Intro to PT study guide

CLASS 1: KNOW ALL SLIDES

Settings a physical therapist can work in
Hospital: specialty units
Inpatient rehab: Medical rehabilitation unit, nursing home
Home care
Outpatient
Education
Schools
Industrial
Sports teams
Fitness/wellness centers
Administrative
Regulatory
Professionals
Abbreviation Medical
meaning
MD
Medical doctor
DO
Doctor of
osteopathy
OB GYN
Obstetrician
gynecologist
DPM
Doctor of
pediatric
medicine
DC
Doctor of
chiropractics
PA
Physicians
assistant
NP
Nurse practitioner
ANP
Adult nurse
practitioner
FNP
Family nurse
practitioner
PTA
Physical
therapists
assistant

Other professionals:

Abbreviation Medical meaning

OT
COTA
RN

Occupational therapist
Certified occupational therapists
assistant
Registered nurse

LPN

Licensed practical nurse

CNA

SLP
SW

Certified nursing aide: no certificate

needed unless long term facility
Respiratory therapist/recreational
therapy
Speech and language pathologist
Social worker

LMT

Licensed massage therapist

CPO

Certified prosthetist and orthotist

RT

Equipment vendors: exercise machines

Case managers
Facility staff
Insurance companies
Coaches/teams/teachers
Human resources
Regulatory agencies
Physical therapy programs

Department of Health and Human Services (HHS)

US government principal agency for protecting the health of all Americans
and providing essential human services, especially for those who are least
able to help themselves
Medicare run by HHS, and is the nations largest health insurer. 1 in 4
Americans
Organizations within HHS (bold and * are important ones)
- Administration for Children and Families (ACF)
- Administration for Children, Youth, and Families (ACYF)
- Administration on Aging (AoA)
- Agency for Healthcare Research and Quality (AHRQ)
- Agency for Toxic Substances and Disease Registry (ATSDR)
- Centers for Disease Control and Prevention (CDC)*
- Centers for Medicare and Medicaid Service (CMS)*
-Healthcare financing administration (HCFA)
- Food and Drug Administration (FDA)*
- Health Resources and Services Administration (HRSA)
- Indian Health Service (IHS)
- National Institute of Health (NIH)*[fund research to study
problem]
- National Cancer Institute (NCI)
- Office of the Inspector General (OIG)*
Mission to protect the integrity of HHS programs, as well
as the welfare of the beneficiaries of those programs
Report both to the Secretary and to Congress regarding
problems and recommendations to correct them
Duties carried out through a nationwide network of audits,
investigations, and inspections through the health dept
Daniel R. Levinson is the current inspector general
-since September 8, 2004
Encompasses Medicare, Medicaid, public health, medical
research, food and drug safety, welfare, child and family
services, disease prevention, Indian health, and mental
health services

Exercises leadership responsibilities in public health

emergency preparedness and combating bioterrorism
Branch locations and types differ
- located throughout the US and Puerto Rico

Department of Health (DOH)

Unique to each individual state
Richard Daines MD is the commissioner
Oversees health care facilities and can perform annual inspections
Any patient complaints are directed here
Telephone number to the DOH must be posted
Everything must be documented for inspections by DOH
Joint Commission
Independent nonprofit organization
Accredits and certifies more than 18,000 health care organizations and
programs in US
Accreditation and certification is recognized nationwide as a symbol of
quality reflecting certain performance standards are being met
- Accreditation: earned by an entire health care organization.
Larger system: hospital, nursing home, etc.
- Certification: earned by programs based within a health care
organization. Diabetes, heart disease programs within a
hospital.
Smaller divisions within the larger system
Mission: to continuously improve health care for the public by evaluating
health care organizations and inspiring them to excel in providing safe and
effective care of the highest quality and value
Vision statement: All people always experience the safest, highest quality,
best-value health are across all settings
Optional enrollment
No ability to fine, close or punish any establishment
Inspection every 2-3 years
Provides an increased confidence to patients that the care provided is high
quality
Partner/application fee
Commission on Accreditation of Rehabilitation Facilities (CARF)
Founded in 1966
Independent, nonprofit accreditor of certain health and human
services(only rehabilitation facilities):
Aging services
Vision rehab
Medical rehab

Behavioral health
Opioid treatment programs
Business and services management networks

