Chapter 2 HIM 1000
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HIM 1000 1
Chapter 2: Healthcare Delivery Systems
United States Healthcare System
- Covers a wide range of services from Preventative care like immunizations to Complex procedures like heart transplants.
- Individual contact with the healthcare system begins at birth and continues through death
- Employs an estimated 16 million workers
Medical Practices
- “Doctor” refers to a graduate degree.
- Examples of doctors who are practitioners: o
Chiropractor (DC—Doctor of Chiropractic): focuses on the diagnosis, treatment, and
prevention of disorders of the neuromusculoskeletal system.
o
Dentist (DDS or DMD—Doctor of Dental Surgery or Doctor of Medicine in Dentistry):
focuses on the diagnosis, prevention, and treatment of diseases and conditions of the oral cavity.
o
Medical (MD—Doctor of Medicine): focuses on the diagnosis, treatments, and education of any human disease or condition; most prevalent in U.S.
o
Optometrist (OD—Doctor of Optometry): focuses on vision and visual systems and is trained to prescribe and fit lenses to improve vision.
o
Osteopath (OD—Doctor of Osteopathic Medicine): not only focuses on manipulation
of muscles and bones but also incorporates the diagnosis an treatment of diseases.
o
Podiatrist (DPM—Doctor of Podiatric Medicine): focuses on the treatment of disorders of the foot, ankle, and lower extremities.
- Main difference between a DO and MD is in the philosophy and approach to medical treatment. o
The DO practices osteopathic medicine, which places emphasis on the muscular system, stresses preventative medicine, and takes a holistic approach to patient care.
o
MDs practice allopathic medicine, which utilizes medical treatment as an active intervention to counteract and neutralize the effects of disease. MDs may utilize preventative combined with allopathic medicine.
- Physicians can be categorized as generalists or specialists. o
Generalists are trained in family medicine, general practice, general internal medicine, and general pediatrics. Generalists are considered primary care physicians.
o
Specialists are non-primary care physicians. They must obtain additional certification in their specialty. Pg. 23-26
- Medical specialties are divided into 6 major categories: 1) subspecialties of internal medicine 2) broad medical specialties 3) obstetrics and gynecology 4) surgery 5) hospital-based radiology and anesthesiology 6) psychiatry. o
Sample medical specialties: internal medicine, pediatrics, family practice, cardiology
o
Sample surgical specialties: anesthesiology, orthopedics, cardiovascular surgery
o
Hospitalist—a physician who specializes in the care of inpatient hospital patients. Care is transferred to PCP.
HIM 1000 2
o
Physician Assistants (PA)—licensed to provide care and perform medical procedures only under the supervision of a physician. In most states, Pas have the authority to prescribe medications.
Nursing Practices o
Licensed practical nurses (LPN)—nurses who graduate from nonacademic training programs. Work under direct supervision of RN. o
Registered nurses (RN)—associate degree or bachelor degree
o
Nurse practitioner—RN plus postgraduate education
o
Nurse specialization: surgery, psychiatry, intensive care, nurse-midwives
Allied Health Professions
o
Support physicians, nurses, and physician assistants
o
Receive certificate or higher in healthcare-related science
o
All 50 states require licensure for some allied health professions
o
Significant shortages in many allied health professions are expected to reach up to 2.5 million by 2020.
o
Examples of Allied Health Professions—clinical laboratory science, diagnostic imaging technology, dietetics, emergency medical technology, health information management, occupational therapy, physical therapy, respiratory therapy, speech-
language pathology and audiology. Pg. 28-29
Check your understanding 2.1
1.
Which of the following physicians specializing in the care of inpatient hospital patients? Hospitalist 2.
Which healthcare professional is licensed to practice medicine with physician supervision? Physician Assistant
3.
Which service diagnoses and treats patients who have acute or chronic lung disorders? Respiratory therapy
4.
Which healthcare provider utilizes ultrasound, computed tomography, or magnetic resonance imaging? Radiologic technologist
5.
Which of the following is surgical specialty? Orthopedics
6.
Which statement is true about RNs? RNs are required to have a license in the state in which they practice
7.
Who performs a wide array of tests on body fluids, tissues, and cells to assist in the
detection, diagnosis, and treatment of diseases and illnesses. Clinical laboratory scientists 8.
