HS 330 flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Donabedian structure-process-outcome

A quality framework classifying measures as structure (resources and staffing), process (clinical actions performed), or outcome (resulting health status). Outcome measures matter most to patients but are hardest to attribute to a single provider.

Triple Aim

IHI framework targeting improved population health, better patient experience of care, and reduced per-capita cost. The Quadruple Aim adds clinician and staff well-being as a fourth goal.

EMTALA

Federal law requiring Medicare-participating hospitals with emergency departments to perform a medical screening examination and provide stabilizing treatment regardless of insurance status or ability to pay.

DRG prospective payment

Inpatient payment method paying a fixed amount per discharge based on diagnosis-related group, regardless of actual length of stay or resource use. Hospitals keep savings and absorb losses.

Moral hazard

The tendency for insured individuals to use more health services because insurance lowers the out-of-pocket price at the point of care. Cost-sharing is the standard policy countermeasure.

Adverse selection

A market failure in which sicker individuals disproportionately enroll in a generous plan, raising premiums and driving out healthier enrollees. Risk adjustment and mandates mitigate it.

Capitation

Payment of a fixed amount per enrolled patient per period, independent of services used. It shifts financial risk to providers and creates incentives for prevention and reduced unnecessary utilization.

HIPAA Privacy Rule

Federal rule governing use and disclosure of protected health information. Treatment, payment, and operations generally need no authorization; other disclosures require patient authorization or a specified exception.

Informed consent elements

Valid consent requires patient decision-making capacity, disclosure of material risks, benefits, and alternatives, voluntariness free of coercion, and documentation. Emergencies create a limited exception.

Four principles of bioethics

Autonomy (respecting patient self-determination), beneficence (acting for the patient's benefit), nonmaleficence (avoiding harm), and justice (fair allocation of scarce resources).

Medicare Part A

Hospital insurance covering inpatient stays, skilled nursing facility care after a qualifying stay, hospice, and some home health. Funded primarily through payroll taxes.

Medicare Advantage

Part C option in which private plans contract with Medicare to deliver Part A and Part B benefits, often with extra benefits and network restrictions in exchange for a capitated payment.

FMAP

Federal Medical Assistance Percentage, the share of Medicaid costs paid by the federal government. It rises automatically when a state's per-capita income falls relative to the national average.

Accountable care organization

A provider group accepting responsibility for the total cost and quality of a defined patient population, eligible for shared savings when spending benchmarks and quality thresholds are met.

501(r) requirements

IRS conditions for nonprofit hospital tax exemption, including a community health needs assessment every three years, a written financial assistance policy, and limits on collection practices.

Root cause analysis

A retrospective, systems-focused investigation of a sentinel event that identifies contributing process failures and produces corrective actions. Contrasts with prospective failure mode and effects analysis.

PDSA cycle

Plan-Do-Study-Act, a rapid-cycle improvement method in which small tests of change are run, measured, and refined before full-scale spread across a system.

Risk adjustment

Statistical adjustment of quality and cost comparisons for differences in patient case mix, preventing providers who care for sicker populations from appearing worse than they are.

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems, a standardized, publicly reported survey of inpatient experience covering communication, responsiveness, cleanliness, and discharge information.

Incremental cost-effectiveness ratio

The difference in cost between two interventions divided by the difference in health effect, commonly expressed as cost per quality-adjusted life-year gained.

QALY

Quality-adjusted life-year, a metric combining length of life with health-related quality of life on a 0-to-1 scale, used to compare value across interventions.

Relative value unit

The unit underlying the Medicare physician fee schedule, combining physician work, practice expense, and malpractice cost, then adjusted by geographic practice cost indices.

Anti-Kickback Statute

Federal law prohibiting knowingly offering or receiving remuneration to induce referrals of items or services reimbursed by federal health programs. Violations can be criminal or civil.

Stark Law

Physician self-referral prohibition barring referrals of designated health services to entities with which the physician has a financial relationship, unless a specific regulatory exception applies.

Negligence elements

A malpractice claim requires four elements: a duty of care owed, breach of that standard, causation linking breach to injury, and actual damages. All four must be proven.

Vertical integration

Combining organizations at different stages of the care continuum, such as a hospital acquiring physician practices or an insurer merging with a pharmacy chain, to coordinate and capture margin.

Patient-centered medical home

A primary care model emphasizing comprehensive, coordinated, accessible, and continuous care delivered by a physician-led team with enhanced access and quality measurement.

Medical staff self-governance

The arrangement in which physicians are credentialed and privileged through medical staff bylaws and committees, with the governing board retaining ultimate accountability for quality and safety.

Essential health benefits

Ten benefit categories that ACA-compliant individual and small-group plans must cover, including hospitalization, prescription drugs, maternity care, and mental health services.

Medicaid expansion

ACA option extending eligibility to adults under 138 percent of the federal poverty level, with enhanced federal matching funds; states that did not expand have larger coverage gaps.

Cost-sharing reduction

A subsidy lowering deductibles, copays, and out-of-pocket maximums for marketplace enrollees with incomes between 100 and 250 percent of the federal poverty level.

Bed occupancy and flow

Capacity metric comparing occupied beds to staffed beds. High occupancy with emergency department boarding signals discharge delays and prompts flow interventions such as early discharge.