Durable medical equipment, prosthetics,

orthotics, and supplies (DMEPOS)
Employment and community services

Child and youth services

Accreditation extends to 17 countries in N America, S America, Europe,

Asia, and Africa with 47,000 programs at 20,000 locations
Can not do any harm to a program if it does not meet expectations

Terms

Beneficiary: anyone holding a health insurance plan

Participating provider: any health care provider with an agreement
between an insurance company to provide services to patients
Provider participation agreements: contract b/w particular provider and an
insurance company
Benefit plan: individual persons health care plan
Capitation: set amount of money to care for needs of a patient
Referral: Script a MD/Prim care physician gives for a specialist

Abbreviations
CMS: center of Medicare (MCR)/Medicaid (MCD) services
HCFA: health care financial administrator
ICD9CM: International classification of diseases 9th edition clinical modification
CPT: Current procedural terminology
MDS: minimal data sets
RUG: Resource utilization group
DRG: Diagnosis related group
HMO: health maintenance organization
PPO: preferred provider organization
POS: point of service plan
CLASS 2: DO NOT need to know $ amounts, MDS subcategories, Medicaid income
guidelines
Medicare (MDR)
Signed into law in 1965. Title 18 of Social Security Act
Provides care for elderly, permanently disable, and those with end-stage
renal disease (kidney dialysis, transplant)
Eligible if worked at least 10 years and paid MCR taxes, at least 65 years
old, permanent resident of US.
Must have received social security or railroad retirement board disability
for at least 24 months
4 parts: A, B, C, D

and

Part A: Hospital insurance covers costs for inpatient stays,

critical access hospitals, skilled nursing facilities, hospice
some home health care.
Usually receive it automatically at 65 w/ no monthly
premium as long as they/spouse paid Medicare taxes while
employed for more than 10 years. Can buy into it if not
After 150 days, patient incurs all costs of hospital bills
Days 1-20 covered in full at rehab or skilled nursing
facility, after day 20 money owed
Part B: Medical insurance covers costs for doctors visits,
outpatient hospital care, PT, OT, and Speech, prosthetics and
durable medical equipment
Optional: must sign up for it to get it. Initial enrollment
period is 3 months before you turn 65 and lasts 7 months.
Benefits begin July 1 of that year.
If do not sign up right away, cost rises 10% every year you
could have and did not
Part C: Advantage plans run by private companies but approved
by Medicare
Optional. Covers parts A and B as well as give prescription
drug plans
Since 1982, known as Medicare Risk contracts or Medicare
Choice Plans previously
Acts as a replacement for traditional Medicare
HMO, PPO, Private Fee-for-Service plans, Medicare
Special Needs Plans
Must have Part A and B to get the advantage plan
May require referral to see specialists
Co-pays for treatments and office visits
Often have networks, which require you going to a certain
hospital or doctor
May have limited benefits and services
65 plans in Erie County to choose from
Part D: Prescription Drug Plan covers brand-name and generic
medication
Designed to provide protection for patients with high
medication costs and unexpected medical bills in the future
Optional, must sign up for it. If do not sign up right away,
late enrollment penalty usually applied
Monthly premium and yearly deductibles

May have a coverage limit, then pay full costs

Medicare Special Needs Plan

Special Medicare advantage plan providing part A and B to people

who can benefit most from special care for chronic illnesses, care
management of multiple diseases, and focused care management.
Membership limited to people in certain institutions, eligible for
both MCR and MCD, or with certain chronic or disabling
conditions

Diagnosis-Related Group (DRG)

System to classify hospital cases into one of 500 groups expected
to have similar hospital resource use.
Developed for MCR as part of the prospective payment system
Assigned by a grouper program based on ICD diagnoses,
procedures, age, sex and presence of complications/co-morbidities.
Used since 1983 to determine how much MCR pays the hospital
Patients within each category are similar clinically and expected to
use the same level of resources.
Pay same amount even if something happens
Based on diagnoses
Long Term Care Minimum Data Set (MDS)
Standardized primary screening tool of health status
Forms the foundation of the comprehensive assessment for all
residents of long-term care facilities certified to participate in
MCR/MCD
Contain items that measure physical, psychological, and psychosocial functioning.
Items give a multidimensional view of patients functional
capacities
Can be used to present a nursing homes profile
Plays a key role in MCR and MCD reimbursement system and
monitoring the quality of care provided to residents
Regularly completed for a 5 day, 14 day, 30 day, 60 day, and 90
day report on a patients status
Resource Utilization Groups (RUGs)