T or F: HIM professionals are responsible for ensuring the availability, accuracy, and
protection of clinical information. True
9.
T or F: Audiologists provide comprehensive diagnostic and treatment and rehabilitative services for auditory, vestibular, and related impairments. True
10.
T or F: Physical therapists and occupational therapists are the only members
of the rehabilitation service team. False
Organization and Operation of Modern Hospitals
o
Integrated delivery system (IDS): Second curve of healthcare. o
Hospitals/ healthcare facilities merged to form IDS. o
These healthcare systems combine financial and clinical aspects of healthcare and
uses a group of healthcare providers, selected on the basis of quantity and cost
HIM 1000 3
management criteria, to furnish comprehensive health service across the continuum of care.
o
Integrated delivery network (IDN)
o
Health expenditures: Approx $3.5 trillion; 17.9% of the total American economy
o
Hospital
- Has organized medical staff
- Provides permanent medical staff
- Provides permanent inpatient beds
- Offers around-the-clock nursing service
- Provides diagnostic and therapeutic services
o
Acute Care hospital
- Short-term care provided to diagnose treat illness or injury
- Average length of stay is 25 days or less
-Includes long term acute care hospitals
- Inpatient and outpatient care
Hospital Classification
o
5 major criteria used to classify hospital types: pg. 33-34
- Functionality, location, number of beds, specialization, types of ownership. o
Number of beds: - Bed capacity (licensed or staffed); Adult and Pediatric
o
Types of Services provided: - Rehabilitation, Psychiatric, General, Specialty
o
Types of patients served
o
For-profit or not-for-profit status
o
Type of ownership: pg. 34
- Government-owned, proprietary, voluntary
o
Safety net hospitals - Highest number of inpatient stays that were paid by Medicaid or uninsured
- More likely to be a teaching hospital
- Large number of inpatient beds
- 27% located in large metropolitan areas
o
Critical access hospital
- Part of Balanced Budget Act of 1997
- If specific criteria are met, CAH are allowed a separate payment system not
subject to
IPPS or OPPS, and pays 101% of reasonable costs
-Criteria to qualify—
- Located in a state that accepted a grant under the Medicare Rural Hospital Flexibility Program
- Located in a rural area
- Furnish 24-hour emergency care services
- Maintain no more than 25 inpatient beds
- Have an ALOS of 96 hours or less per patient (ALOS is the mean length of stay
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HIM 1000 4
for hospital inpatients discharged during a given period of time)
- Be located more than 35 miles from any other hospital
- Be certified as CAH prior to January 1, 2006
Organization of Hospital Services
- Board of directors:
o
Aka the governing board or board of trustees
o
Has primary responsibility for setting the overall direction of the hospital. o
Develops hospital’s strategic direction, mission, vision, and values. o
Establishing bylaws in accordance with organization’s legal and licensing requirements. o
Selecting qualified administrators.
o
Approving the organization and makeup of the clinical staff
o
Monitoring the quality of care
o
Pg 35
- Professional medical staff:
o
Consists of physicians who have received extensive training in various medical disciplines.
o
Primary objective to provide high quality patient care to the patients who come to hospital o
Diagnose illnesses and develop patient centered treatment regimens
o
May serve on hospitals governing board
o
Medical staff classifications—active, provisional, honorary, consulting, courtesy, and medical resident assignments
o
Diagnose and treat patients, clinical privileges, officers, medical staff bylaws
o
Pg.36
- Executive administrative staff:
o
CEO is leader
o
CEO implements policies and strategic direction set by hospitals board of directors
o
CEO responsible for building an effective executive management team and coordinating the hospital’s services
o
Chief Financial Officer (CFO): senior manager responsibly for fiscal management of
the organization
o
Chief Operating Officer (COO): executive responsible for high level day-to-day operations
o
Chief Information Officer (CIO): senior manager responsible foe the management of information resources
o
Chief Nursing Officer (CNO)
o
Team is responsible for managing the hospital’s finances and ensuring compliance
with the federal, state, and local rules, standards, and laws that govern the delivery of healthcare services
- Medical and surgical services
- Patient care (nursing) services:
o
Most direct patient care in hospitals provided by professional nurses.
