PAHM flashcards
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32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Beveridge model
- Government owns and operates providers and pays for care through general tax revenue, as in the UK National Health Service; care is universal and publicly financed.
- Bismarck model
- Statutory social insurance funded by employer and employee payroll contributions, with a mix of public and private providers, as in Germany's system.
- Vertical integration
- A strategy in which an organization owns or aligns providers across different levels of care, such as hospitals, physician groups, and post-acute services.
- Safety-net providers
- Hospitals and clinics, including public hospitals and FQHCs, that serve uninsured and low-income patients regardless of ability to pay.
- Actuarial value
- The percentage of total allowed costs a health plan pays for a standard population; ACA metal tiers range from about 60% (Bronze) to 90% (Platinum).
- Out-of-pocket maximum
- The cap on a member's cost-sharing for covered in-network essential health benefits during a plan year; after it is met, the plan pays 100%.
- HMO gatekeeping
- A managed care feature in which a primary care physician coordinates care and referrals are required for specialist visits, limiting out-of-network coverage.
- Medical loss ratio
- The share of premium dollars spent on claims and quality improvement; ACA requires 80% in individual/small group and 85% in large group markets.
- Adverse selection
- A market dynamic in which sicker individuals disproportionately enroll in richer plans, raising costs and premiums and potentially driving healthier members away.
- Capitation
- A payment model in which a provider receives a fixed per-member-per-month amount regardless of services used, shifting utilization risk to the provider.
- DRG prospective payment
- A fixed payment per hospital discharge based on a diagnosis-related group, adjusted for wage index, case mix, and outlier costs.
- RVU payment formula
- Medicare physician payment equals the sum of work, practice expense, and malpractice RVUs, multiplied by geographic practice cost indices and the conversion factor.
- Bundled payment
- A single target price covering all services in a defined care episode, such as joint replacement, shared among participating providers.
- Contribution margin
- Revenue minus variable costs; dividing fixed costs by contribution margin per unit yields the break-even volume for a service line.
- Donabedian model
- A quality framework that evaluates care through structure (resources), process (what is done), and outcomes (results achieved).
- IOM six aims
- The Institute of Medicine's goals for improvement: care that is safe, effective, patient-centered, timely, efficient, and equitable.
- PDSA cycle
- Plan-Do-Study-Act, a rapid-cycle improvement method for testing small changes, studying results, and spreading what works.
- Little's Law
- Average work-in-process equals arrival rate multiplied by average time in the system; used to analyze patient flow and queue sizing.
- Root cause analysis
- A retrospective structured method for investigating sentinel events to identify underlying system causes and prevent recurrence.
- EMTALA
- A federal law requiring hospitals with emergency departments to provide a medical screening exam and stabilizing treatment regardless of insurance or ability to pay.
- Stark Law
- A physician self-referral prohibition barring referrals for designated health services to entities with which the physician has a financial relationship, absent an exception.
- Anti-Kickback Statute
- A criminal law prohibiting knowingly offering or receiving remuneration to induce referrals for services paid by federal healthcare programs; safe harbors protect certain arrangements.
- HIPAA minimum necessary
- A Privacy Rule standard limiting uses and disclosures of protected health information to the minimum needed for the purpose, excluding treatment disclosures.
- False Claims Act
- A law imposing liability for knowingly submitting false claims to government programs; qui tam provisions let whistleblowers sue on the government's behalf.
- EHR versus EMR
- An electronic health record is longitudinal and interoperable across settings, while an electronic medical record is confined to a single organization's record.
- HITECH Act
- A 2009 law that created meaningful use incentives and penalties for EHR adoption and strengthened HIPAA breach notification and enforcement.
- FHIR standard
- A modern interoperability standard using RESTful APIs and JSON or XML resources to exchange healthcare data across systems.
- Analytics maturity tiers
- Progressive levels of analytics: descriptive (what happened), diagnostic (why), predictive (what will happen), and prescriptive (what action to take).
- HCAHPS
- A standardized survey measuring patient experience of hospital care, used in public reporting and value-based purchasing programs.
- Porter's Five Forces
- A framework assessing industry attractiveness through rivalry, new entrants, substitutes, supplier power, and buyer power; applied to healthcare markets.
- Transformational leadership
- A leadership style that motivates followers through vision, inspiration, intellectual stimulation, and individualized consideration to achieve high performance.
- Balanced Scorecard
- A strategic performance framework measuring four perspectives: financial, customer/patient, internal process, and learning and growth.