Intended to identify the service needs of persons in skilled nursing

facilities and to pay an all-inclusive per diem payment to providers
for the care
Help figure out the MDS score
Look at overall health of a person
7 categories with subcategories
- ultra high, very high, high, medium, low

Recovery Audit Contractors (RACs)

Tax Relief and Health Care act of 2006 required permanent and
national RAC program to be in place by Jan 1, 2010.
Outgrowth of a successful demonstration program used to identify
Medicare overpayments and underpayments to health care
providers
o resulted in over $900 million in overpayments being
returned to MCR b/w 2005 and 2008 and $38 million in
underpayments returned to health care providers
Goal is to identify improper payments made on claims of health
care services provided to MCR beneficiaries
Under or over payments
Under review include hospitals, physician practices, nursing
homes, home health agencies, durable medical equipment suppliers
and any other provider or supplier that bills MCR parts A and B
Fiscal Intermediary (FI)
o Private insurance companies that serve as the federal governments
agents in the administration of the MCR program
o 2 primary functions
- reimbursement review: paid what needed to be paid
- medical coverage review: patient needed the service
o Manages funds, makes payments, and accounts for expenditure
made on behalf of the consumer
o Not a direct service provider, but handles the business end of
securing services and supports
o Can be nonprofit agency, payroll service, individual, or any
organization that the person selects
Medicaid
o Signed into law by Title 19 of the Social Security Act
o Can qualify if
- have high medical bills
- receive Supplemental Security Income (SSI)
o meet certain income, resource, age, or disability requirements
o Funded by both state and federal governments

o
o
o
o

Can differ state to state

Money provided by government depends on the financial status of the state
Everything covered in full, except certain medications (brand names)
Supposed to be a 50/50 split b/w state and government but never has happened
- poorer states: 30% government 70%
- wealthier states: 40% government 60%
- Baumgarden mentioned 20% 80% but the notes say
30/70 so just a heads up

CLASS 3: DO NOT need to know individual differences b/w companies

Managed Care
Plans vary greatly in what and how much they cover as well as how much they
cost
Co-pays range depending on the plan
Deductibles vary as do coverage plans
Some plans require pre-authorization or referrals for certain treatments
Some have limited visits for outpatient services and some have no limit as long
as its medically necessary
Comparison
Deductible cost
Co-pay cost
Need for referral
Prescription

Medicare
Set deductible
20% co-pay for outpatient
No referrals/pre-authorizations
Separate coverage

Managed Care
Deductible varies
Varies from $0-40 and up
Needed for some plans
Often included in basic

Health Maintenance Organizations (HMO)

Health insurance plan that assumes all responsibility for all of the subscribers
health care costs for a fixed, all inclusive price
Responsible for the quality and cost of care the enrollee receives
Restricts the choice of health care providers to those with agreement with plan
Providers contract with an HMO to receive more patients and usually agrees to
provide services at a discount
Manage their patients health care and reduce unnecessary services
Manage care through utilization review
- intended to identify providers providing an unusually high amount of
services, which may not be necessary, or an unusually low amount
of
services, which may be endangering patients
2 models
- Staff Model: physicians are salaried and have offices in HMO buildings
: physicians are direct employees of the HMOs
-