HIM 1000 5
o
In almost every hospital, patient care services makes up the largest clinical department in terms of staffing, budget, specialized services offered, and clinical expertise required
o
Responsible for performing patient assessments, creating care plans, evaluating the appropriateness of treatment, and evaluating effectiveness of care. - Diagnostic services:
o
Allied health professionals
o
Clinical laboratory, radiology, and nuclear medicine. Therapeutic services include clinical lab services, radiology and radiation therapy.
- Rehabilitation services:
o
Dedicated to eliminating patient’s disability or alleviating it as fully as possible. o
Goal is to improve the cognitive, social, and physical abilities of patients impaired
by chronic disease or injury.
o
Include: physicians, burses, occupational therapists, physical therapists,
respiratory therapists, speech therapists
o
Service can be provided within the acute-care setting or in specialty hospitals
performing many forms of rehab. - Ancillary Support services:
o
Provide vital clinical and administrative support services to patients, medical
staff, visitors & employees
o
Provides following services—pharmaceutical, food and nutrition, health
information , social work and social services, patient advocacy, environmental
(housekeeping), purchasing, central supply, and materials management services,
engineering and plant operations (maintenance)
- Administrative Support Services
o
Admissions and central registration, claims and billing, accounting, information
services, human resources, public relations, fund development, marketing
- Healthcare Organizational Chart—pg. 38
Check your understanding 2.2
1. The emphasis on treating individual patients at the level of care required by their
treatment across all healthcare services refers to? Continuum of care
2. Who has the primary responsibility to guide the direction of the hospital? Board of
directors
3. What is an example of a federally run hospital? Veterans Administration
4. This type of hospital has the majority of its inpatient visits paid for through Medicaid?
Safety net hospitals
5. Dr. Smith has been granted permission by community hospital to perform cardiac
catheterizations. This permission is called? Clinical privileges 6. T or F: Acute-care hospitals provide short term care to diagnose or treat an illness.
True
7. T or F: Case management is the ongoing, concurrent review to ensure the necessity
and effectiveness of clinical services provided to patients. True
8. T or F: Pharmaceutical services are considered part of the clinical support services.
True
HIM 1000 6
9.
T or F: Critical access hospitals specialize in the treatment of patients with serious
medical conditions that require care on an ongoing basis. False, long-term acute-
care hospitals specialize in the treatment of patients with serious medical
conditions that require care on an ongoing bases
Managed Care
o
A generic term for a healthcare reimbursement system that manages cost, quality
and access to services
o
Managed care delivery systems attempt to manage cost and quality by:
- Implementing various forms of financial incentives for provides
-
Promoting healthy lifestyles
-
Identifying risk factors and illnesses early in the disease process
-
Providing patient education
o
3 types of managed care plans:
- Health maintenance organizations (HMOs)—provide healthcare within a
closed network
- Preferred provider organizations (PPOs)—provide reduced costs if plan
member stays
within network but will contribute at a reduced cost if member goes outside
of network
- Point of Service (POS)—allows patients to choose between an HMO or PPO
each time
they have a medical encounter.
o
Control costs, access, and promote high quality
o
Negotiate fees and control access
o
Premium
Accountable Care Organizations (ACOs):
o
Partnership between hospitals and physicians
o
Three modes: 1.
Medicare Shared programs that gives Medicare fee-for-service providers an
opportunity to become an ACO
2.
Advance Payment ACO model designed as a supplementary incentive program
for selected participants 3.
Pioneer ACO model created for early adopters of coordinate care, though CMS
is no longer accepting applications for this model
Other Types of Healthcare Services:
- Private Medical Practices
o
Primary care
o
Medical or surgical specialty care
o
Freestanding office setting
o
Physician-owned entities - Medical home
o
Model of primary care
o
Patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety
- Hospital based ambulatory care services
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HIM 1000 7
o
Ambulatory care—the preventative or corrective healthcare provided in a practitioner’s office, a clinic, or a hospital on a nonresident (outpatient) basis. o
Primary care
o
Emergency services and trauma care
o
Outpatient surgical services
o
Outpatient diagnostic and therapeutic services
o
Ambulatory care settings:
- Urgent care centers, school-based clinics, public health clinics, and neighborhood and
community health centers
- Community-based ambulatory care services
o
Freestanding ambulatory care centers
o
Freestanding ambulatory surgery centers
o
Not owned by or affiliated with a hospital
o
Facilities range it size from small medical practice with 1 physician to a large clinic with an organized medical staff. o
Examples: birthing centers, cancer treatment centers, renal dialysis centers, and rehabilitation centers
- Public health services:
o
The Department of Health and Human Services (HHS) is the principal federal agency that ensure health and provides essential human services
o
Two units in the office of the secretary of HHS are important to public health
1.
