffer; queue length grows nonlinearly as utilization approaches 100% (queueing theory).

Little's Law: average number in system = arrival rate × average time in system.

Vertical vs. horizontal strategy: market penetration, market development, product development, diversification (Ansoff matrix).

Operational metrics: throughput, cycle time, utilization, and cost per case; benchmark against peer groups.

EHR vs. EMR: EHR spans care settings and is patient-centric; EMR is a single-organization record.

Meaningful Use / Promoting Interoperability stages require certified EHR technology and reporting of clinical quality measures.

HL7 v2 and FHIR are interoperability standards; FHIR uses RESTful APIs and resources for modern exchange.

CDS (clinical decision support) should be actionable, timely, and evidence-based; alert fatigue reduces effectiveness.

CPOE reduces medication errors; barcode medication administration (BCMA) adds a verification step at administration.

HITRUST and HIPAA Security Rule govern safeguards (administrative, physical, technical); breach notification generally within 60 days.

Data governance defines ownership, stewardship, and quality; master patient index (MPI) links identity across systems.

Telehealth and remote monitoring expand access; licensure, reimbursement, and privacy rules still apply.

Physician compensation models: salary, productivity (wRVU), quality incentives, and blended models; wRVU aligns pay to work effort.

FTE (full-time equivalent) standardizes staffing; 1.0 FTE typically = 40 hours/week or a defined clinical schedule.

Credentialing verifies training/licensure; privileging grants specific clinical privileges; both are required before independent practice.

Peer review and OPPE (ongoing professional practice evaluation) monitor competence; FPPE (focused) evaluates new or flagged providers.

Burnout drivers (Maslach): emotional exhaustion, depersonalization, reduced personal accomplishment; system factors outweigh individual resilience.

Recruitment and retention: total compensation, call burden, schedule flexibility, and culture drive turnover.

Labor rules: FLSA exempt/non-exempt classification, overtime, and independent-contractor vs. employee status affect liability and taxes.

Succession planning and workforce analytics forecast shortages and align hiring with strategic goals.

Four principles (Beauchamp & Childress): autonomy, beneficence, nonmaleficence, justice.

Informed consent requires capacity, disclosure, comprehension, and voluntariness; surrogate decision-making follows substituted judgment then best interests.

Advance directives: living will (treatment preferences) and durable power of attorney for health care (health care proxy).

Confidentiality exceptions: mandated reporting, imminent harm to self/others, court order, and public health reporting.

Conflict of interest: disclose, recuse, or manage; financial ties to industry must follow transparency (e.g., Open Payments).

Professionalism includes altruism, accountability, excellence, duty, honor/integrity, and respect for others.

Board governance: fiduciary duties of care and loyalty; boards set strategy, hire/oversee the CEO, and ensure financial integrity.

Research ethics: IRB review, informed consent, equipoise, and Belmont principles (respect for persons, beneficence, justice).