Group Model: HMO does not pay the physicians directly

: HMO pays physician group

: group decides how to distribute the money to the
individual physicians
Preferred Provider Organization (PPO)
Managed care organization of medical doctors, hospitals, and other health care
providers who have contracted with an insurer or 3rd party administrator to
provide health care at reduced rates to the insurers clients
Similar to HMO
Providers give insured members of the group a substantial discount below the
regularly-charged rates
Provider hopes to see an increase in its business, as almost all insured clients in
the organization will use only providers who are members
Can refer yourself to a specialist without getting approval (if in-network)
If choose to go out of network, you pay full price out of pocket
May require pre-authorization for non-emergency hospital admission or
outpatient surgery
Generally include a utilization review to verify treatments are appropriate for the
condition being treated
Point of Service Plan (POS)
Similar to PPO but introduce a gatekeeper [primary care physician (PCP)]
You choose your PCP from the network of doctors
Can go outside the network and still get some level of coverage
HMO/PPO hybrid
- Minimal fees if stay in network
- Additional fee if want to go out of network
Consumer Driven Health Plans (CDHP)
Provide reliable coverage while still saving members and employers
Plans are customized solutions designed to allow you to make educated decisions
about your own health care
Can be combined with consumer driven accounts (health savings accounts, health
retirement accounts) which are funded by you or sponsored by your employer
Offer tax deduction or benefit of pre-tax dollar contributions
Managed care plans: (Baumgarden mentioned knowing who can get the plansI do not
know the answer to that for Univera, Community Blue, or Independent Health. Let me
know if anyone has that info)
Univera
All plans have some form of prescription drug coverage
All rates, deductibles, and co-pays vary
Pre-authorization required for inpatient stays or surgery

No pre-authorization or referral for outpatient

Evaluation plus 16 visits then need request for more

Community Blue
All plans have some form of prescription drug coverage
Rates deductibles and co-pays vary
Pre-authorization required for inpatient stays or surgery
No pre-authorization or referral for outpatient
Plans vary greatly in terms of number of visits
No need for updates or notification
Independent Health
All plans have some prescription
Rates deductibles and co-pays vary
Pre-authorization required for inpatient stays or surgery
Evaluation plus 16 visits need updates and request for more
Some plans have visit limits others do not
Tricare (CHAMPUS [old name])
Civilian Health and Medical Program of the Uniformed Services
Federal insurance for people in military
Covers active duty and retired uniformed services member and
their families
Move over to Medicare at 65
Workers compensation
Insurance for people hurt at work
Patient pays NOTHING
Medical treatment guidelines
Claims from physician
Progress note after 3-4 weeks
No-fault
Insurance for people injured in motor vehicle accidents, at work
Patient pays NOTHING
Monthly updates to insurance
Benefits as long as treatment is medically necessary
COBRA
Consolidated Omnibus Budget Reconciliation Act
Passed by Congress in 1986

Temporary continuation of health coverage at group rates to former

employees, retirees, spouses and dependents
Rates are higher than active employees but less than buying own

CLASS 4: KNOW EVERY SLIDE

Healthcare Reform
Why is it such a hot topic?
o nearly 46 million Americans do not have insurance
o 25 million Americans are underinsured
o Lack of insurance because many employers have stopped offering
insurance to employers because of the high cost
o $2.4 trillion dollars in 2007
o US spends 52% more per person than the next costly nation (Norway)
o No debate that reform is necessary between any of the involved programs:
theres disagreement on how it should be changed though
How does president plan to pay for reform?
o Says hes identified hundreds of billions of dollars worth of saving in
the federal government. Ex. Rooting out waste, fraud, and abuse in MCR
and MCD as well as reducing tax deductions for high-income Americans
How do doctors feel about health care reform?
- AMA feels public health insurance option is not the best way to expand
insurance coverage
- Doctors fear a government sponsored health program would reimburse
them at MCR rates, which do not keep pace with the cost of practice
- MCR rates are at 2001 rates, not where bills are
- Some doctors groups do support Obamas plan: American Academy of
Family Physicians, National Physicians Alliance
-they feel it will help make health care more affordable for
patients, foster greater competition in insurance market and
guarantee quality and affordable coverage will be there for
patients
no matter what

CONS
-

will make health care more expensive

raise taxes
ration care
allow bureaucrats to make key medical decisions instead of patients and
doctors
will force at least 23 million Americans to lose their current health plan
and forced into the government-run plan
will crowd out all competition
middle class families and small businesses do not support

PROS
- Stability and Security for all Americans

--provide more security to those with health insurance

-ends discrimination against those with pre-existing
conditions
- prevents insurance companies from dropping coverage
when people are sick and need it most
- caps out-of pocket expenses
-- give those w/out insurance comfort of health care
- creates new insurance marketplace
-the Exchange
- allows people w/out insurance to compare plans and buy
insurance at competitive prices
- provides new tax credits to help people buy insurance and
to help small businesses cover their employees
- offers a public health insurance option if can not afford
- offers new low-cost coverage to protect high-risk
people with pre-existing conditions from financial
ruin