Office of the Surgeon General of the United States
- Appointed by the President - Provides leadership and authoritative, science-based recommendations about
the publics health
- Has responsibility for public’s health service workforce (PHS)
2. Office of Disease Prevention and Health Promotion (ODPHP)
- Provides an analysis of and leadership role for health promotion and disease
prevention - Home care services:
o
Fastest-growing sector to offer services for Medicare recipients
o
Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy,
medical social services, durable medical equipment, supplies and other services
- Voluntary agencies:
o
Provide healthcare and healthcare planning services, usually at the local level and to low-income patients
o
Example: community health center, the Red Cross
- Subacute care: o
Offer patients access to constant nursing care while recovering at home
HIM 1000 8
o
Patients considered appropriate for this care—recovering from stroke, cardiac surgery, serious injury, amputation, joint replacement, or chronic wounds
Long-Term Care
o
Care rendered in nonacute-care facility to patients needing inpatient nursing and related services for more than 30 consecutive days
o
Types of long-term care: skilled nursing facilities, nursing homes, rehabilitation hospitals
o
Mainly rehabilitative and supportive—not curative
o
Healthcare workers other than physicians can provide long-term care in home, residential or institutional setting
- Longer-term care in the Continuum of Care
o
People are living longer, baby boomers
o
Typical continuum of care: Primary care provider in hospital, home care, skilled nursing facility
- Delivery of long-term care services:
o
Skilled nursing facilities and nursing homes
- Provide medical, nursing, or rehab care around the clock
o
Residential care facilities
- New living environments more homelike and less institutional. - Have affordable and appropriate housing for elderly and disabled people
- Assistance with daily activities in available
o
Hospice programs
- Provided to patients with terminal illness with a limited life expectancy of 6
months or less
- Palliative care
o
Adult daycare programs
Behavioral Health Services:
-
Traditional long-stay state institutions were used.
-
Current programs:
o
Long-stay state institutions
o
Residential treatment centers—inpatient services to children until 18
o
Day-hospital—alternative to inpatient care, transition from inpatient to outpatient
- Insurance coverage lagged behind other care
o
Non-parity
o
Usually many restriction such as number of outpatient visits
Biomedical and Technological Advances in Medicine:
-National Institutes of Health created a “roadmap” program to: accelerate biomedical advances, create effective prevention strategies and new treatments, bridge knowledge gaps
- Telehealth:
HIM 1000 9
o
Use of electronic information and telecommunications to technologies to support and promote long-distance clinical health care audiovisual link between o
Types of application
a.) Live (synchronous) video conferencing: A 2-way audiovisual link between patient and a care
provider
b.) Store-and-forward (asynchronous) video conferencing: transmission of a recorded health history to a health practitioner, usually a specialist c.) Remote patient monitoring (RPM): The use of connected electronic tools to record personal health and medical data in one location for review by a provider in another location, usually at a different time
d.) Mobile Health (mHealth): healthcare and public health information provided through mobile devices
- Electronic health records and health data
o
Tremendous impact on the delivery of health care—ability to record, capture and manipulate health data
o
Big data: large amounts of data collected from the sources that are then processed and used for analytics
o
Data utilized:
- To develop new treatments for common health problems
- Reducing healthcare costs
- Predicting epidemics
- Avoiding preventable deaths
- Improving quality of life
- Reducing healthcare waste
- Improving efficiency and quality of care
- Developing new drugs and treatments
o
Increased need for security and data protection
Check your understanding 2.3
1.
The healthcare organization provides healthcare services to low-income patients in the local community at a? Voluntary agency
2.
My daughter fell and cut herself tonight. Not an emergency, believe she needs
stitches and should see a physician tonight. Which type of setting would I most
likely access? Freestand ambulatory care center
3.
