1. Ch 3
Working in Health Care

2. Learning Outcomes
3.1 Define licensure, certification, registration, and accreditation.
3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board.
3.3 Discuss the composition of the health care team and the roles of its members.
3.4 Define the major types of medical practice management systems.
LO 3.1 Define licensure, certification, registration, and accreditation.
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board.
LO 3.3 Discuss the composition of the health care team and the roles of its members.
LO 3.4 Define the major types of medical practice management systems.

3. Learning Outcomes (cont.)
3-3
Learning Outcomes (cont.)
3.5 Define the different types of managed care health plans.
3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing.
3.7 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment.
LO 3.5 Define the different types of managed care health plans.
LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing.
LO 3.7 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. 3

4. Licensure
Mandatory credentialing process established by law, usually at the state level
Required in every state for physicians, nurses, other health care practitioners
LO 3.1 Define licensure, certification, registration, and accreditation.

5. Certification Voluntary credentialing process
3-5
Certification
Voluntary credentialing process
Usually national in scope
Usually sponsored by a non- governmental, private-sector group
Signifies that an applicant has attained a certain level of knowledge and skills
LO 3.1 Define licensure, certification, registration, and accreditation. 5

6. 3-6
Question
Tell whether the following statement is true or false.
Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements.
True
False
LO 3.1 Define licensure, certification, registration, and accreditation. 6

7. 3-7
Answer
True
Registration is an entry in an official registry or record, listing the names of persons in a certain occupation who have satisfied specific requirements. The list is usually made available to health care providers.
LO 3.1 Define licensure, certification, registration, and accreditation. 7

8. 3-8
Registration
An entry in an official registry or record listing the names of persons in a certain occupation who have satisfied specific requirements
An applicant can add his or her name to the list.
An applicant can attain a certain level of education and pay a fee.
LO 3.1 Define licensure, certification, registration, and accreditation. 8

9. 3-9
Accreditation
Official authorization or approval for conforming to a specified standard
Joint Commission accredits:
Health care practitioner education programs
Health care facilities
Managed care plans
LO 3.1 Define licensure, certification, registration, and accreditation. 9

10. Obtaining a License in Another State
3-10
Obtaining a License in Another State
Reciprocity
A state accepts a person’s valid license from another state
If a state does not grant reciprocity, the person must take the required examination to obtain a license
LO 3.1 Define licensure, certification, registration, and accreditation. 10

11. Doctor of Medicine (MD) Degree
3-11
Doctor of Medicine (MD) Degree
Graduation with Bachelor’s Degree from 4-year pre-medicine course
Graduation from a 4-year medical school
In the U.S. a school accredited by the Liaison Committee on Medical Education
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 11

12. U. S. Medical Licensing Examination
3-12
U. S. Medical Licensing Examination
Commonly called medical boards
Take part 1 after first year of medical school
Take part 2 during fourth year of medical school
Take part 3 during the first or second year of postgraduate medical training
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 12

13. National Board of Medical Examiners
3-13
National Board of Medical Examiners
Certifies physicians as NBME diplomate
Following completion of residency and medical boards
To specialize physicians must complete more years training
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 13

14. Doctor of Osteopathy (DO) vs. MD
3-14
Doctor of Osteopathy (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.
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 14

15. Reasons Physicians Specialize
3-15
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
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 15

16. Criteria for Granting State License
3-16
Criteria for Granting State License
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board.
Figure 3-1 16

17. Revocation of a Physician’s License
3-17
Revocation of a Physician’s License
Conviction of a felony
Unprofessional conduct
Personal or unprofessional incapacity
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 17

18. 3-18
Medical Practice Acts
Define what is meant by practice of medicine in each state
Explain requirements and methods for licensure
Establish medical licensing boards
Establish ground for suspension or revocation of license
Give conditions for license renewal
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 18

19. Fraud Falsifying medical credentials
3-19
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
LO 3.2 Demonstrate an understanding of how physicians are licensed, how physicians are regulated, and the purpose of a medical board. 19

20. Question Tell whether the following statement is true or false.
3-20
Question
Tell whether the following statement is true or false.
LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs.
True
False
LO 3.3 Discuss the composition of the health care team and the roles of its members. 20

21. 3-21
Answer
True
LPNs and LVNs are licensed health care team members who work under the supervision of physicians or RNs.They perform many of the same duties as RNs with some exceptions.
LO 3.3 Discuss the composition of the health care team and the roles of its members. 21

22. Respondeat Superior Latin for “Let the master answer”
Physicians are legally responsible for their own acts of negligence and those of employees working within the scope of their employment.
LO 3.4 Define the major types of medical practice management systems.

23. Types of Medical Practice
3-23
Types of Medical Practice
Sole proprietorship
Partnership
Professional Corporation
Group practice
LO 3.4 Define the major types of medical practice management systems. 23

24. 3-24
Managed Care
Corporations that pay for and deliver health care to subscribers for a set fee using a network of physicians and other health care providers
Indemnity: coverage of an insured person against personal loss of money from medical expenses
LO 3.5 Define the different types of managed care health plans. 24

25. Cost-Containment Measures
3-25
Cost-Containment Measures
Co-insurance
Co-payment
Deductible
Formularies
Utilization review
LO 3.5 Define the different types of managed care health plans. 25

26. Question Tell whether the following statement is true or false.
3-26
Question
Tell whether the following statement is true or false.
Co-insurance refers to flat fees insurance subscribers pay per service.
True
False
LO 3.5 Define the different types of managed care health plans. 26

27. 3-27
Answer
False
Co-payment refers to flat fees insurance subscribers pay per service. Co-insurance is the amount of money insurance subscribers must pay out of pocket.
LO 3.5 Define the different types of managed care health plans. 27

28. Types of HMOs Group model HMOs Prepaid packages Staff model HMOs
3-28
Types of HMOs
Group model HMOs
Prepaid packages
Staff model HMOs
Individual practice association
Preferred provider organization
Physician-hospital organizations
LO 3.5 Define the different types of managed care health plans. 28

29. Types of HMO Plans Point-of-service plans Open access plans
3-29
Types of HMO Plans
Point-of-service plans
Allow plan members to seek health care from non-network physicians, but plan pays highest benefits for care given by PCP or referral by PCP
Open access plans
Subscriber can see any in-network health care provider
LO 3.5 Define the different types of managed care health plans. 29

30. Legislation Affecting Health Care
3-30
Legislation Affecting Health Care
Patient Protection and Affordable Care Act (PPACA)
Health Care and Education Reconciliation Act (HCERA)
Health Insurance Portability and Accountability Act (HIPAA)
Healthcare Integrity and Protection Data Bank (HIPDB)
LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 30

31. Legislation Affecting Health Care
3-31
Legislation Affecting Health Care
National Practitioner Data Bank (NPDB)
Federal False Claims Act (FFCA)
Patient Bill of Rights Act
LO 3.6 Discuss the federal legislation that impacts health care reimbursement and prohibits fraud and abuse in health care billing. 31

32. 3-32
Telemedicine
Remote consultation with physicians or other health care professionals via telephone, closed-circuit television, fax machine, or the Internet
Cybermedicine
direct online contact between physician and patient
E-health
increasing use of the Internet as a source of consumer information about health
LO 3.1 Define telemedicine, cybermedicine, and e-health, and discuss their roles in today’s health care environment. 32