-- lowers cost of health care

- eliminates extra charges for preventive care
- wont add to the deficit
- paid for upfront
- creates an independent commission of doctors and
medical experts to identify waste, fraud, and abuse
in the
health care system
- orders immediate medical malpractice reform projects
that could help doctors focus on putting their
patients first,
not practicing defensive medicine
- requires large employers to cover their employees and
individuals who can afford it to buy insurance so
everyone
shares in the responsibility of reform
American Recovery and Reinvestment Act (ARRA)
- signed into law by Obama in Feb 2009
- aims to stimulate the economy through investments in infrastructure,
unemployment benefits, transportation, education, and healthcare
- $155.1 billion split between MCD, technology investments and incentive
payments, 65% subsidy of health care insurance premiums for
unemployed, health research and construction of health facilities,
community health centers, military hospitals, study comparative
effectiveness of treatments, prevention and wellness, veterans health
admin, healthcare services on Indian reservations, training, temporary
moratorium for certain MCR regulations, aid in development of IT
- Designed to improve US healthcare through development of a solid health
information infrastructure while simultaneously stimulating the economy
through new investment and job growth
a. improve quality, safety, efficiency, and reduce health disparities

b. engage patients and families

c. improve care coordination
d. ensure adequate privacy and security protections for personal
health info
e. improve population and public health

Accountable Care Organizations (ACO)

- phrase attributed to Dr. Elliot Fisher of Dartmouth Medical School
-- led Dartmouth Atlas Project
- project that has documented the variation in care
across the US for last 30 years
- focused on both quality of health care and its cost
and reported on the relationship between the
two
- findings show there is a wide variation in the cost
of care across the country and the regions
that spend
more per patient do not obtain better
outcomes.
- Coordinates a broad continuum of care designed to improve/maintain the
health of a large number of patients
- Would be paid a flat rate for each person in its care as opposed to billing
for each procedure or treatment
- Care is closely coordinated and stresses prevention and chronic disease
management its expected to reduce emergency room visits and return
hospitalizations, leading to reduced costs
- Who can become an ACO?
1. Physicians and other professionals in group practices
2. Physicians and other professionals in networks
3. Partnerships b/w hospitals and physicians
4. Hospitals employing physicians
5. Other forms the Secretary of Health and Human
Services may determine appropriate
- Requirements
1. have a formal legal structure to receive and distribute shared
savings
2. have a sufficient number of primary care professionals for the
number of assigned beneficiaries
3. agree to participate in the program for not less than 3 years
4. have sufficient information regarding participating ACO health
care professionals as the Secretary determines necessary to
support beneficiary assignment and for the determination of
payments for shared savings
5. have a leadership and management structure that includes
clinical and administrative systems
6. have defined processes to

a. promote EBM
b. report necessary data to evaluate quality and cost
measures
c. coordinate care

7. demonstrate it meets patient-centeredness criteria, as

determined by the Secretary
Plan to establish the program by January 1, 2012
-- agreements will begin for performance periods, at least 3 years,
on or after that date

Meaningful Use
- Give more money for efficiency
- Incentive program for providers to transform healthcare through IT
product
- 15 criteria must be met by eligible professionals (EPs) and 14 for eligible
hospitals (EHs)
- First year of eligibility under MCR EPs and EHs will have to attest to
having used certified electronic health records (EHR) for 90 consecutive
days in their reporting year
- EPs will have to report on specific meaningful use measures met as well
as summary data on applicable quality measures
- For those seeking MCD incentives, it will only be necessary to
demonstrate adoption, implementation, or upgrade of certified HER
technology in the first year
- Future years will require meaningful use for 365 days and electronic
reporting of quality measures from the HER
- Revisions
-- eliminate the all or nothing approach to meaningful use,
allowing some flexibility for providers with core and menu
objectives and measures
-- computerized provider order entry (CPOE) for EPs reduced
from 80% to 30% and refined
--CPOE for EHs and CAHs threshold changed from 10% to
30% and includes only medication orders
-- E-Prescribing EPs were changed from 75% to 40% of their
prescriptions
-- providing patients with an e-copy of their health information
changed from 48 hours to 72 hours and reduced threshold from
80% to 50% that request and electronic copy
-- provide patients with an e-copy of their discharge summary
changed from 80% to 50% of all patients who are discharged
from an EH or CAH who request the electronic copy

Research Paper help

https://www.homeworkping.com/