PAHM cheat sheet

Beveridge model: government owns and operates providers and pays via general tax revenue (e.g., UK NHS).

Bismarck model: statutory social insurance funded by employer/employee payroll contributions, private and public providers (e.g., Germany).

National Health Insurance model: single public payer contracts private providers, funded by taxes (e.g., Canada).

Out-of-pocket model: payment at point of service with limited risk pooling; dominant in low-income settings.

US delivery settings: ambulatory/physician offices, acute inpatient hospitals, post-acute (SNF, IRF, LTACH), home health, hospice.

Safety-net providers (public hospitals, FQHCs) serve uninsured and Medicaid populations regardless of ability to pay.

Vertical integration aligns hospitals, physician groups, and post-acute providers under one organization; horizontal integration consolidates same-level providers.

ACO models: Medicare Shared Savings Program (MSSP), Pioneer/Next Generation, and commercial ACOs tie payment to total-cost and quality benchmarks.

Premium = base rate adjusted for age, geography, tobacco use, and plan tier (metal level); cost-sharing is separate from premium.

Metal tiers reflect actuarial value: Bronze ~60%, Silver ~70%, Gold ~80%, Platinum ~90% of allowed costs paid by plan.

Deductible: member out-of-pocket before plan pays; coinsurance is a percentage of allowed amount after deductible; copay is a fixed dollar amount.

Out-of-pocket maximum caps member cost-sharing for covered in-network essential health benefits in a plan year.

HMO: closed network, PCP gatekeeping, referrals required, no non-emergency out-of-network coverage except emergencies.

PPO: open network with in-network vs out-of-network benefits, no referral requirement, higher premiums than HMO.

POS and EPO are hybrids: POS has gatekeeping with out-of-network option; EPO covers only in-network care except emergencies.

Risk selection and adverse selection: sicker enrollees disproportionately join richer plans, driving premium spirals; risk adjustment offsets this.

Medical loss ratio (MLR) = claims + quality improvement spending / premium; ACA requires 80% individual/small group and 85% large group rebates if missed.

Fee-for-service (FFS) pays per unit of service; volume drives revenue and incentivizes utilization.

Capitation pays a fixed per-member-per-month (PMPM) amount regardless of services used, shifting utilization risk to the provider.

Bundled/episode payment covers a defined care episode (e.g., joint replacement) across providers with a single target price.

DRG prospective payment: hospitals paid a fixed amount per discharge based on diagnosis-related group, adjusted for wage index, case mix, and outliers.

RVU formula: Medicare physician payment = (work RVU + practice expense RVU + malpractice RVU) × GPCI × conversion factor.

APM frameworks: CMS categories 1 (FFS) through 4 (population-based) with increasing risk and quality accountability.

Value-based purchasing ties a percentage of payment to quality measure performance (e.g., Hospital VBP, HRRP readmissions penalties).

Payer mix and cost shifting: providers offset uncompensated care and low public payer rates by charging commercial payers more.

Contribution margin = revenue − variable costs; break-even volume = fixed costs / contribution margin per unit.

Donabedian model: structure (resources), process (care delivery), and outcomes (results) are the three quality dimensions.

IOM six aims: safe, effective, patient-centered, timely, efficient, equitable.

Plan-Do-Study-Act (PDSA) is the core rapid-cycle improvement method; DMAIC (Define-Measure-Analyze-Improve-Control) is Six Sigma's.

Lean eliminates waste (waiting, overproduction, defects, transport, inventory, motion, overprocessing, unused talent); Six Sigma reduces variation.

Little's Law: average work-in-process = arrival rate × average time in system; used to size queues and flow.

Capacity planning: utilization = demand / capacity; queue times rise sharply as utilization approaches 100%.

Root cause analysis (RCA) investigates sentinel events; failure mode and effects analysis (FMEA) proactively assesses process risk.

Common quality measures: HEDIS (ambulatory/health plan), CAHPS (patient experience), Hospital Compare/Star Ratings, readmission and mortality rates.

Benchmarking compares performance to internal or external standards; statistical process control charts distinguish common vs special cause variation.

HIPAA Privacy Rule governs use/disclosure of protected health information (PHI); Security Rule covers administrative, physical, and technical safeguards.

HIPAA minimum necessary standard limits PHI disclosure to the minimum needed for the purpose; treatment, payment, and operations are permitted uses.

EMTALA requires hospitals with emergency departments to provide medical screening and stabilizing treatment regardless of insurance or ability to pay.

Stark Law (physician self-referral) prohibits referrals for designated health services to entities with which the physician has a financial relationship, absent an exception.

Anti-Kickback Statute criminalizes knowingly offering or receiving remuneration to induce referrals for federally payable services; safe harbors protect certain arrangements.

False Claims Act imposes liability for knowingly submitting false claims; qui tam provisions allow whistleblowers to sue on the government's behalf.

ACA market reforms: guaranteed issue, no preexisting-condition exclusions, dependent coverage to age 26, essential health benefits, medical loss ratio rebates.

Medicare Conditions of Participation (CoPs) and Joint Commission accreditation are conditions for participation and deemed status.

Compliance program elements: written policies, compliance officer, training, monitoring/auditing, hotline, enforcement, and corrective action.

EHR vs EMR: EHR is longitudinal and interoperable across settings; EMR is a single-organization record.

HITECH Act (2009) established meaningful use incentives and penalties for EHR adoption and strengthened HIPAA breach notification.

HL7 v2/FHIR are interoperability standards; FHIR uses RESTful APIs and JSON/XML resources for data exchange.

ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures) support coding, billing, and analytics; CPT/HCPCS cover outpatient/professional services.

Data quality dimensions: completeness, accuracy, timeliness, consistency, validity, and uniqueness.

Analytics tiers: descriptive (what happened), diagnostic (why), predictive (what will happen), prescriptive (what to do).

Key metrics: readmission rate, HCAHPS scores, length of stay, case mix index, ED throughput, and denial rate.

Population health analytics stratify risk using claims, EHR, and social determinants data to target care management.

Privacy/security controls: role-based access, audit logs, encryption at rest and in transit, and business associate agreements (BAAs).

Strategic planning cycle: environmental scan (SWOT/PESTLE) → mission/vision → goals → strategies → implementation → evaluation.

Porter's Five Forces applied to healthcare: rivalry, new entrants, substitutes, supplier power, and buyer power.

Value chain analysis identifies activities that create competitive advantage (e.g., care coordination, supply chain, technology).

Leadership styles: transactional (rewards/penalties), transformational (vision/inspiration), servant (follower needs), situational (adapt to context).

Ethical principles: autonomy, beneficence, nonmaleficence, justice; used in resource allocation, end-of-life, and informed consent decisions.

Stakeholder analysis maps influence vs interest to prioritize engagement (e.g., payers, clinicians, patients, regulators).

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

Change management: Kotter's 8 steps (urgency, coalition, vision, communicate, empower, quick wins, consolidate, anchor).

Key financial ratios: current ratio (liquidity), operating margin (profitability), days cash on hand (reserves), and debt-to-equity (leverage).