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65 Cards in this Set

  • Front
  • Back
the 3 major challenges of the health care system
controlling cost, providing access, ensuring quality
the 5 players in the health care system
consumers, providers, employers, insurers, federal and state policy makers
factors contributing to the rising health care costs
changing demographics, technology and intensity, price inflation, malpractice and defensive medicine
in the 1920s, concerns about the cost and maldistrubition of medical care resulted in
the formation of the Committee on the Costs of Medical Care
todays healthcare is a $___ industry
2 trillion
just ___% of the population accounts for ___% of all expenditures
___% of all expenditures are related to chronic diseases
___% of the healthcare coverage is paid by employers
healthcare spending is ___ times the amount spent on nationl defense
consumers ultimately bear the burden of paying for increasing healthcare costs through
higher taxes, reduced wages, higher product costs
financing healthcare (sponsors)
public system and private system
the public system consists of
government, federal, and state
the private system consists of
businesses (employers) and households/individuals
public sources that pay for healthcare
medicare, medicaid, public health, military (tri care), veterans, prisioners, indian health service
medicare was enacted in ___ by ____.
Centers for Medicare and Medicaid (CMS)
there is no ___ qualification for medicare
the 3 factors that make a person eligible for medicare are
65 years old or older, end stage renal disease, under 65 with a disability for a minimum of 2 years
medicare was origionally a ___ part program
the 2 parts are
A. hospital insurance (HI)
B. medical insurance (SMI)
part C =
medicare + choice program
part C was established by the
Balanced Budget Act of 1997 (BBA)
part C expanded the
option for beneficiaries to enroll in private managed care plans
part D =
medicare prescription drug benefit
part D was created by the ___ and began in janurary 2006
medicare modernization act of 2003 (MMA)
part D entailed
new drug discount cards which began in 2004 and preventive benefits
part A (HI) coverage costs
automatic and without premium
part B (SMI) coverage costs
deducted from social security benefit (monthly premium)
financing medicare: hospital program (HI)
mandatory payroll taxation
financing medicare: supplemental program (SMI)
premium payments
financing medicare: medicare+choice
capitated payments from the HI and SMI trust funds
retrospective payment system (prior to 1982)
health care institutions were paid their "reasonable and necessary charges"
in the retrospective payment system, billing
was submitted AFTER services were provided and institution was paid
prospective payment system (PPS) was established by
the tax equity and fiscal act of 1982 (TERFA)
in the PPS, reinbursement is made according to
a predetermined classification system
the first area affected by the PPS was the ___. it created ___.
diagnostic related groups (DRG)
PPS was established by the
balanced budget act of 1990 (BBA)
the second area affected by the PPS was the ___, the third area was ___, and the last area was ___.
nursing homes (MDA)
home health care (OASIS)
ambulatory care
notable outcome from PPS
earlier discharge of clients, decline in the number of admissions, increased number and type of out-patient services, limited delivery of services, and increased emphasis on costs
medicaid was enacted in ___ , jointly with ___.
medicaid provides
federal matching funds to states to help pay the cost of medical care for low income persons (medically indigent)
medicaid is administered by
each state medicaid office
to be eligible for medicaid (determined by each state)
medically indigent
disabled over 1 year
income requirements to be able to recieve medicaid
income total less than $1,635 a month; total cash assets of $2,000 or less; spouse may exempt some income and property
medicaid pays
premiums for medicare SMI (part B), deductible for medicare HI (part A), and some other services
some other services that medicaid pays for
prescription medcations, eyeglasses, dental services, skilled nursing care(NH), durable medical equipment
medicaid acts as a ____. this means that:
vendor program
states pay providers (vendors)
the vendor program of medicaid relies ___ or ___.
directly on a fee-for-service basis
through pre-paid (capitated) arrangements
state childrens health insurance program (SCHIP) was established by
title XXI of the social security act
SCHIP began in ___. ___ was the first state with a SCHIP plan.
SCHIP provides funds to
states to expand medicaid eligibility to a greater number of uninsured children
in most states, the largest percentage of medicaid expenditures is for
nursing homes and home health
private health insurance is insurance that may purchased
individually or by groups
private insurance can be either
not-for-profit or for-profit
a not-for-profit organization
blue cross blue shield
for-profit organizations
metropolitan life, aetna, travelers
health care money goes first to ___ then to ___ then to ___ then to ___ then to ___ then to ___ and lastly to ___.
prescription drugs
nursing homes
home care agancies
public health
managed care
a philosophy of health care that integrates the financing, delivery, and use of care
the goal of managed care
provide cost-effective, quality care and improved outcomes for clients
types of managed care arrangements
health maintenance organizations (HMO), preferred provider organizations (PPO), case management
four basic options for slowing the trends in health care spending
increase the efficiency of health care delivery, increase the incentives for patients to limit their use of services, increase the administrative controls on the use of services, and limit the resources available to the health care system
specific options for slowing the trends in health care spending
adherence to clinical practice guidelines, professional liability reform, more and better use of technology, involve the patient as a more prudent consumer of services, reward primary care providers for coordinating care, more health planning at the community and state level, more emphasis on preventative services
cost increases are inevitable until
the baby boomer generation moves through the system
baby boomers were born ___. they will retire ____. expire ___.
1946 - 1964
2011 - 2029
2021 - 2039
concerns beyond the high cost of health care
uneven quality of care across the country, worse care for radical and ethnic minorities, reimbursement for care not recommended by experts or based on evidence, medical errors, increasing number of uninsured or underinsured
the u.s. is spending more but we are getting more
newer diagnostic tests, less invasive surgeries, low birth weight babies are surviving, better prescription medications, targeted chemo/radiation therapies for cancer