© 2016 McGraw-Hill Education. All rights reserved. Ch 3 Working in Health Care

© 2016 McGraw-Hill Education. All rights reserved.. Accountable Care Organization (ACO) accreditation allopathic associate practice certification group practice Health Care and Education Reconciliation Act (HCERA) Health Insurance Portability and Accountability Act (HIPAA) health maintenance organization (HMO) individual (or independent) practice association (IPA) licensure 3-2 Key Terms

© 2016 McGraw-Hill Education. All rights reserved.. Key Terms (cont.) managed care medical boards medical practice acts partnership patient portal Patient Protection and Affordable Care Act (PPACA) physician-hospital organization (PHO) preferred provider organization/ association (PPO/PPA) primary care physician (PCP) professional corporation 3-3

© 2016 McGraw-Hill Education. All rights reserved.. Key Terms (cont.) reciprocity registration sole proprietorship telemedicine 3-4

© 2016 McGraw-Hill Education. All rights reserved. Learning Outcomes 3.1 Define licensure, certification, registration, and accreditation. 3.2Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 3.3Discuss the changing configuration of health care management. 3-5

© 2016 McGraw-Hill Education. All rights reserved. 3.4Distinguish among the different types of managed care health plans. 3.5Discuss the federal legislation that impacts health care plans. 3.6Discuss the impact of telemedicine and social media on the health care workplace. 3-6 Learning Outcomes (cont.)

© 2016 McGraw-Hill Education. All rights reserved. Licensure Mandatory credentialing process established by law, usually at the state level, that grants the right to practice certain skills and endeavors –Required in every state for physicians, nurses, and other health care practitioners 3-7

© 2016 McGraw-Hill Education. All rights reserved. Certification A voluntary credentialing process whereby applicants who meet specific requirements may receive a certificate –Usually an exam is required 3-8

© 2016 McGraw-Hill Education. All rights reserved. Registration A credentialing procedure whereby one’s name is listed on a register as having paid a fee and/or met certain criteria within a profession 3-9

© 2016 McGraw-Hill Education. All rights reserved. Accreditation Official authorization or approval for an organization conforming to specific standards Joint Commission accredits: –Health care practitioner education programs –Health care facilities –Managed care plans 3-10

© 2016 McGraw-Hill Education. All rights reserved. Obtaining a License in Another State Reciprocity: the process by which a professional license obtained in one state may be accepted as valid in other states by prior agreement without re-examination 3-11

© 2016 McGraw-Hill Education. All rights reserved. Physician Education (M.D. and D.O.) Graduation with Bachelor’s Degree from 4-year pre-medicine course Graduation from a 4-year medical school –Allopathic school for Medical Doctor (MD) –Osteopathic school for Doctor of Osteopathy (DO) Two to six years of internship and residency 3-12

© 2016 McGraw-Hill Education. All rights reserved. DO vs. MD Both have 12+ years education Both prescribe drugs and perform surgery DOs focus on the musculoskeletal system and correction of joint and tissue problems MDs focus on allopathic medicine, using drugs/surgery for cures 3-13

© 2016 McGraw-Hill Education. All rights reserved. Reasons Physicians Specialize Higher financial compensation Decreased prestige for generalists Medical training usually provided in tertiary care settings Decreased exposure to generalist role models Lack of attractiveness of general practices 3-14

© 2016 McGraw-Hill Education. All rights reserved. Revocation of a Physician’s License A physician’s license may be revoked for: –Conviction of a felony –Unprofessional conduct –Personal or unprofessional incapacity 3-15

© 2016 McGraw-Hill Education. All rights reserved. Medical Practice Acts Define practice of medicine in each state Explain requirements and methods for licensure Establish medical licensing boards Establish grounds for suspension or revocation of license Give conditions for license renewal 3-16

© 2016 McGraw-Hill Education. All rights reserved. Revocation of License for Fraud Falsifying medical credentials Billing government agency for services not rendered Falsifying medical reports Falsely advertising to a patient “secret cures” or special curative powers 3-17

© 2016 McGraw-Hill Education. All rights reserved. Types of Medical Practice Sole proprietorship Group practice Associate practice Partnership Professional corporation 3-18

© 2016 McGraw-Hill Education. All rights reserved. Managed Care Plans A system in which financing, administration, and delivery of health care are combined to provide medical services to subscribers for a specific fee May take the form of: –Contracted fee schedules –Percentage of fees –Capitation 3-19

© 2016 McGraw-Hill Education. All rights reserved. Types of Health Maintenance Organizations Group model HMOs –Prepaid packages Staff model HMOs Individual practice associations Preferred provider organizations Physician-hospital organizations 3-20

© 2016 McGraw-Hill Education. All rights reserved. Indemnity Plans A traditional form of health insurance that covers the insured against a potential loss of money from medical expenses resulting from an illness of accident Known as traditional “fee for service,” this type of healthcare insurance is no longer a popular form of health care 3-21

© 2016 McGraw-Hill Education. All rights reserved. Cost-Containment Measures Managed care has helped to reduce costs to employers using: –Coinsurance –Copayment fees –Deductibles –Formularies –Utilization review 3-22

© 2016 McGraw-Hill Education. All rights reserved. Legislation Affecting Managed Care Patient Protection and Affordable Care Act (PPACA) Health Care and Education Reconciliation Act (HCERA) Health Insurance Portability and Accountability Act (HIPAA) Health Care Quality Improvement Act (HCQIA) 3-23

© 2016 McGraw-Hill Education. All rights reserved. Telemedicine Began as a remote consultation with physicians or other health care professionals via telephone, closed- circuit television, and fax machine Takes many forms in today’s health care setting, including patient portals 3-24

© 2016 McGraw-Hill Education. All rights reserved. Social Media in Health Care Use of social media in health care is increasing –User generated content –Community use –Rapid distribution –Open two-way dialogue Examples –Facebook, LinkedIn, Twitter 3-25

© 2016 McGraw-Hill Education. All rights reserved. Precautions When Using the Internet Identify the sponsor of the site—are they legitimate? Are several reliable web sites offering similar information? If the site says they have miracle cures, check with a trusted health care provider first 3-26