HS 330 cheat sheet

The U.S. health system is a hybrid: employer-sponsored private insurance, government programs (Medicare, Medicaid, CHIP, VA), and out-of-pocket spending coexist with no single national payer.

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health, funded through payroll taxes; Part B covers outpatient and physician services, funded by premiums and general revenue.

Medicare Part C (Medicare Advantage) contracts private plans to deliver Part A and B benefits; Part D covers outpatient prescription drugs through private stand-alone or MA plans.

Medicaid is a federal-state partnership: federal government sets minimum requirements, states administer and share costs via FMAP, which rises when state per-capita income falls.

The uninsured rate reflects eligibility gaps: undocumented immigrants, childless adults in non-expansion states, and workers above subsidy thresholds are common categories.

Health policy goals are commonly summarized as access, cost, and quality (the 'iron triangle'); reforms that improve one often pressure the other two.

The ACA created health insurance marketplaces, premium tax credits, Medicaid expansion, essential health benefits, and prohibitions on denying coverage for preexisting conditions.

Payment models exist on a spectrum from fee-for-service (volume-driven) to capitation and shared savings (value-driven), with bundled payments and pay-for-performance in between.

Regulatory vs. competitive approaches: certificate-of-need and rate-setting are regulatory; price transparency and insurance exchanges are market-based.

Donabedian's model separates structure (resources, staffing), process (what is done), and outcome (health status results); structure and process are easier to measure, outcomes matter most to patients.

The IOM (now NAM) six aims for improvement are safe, effective, patient-centered, timely, efficient, and equitable.

Institute for Healthcare Improvement's Triple Aim: improve population health, enhance patient experience, and reduce per-capita cost; the Quadruple Aim adds clinician well-being.

Common quality measures: readmission rates, hospital-acquired infection rates, mortality (risk-adjusted), patient experience scores (HCAHPS), and adherence to evidence-based process measures.

Risk adjustment is required when comparing providers, because differences in case mix can otherwise be misread as differences in quality.

Never events and hospital-acquired conditions (e.g., wrong-site surgery, retained foreign body) are tracked because they are largely preventable and often non-reimbursable.

Root cause analysis is retrospective and systems-focused; failure mode and effects analysis is prospective and identifies where a process could fail before harm occurs.

Plan-Do-Study-Act (PDSA) is the standard rapid-cycle improvement method; small tests of change precede full-scale implementation.

Measurement validity concerns: process measures may not track outcomes, and small denominators produce unstable rates that require confidence intervals or pooling.

Moral hazard: insurance lowers the marginal price of care, increasing utilization; cost-sharing (deductibles, copays) is the standard countermeasure and reduces both necessary and unnecessary care.

Adverse selection occurs when sicker people disproportionately buy a given plan; community rating without mandates or risk adjustment can trigger a premium death spiral.

Demand for health care is relatively price-inelastic for urgent care and more elastic for elective and preventive services.

DRG-based inpatient prospective payment pays a fixed amount per discharge by diagnosis; hospitals absorb costs above the DRG payment and keep savings below it.

RVU-based physician payment under the Medicare fee schedule combines work, practice expense, and malpractice components, adjusted by geographic practice cost indices.

Cost-effectiveness analysis reports cost per quality-adjusted life-year (QALY); the incremental cost-effectiveness ratio is the difference in cost divided by the difference in effect between two options.

Gross domestic product share spent on health (about 17-18 percent in the U.S.) is a common cross-national comparison; the U.S. spends more per capita with mixed outcome rankings.

Capitation pays a fixed amount per enrolled person per period, shifting financial risk to the provider and incentivizing prevention and reduced unnecessary utilization.

Value-based purchasing ties a portion of payment to quality performance, blending fee-for-service with performance-based adjustment.

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

HIPAA Privacy Rule permits disclosure for treatment, payment, and operations without authorization; other uses require patient authorization, with exceptions such as public health reporting.

The HIPAA Security Rule covers electronic protected health information and requires administrative, physical, and technical safeguards plus risk analysis.

Informed consent requires capacity, disclosure of material risks and alternatives, voluntariness, and documentation; emergency exceptions apply when immediate treatment is needed.

Four core principles of biomedical ethics: autonomy (self-determination), beneficence (act in the patient's interest), nonmaleficence (avoid harm), and justice (fair distribution).

Anti-kickback Statute prohibits remuneration for referrals of federally reimbursed items; the Stark Law separately bans physician self-referral for designated health services, with specific exceptions.

The False Claims Act imposes liability for knowingly submitting false claims, with qui tam relators sharing in recoveries.

Negligence requires duty, breach, causation, and damages; institutional liability often rests on respondeat superior or corporate negligence for credentialing and policy failures.

Mandatory reporting laws require clinicians to report suspected child abuse, elder abuse, and specified communicable diseases to designated authorities.

Governance structures: a board of directors sets strategy and hires the CEO; the medical staff is typically self-governing through bylaws and credentialing committees.

Hospital classifications by ownership (nonprofit, for-profit, government) and by length of stay (acute care vs. long-term care) drive different tax and regulatory obligations.

Nonprofit hospitals must satisfy IRS section 501(r) requirements, including a community health needs assessment every three years and a financial assistance policy.

Vertical integration joins different stages of care (hospital plus physician group plus insurer); horizontal integration joins competitors (hospital systems, mergers).

Accountable care organizations accept responsibility for a defined population's total cost and quality, sharing savings if benchmarks are met.

Patient-centered medical home principles: comprehensive, coordinated, accessible, and continuous care with a physician-led team and enhanced access.

Workforce planning uses supply-demand projection models; shortages in primary care and behavioral health are attributed to pipeline, distribution, and reimbursement factors.

Capacity management tools: bed occupancy targets, discharge-before-noon practices, and patient flow analysis reduce emergency department boarding.

Strategic planning sequence: environmental scan (SWOT), mission and goals, strategy selection, implementation, and evaluation against measurable objectives.