Most patients in long-term care facilities require inpatient nursing and related services more than how many consecutive days? 30
4.
Which healthcare organization offers palliative care for end-of-life care so that the patient may live life as fully and as comfortably as possible? Hospice
5.
The ability of a computer to think and learn? AI
6.
E. Managed Care—manages cost, quality and access to services
7.
B. Freestanding ambulatory care centers—provides emergency services and urgent care for walk-in patients
8.
A. Humane Genome Project—answer in back of book
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HIM 1000 10
9.
C. Subacute care—care that offers patients access to constant nursing care while recovering at home
10.
D.
Continuum of care—care provided by different caregivers at several different levels of the healthcare system
Healthy People 2020: Formerly Institute of Medicine (IOM)
- “ A society in which all people live long, healthy lives.”
- Goals:
o
Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death
o
Achieve health equity, eliminate disparities, and improve the health of all groups
o
Create social and physical environments that promote good health for all
o
Promote quality of life, healthy development, and healthy behaviors across all life stages
- Social determinants of health: o
Conditions in the environments and age that impact a wide range of health,
functioning, and quality of life outcomes and risks
o
Economic stability
o
Education
o
Social and community context
o
Health and health care
o
Neighborhood and built environment
National Academy of Medicine Reports: Formerly Institute of Medicine (IOM):
o
A nongovernmental agency to provide unbiased advise to decision makers and public. o
To Error is Human
(1999)—reported that as many as 98,000 people die each year from preventable medical errors
o
Crossing the Quality Chasm (2001)—identified gaps in the delivery of patient care services resulting from a complex medical system and the rapid advancement in medical knowledge
o
Envisioning a National Health Care Quality Report (2001)—addressed the collection, measurement, and analysis of quality data
o
Leadership by Example (2002)—addressed the duplication and contrasting approaches to performance measures by 6 major governmental healthcare programs that serve nearly 100 million Americans
o
Priority Areas for National Action (2003)—recognized priorities from earlier reports and suggested a framework for action
o
Health IT and Patient Safety (2012)—stated that the improvement in safety of health IT is essential and can help improve communication between patients and providers, and enhance patient safety
Center for Disease Control and Prevention (CDC):
- The leading federal agency charged with protecting the public health and safety
through the control and prevention if disease, injury, and disability. - Leads nation in the following services:
HIM 1000 11
o
Detecting and responding to diseases and conditions
o
Promoting healthy living
o
Providing information for travelers’ health
o
Education for emergency preparedness
Local, State, and Federal Policies:
o
Local
-Community medical and mental health services
o
State
- How to allocate state dollars for multiple healthcare services
o
Federal
- 6 agencies provide healthcare for over 100 milllion Americans
- Medicare, Medicaid, S C H I P, VHA,TRICARE, I H S
Patient-Centered Outcomes Research Institute (PCORI)
o
Created from Patient Protection and Affordable Act (PPACA) as a non-profit nongovernmental organization
o
Mandated to improve the quality and applicability of evidence available to help all stakeholders to make knowledgeable healthcare choices
o
Uses Comparative Effectiveness Research (CER)
Check your Understanding 2.4:
1.
According to the publication To Error is Human
, how many patients die each year from preventable medical mistakes? 98,000
2.
To “create social and physical environments that promote good health for all” is a goal of? Healthy People 2020
3.
Identify a nonprofit, nongovernmental organization? National Academy of Medicine
4.
The federal agency that monitors healthy precautions for international travelers? CDC
5.
Leadership by Example
6.
PCORI is the largest single research funder that has comparative effectiveness as its main focus
7.
T or F: Healthcare policy is only formulated at the federal level. False
8.
T or F: Hospitals and care system need to redesign how patient care is delivered so inefficiencies can be eliminated within the system. True
9.
T or F: The organization that collects, analyzes, and creates national statistical databases and publishes paper on important health issues is the CDC. True
10.
