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Government Involvement and Quality

Terms in this set (49)

T/F: The US constitution makes no mention of healthcare
True
What sections of the constitution have been interpreted to authorize government involvement in healthcare?
Article I, Section 8, Clauses 1 and 3
Definition: Article I, Section 8, Clause 1
Taxing and Spending General Welfare: "The congress shall have Power to lay and collect taxes, duties, imposts, and excises to pay the debts and provide the common defense and GENERAL WELFARE of the United States
Definition: Article I, Section 8, Clause 3
Commerce: The Congress shall have power...to regulate commerce with foreign nations, and among several states with Indian tribes
What does Clause 1 grant the federal government?
Gives the federal government the means to exercise its duties and responsibilities
What does Clause 3 grant the government?
The power to regulate commerce grants the federal government the greatest authority over the rights of individuals and the states
Definition: 16th amendment
The authority of the government to levy a tax on income
What does the 16th amendment grant the federal government?
Afforded the ability of the government to raise enough money to expand the US healthcare system
Definition: Social Security Act
Provided for federal grants for maternal and child healthcare services, public health laboratories, and public health departments
Definition: The Hospital Survey and Construction Act (Hill-Burton Act) 1946
Authorized grants for construction of hospitals and public health centers
Medicare (Title XVIII) and Medicaid (Title XIX) 1965
added to the SSA
Four roles of government in healthcare
1) Payer
2) Provider
3) Regulator
4) Innovator
Three objectives of the government as a payer (public financier)
1. Ensure adequate funding, while avoiding excessive expenditures

2. Regulate the health insurance market and pool risk when it perceives an uneven distribution of goods and services

3. Subsidizes care for the poor and disadvantaged
The government provides ____% of all expenditures in healthcare
45%
More than ___% of the federal government's healthcare expenditures are spent on Medicare
50%
The government purchases ___% of all health care coverage in the US for its employees and their dependents (not including the military)
15%
Definition: State Children's Insurance Program (SCHIP)
Increased federal funding to states with less restriction in order to allow expansion of eligibility for Medicaid
Definition: Program of All-Inclusive Care for the Elderly (PACE)
provides community-based medical and social services for persons >55 y/o that qualify for long-term care so as to better coordinate Medicare and Medicaid benefits
Definition: Medicare Part D
Offers prescription drug coverage for beneficiaries
Definition: Patient Protection and Affordable Care Act
Not a government insurance expansion but expanded role in regulation

Individual mandate/finance supports; Mandate for companies of 50 employees or more

Pre-existing conditions/Insure up to 26 years of age

Health Insurance Exchanges to assist patients in identification and selection of plans
What are the innovative aspects of the ACA? (4)
1. In addition to expanding coverage of the uninsured, contained elements to improve quality of Medicare and Medicaid programs

2. Movement to patient-centered care/outcomes

3. Established Center for Medicare and Medicaid Innovation (CMMI) in 2015

4. Emphasis on Health Promotion and Disease Prevention
T/F: Medicare and Medicaid provide health care services
False, Medicare and Medicaid via the government purchase health care services from the private sector
What is an example of the government providing comprehensive health care services?
The Veterans Health Administration (VHA) - healthcare coverage for all veterans

Government is a health care payer/provider for active military and their dependents
What 4 things does the government regulate in healthcare?
1. All healthcare providers and services (including drugs and medical devices) and financing schemes (health insurance plans)

2. Education of providers

3. Health care access

4. Standards of quality
Government implementation of quality measures of healthcare (3)
1. Star ratings
2. Survey/HCAHPS
3. Report Cards on Outcomes: CMS
Definition: Star Rating System
CMS utilizes five star rating system and measures Medicare beneficiaries' experiences with their health plans and the health care system
What items are rated in the star rating system? (5)
1. Staying Healthy - access to preventative services

2. Chronic conditions management - rated on care coordination and how frequently services were received

3. Member experience - overall satisfaction

4. Member complaints - # of complaints/left the plan

5. Customer service - quality of call center
Medicare Part D includes what in its star ratings?
1. Member experience
2. Member complaints
3. Customer service
4. Drug safety and drug pricing accuracy
Definition: Survey/HCAHPS
Survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience

Second, public reporting of the survey results crease new incentives for hospitals to improve quality of care

Not restricted to Medicare patients
Government healthcare organizations: Federal (5)
1. Centers for Medicare and Medicaid Services (CMS)

2. Food and Drug Administration (FDA)

3. National Institutes of Health (NIH)

4. Centers for Disease Control and Prevention (CDC)

5. Agency for Health Care Research and Quality
Definition: Centers for Medicare and Medicaid Services (CMS)
Operates programs that cover 1/4-1/3 of Americans

3 centers:
1) Center for Medicare Management
2) Center for Beneficiary Choice
3) Center for Medicaid and State Operations
Definition: Food and Drug Administration
Responsible for assuring safety of food/cosmetics; safety/efficacy of pharmaceuticals, biological products, and medical devices
Definition: National Institutes of Health
27 health institutes and centers that support research

~90% of funded research is extramural - done outside NIH
Definition: National Library of Medicine
World's largest medical library

Expansion of role in healthcare modernization with EMR
What is "meaningful use"?
Monitoring patient safety (screening of medication orders/doses)
Definition: Centers for Disease Control and Prevention
Works to prevent and control infections and chronic disease, injuries, workplace hazards, disabilities, and environmental health threats

Sets national health goals through Healthy People program

Maintains National Center for Health Statistics
Definition: Agency for Health Care Research and Quality
Mission is the creastion and dissemination of knowledge that enhances the quality, appropriateness, and effectiveness of and access to health services

Conducts the Medical Expenditure Panel Survey (MEPS)
Oversight and advisory bodies of healthcare (4)
1. Congress

2. Government Accountability Office (GAO)

3. Office of the Inspector General (OIG)

4. National Academy of Sciences
Definition: Government Office of Accountability
Investigative arm of Congress

Supports Congress by evaluating federal programs and activities and their use of public funds and provide analyses, options, and recommendations to Congress
Definition: Office of the Inspector General
Reports to DHHS and Congress

Protects the integrity of programs and their beneficiaries
Definition: National Academy of Sciences
Source of expert, independent advice on science, technology, and medicine for the government

Institute of Medicine (IOM)
Government Healthcare Organizations: State and Local (4)
1. General

2. Professional regulation and licensure

3. Regulation of health insurance industry

4. Worker's compensation
General role of state/local government in healthcare
Share cost of administration of medicaid

Public health services

Hospitals for the mentally ill and disabled

Funding for local health care services:
- County and municipal hospitals and health centers
- Local health departments
State/local government role in regulation and licensure
Licenses professionals and health care institutions

Assures professionals have completed basic educational requirements and demonstrate knowledge by examination

Disciplinary actions if standards are not met

Accrediting bodies usually assure continued compliance
4 types of payment for healthcare services
1) Fee-for-service
2) Diagnostic related groups
3) Incentive-based payments
4) Accountable care/quality
Definition: Fee-for-service
A service is rendered and the payment is fixed for each service

The government (or insurers) negotiate payments to limit expense
Definition: Diagnostic Related Groups (DRGs)
A set fee based on the admitting diagnosis

Encouraged hospitals to make care efficient (length of stay or LOS)
Definition: Incentive-Based Payments
Efforts to encourage advances such as implementation of electronic health records were incentivized

Hospitals and providers risk losing out on payment
Definition: Accountable care/Quality
Hospitals and caregivers are responsible for outcomes

Provides some flexibility in terms of delivery and is felt to encourage innovation
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