T or F: Social determinants of health are environmental issues that impact a wide range of health, functioning, and quality-of-life outcomes and risks. True
Social Security Act of 1935:
- “ Old-age pension and unemployment insurance bills programs”
Public Law 88-97 of 1965
- Amendment of Social Security Act
- Medicare originally designed for people 65 years of age and older
- Medicare expanded to include:
o
Those willing to premium
o
Disabled
HIM 1000 12
o
Those with chronic kidney disease
- Medicare originally designed for the indigent
- Medicaid expanded to include:
o
Poor children
o
Disabled
o
Pregnant women
o
Very poor adults
- Medicaid joint program with state and federal governments
- Medicaid provides:
o
Inpatient and outpatient services
o
Laboratory and x-ray services
o
Physician services
o
Nursing facility care for those over 21 years of age
o
Family planning
o
31 optional programs
Public Law 92-603 of 1972
-Mandated utilization review for Medicare patients at: hospitals and extended care facilities
o
Utilization review is the process of determining whether the medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified in the organization’s utilization management
o
Extended care facilities: facility licensed by applicable state or local law to offer room and board, skilled nursing by a full-time RN, intermediate care, or a combination of level on a 24-hour basis over a long period of time.
- Now includes Medicaid
- Established professional standards review organizations (PSRO)
o
Perform professional review
o
Evaluate patient care for necessity, quality and cost-effectiveness
Utilization Review Act of 1997:
- Mandated continued stay reviews for Medicare and Medicaid patients
- Reviews determine whether it is medically necessary for a patient to remain hospitalized
Peer Review Improvement Act of 1982
- PRSO changed to Peer Review Organizations
-
Looked at medical necessity and appropriateness of certain admissions prior to admission
-
Name changed to Quality Improvement Organizations (QIOs)
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA):
- Called for gradual implementation of prospective payment system for Medicare reimbursement - Prospective payment system
- A predetermined level of reimbursement is established before the service is provided
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HIM 1000 13
- In contrast, in a retrospective payment system, a service is provided, a claim for payment
for the service is made, and the health care provider is reimbursed for the cost of delivering
the service
Prospective Payment Act (1982)/ Public Law 98-21 of 1983
- Created diagnostic related groups (DRG) for inpatient hospital care
- Each case is assigned to a DRG based on the patient’s diagnosis at the time of discharge
Health Insurance Portability and Accountability Act of 1996 :
- Portability of health insurance after leaving employment
- National standards for electric transactions
- National identifiers for providers, health plans, and employers
- Privacy
- Security
- Healthcare Integrity and Protection Database
American Recovery Reinvestment Act of 2009 (ARRA):
- Health Information Technology for Economic and Clinical Health (HITECH)s Act
-
Allocated funds for implementation of a nationwide health information exchange
-
Use of health information -
Implementation of electronic health records
-
Government involvement in standard development for exchange of health information
-
Strengthened privacy and security standards
-
Made Office of the National Coordinator for Health information Technology a permanent office
Patient Protection and Affordable Care Act of 2010:
- AKA as “Obamacare”
- Provisions include:
- Medicaid expansion
- Creation of health insurance exchanges
- Regulations to prevent health insurers from denying coverage
- Requirements for health insurance with tax penalties for those without insurance
- Penalties to employers that do not offer affordable coverage; excludes small employers
Check your Understanding 2.5
1.
Identify the law that created the HITECH Act. American Recovery and Reinvestment Act
2.
Until World War II, most healthcare was provided: At home
3.
A HIM student asks you why Medicare reimburses healthcare providers through prospective payment systems. Identify the legislation that answers student. Tax Equity and Fiscal Responsibility Act of 1982
4.
Identify the legislation that authorized the creation of the office of National Coordinator for Health Information Technology. ARRA
5.
Medicaid is a: federally mandated healthcare program for low-income people
HIM 1000 14
6.
Tax equity and Fiscal Responsibility Act of 1982—
required the gradual implementation of a prospective payment system (PPS) for Medicare reimbursement
7.
The Social Security Act of 1935—
gave states fund on a matching basis for maternal and infance care, rehab of crippled children, general public health work, and aid for dependent children under 16 years of age
8.
The Public Law 92-603 of 1972—
required concurrent review of Medicare and Medicaid to patients
9.
The Patient Protection and Affordable Care Act of 2010—
provided an individual mandate to have minimum acceptable coverage or pay a tax penalty
10.
The Utilization Review Act of 1977—
required hospitals to conduct continued-
stay reviews for Medicare and Medicaid patients