Health Care Ch 1

Front 1

Acceptable health care delivery system requires 2 objectives

Back 1

1. must enable all citizens to obtain health care when needed
2. services must be cost effective and meet established standards of quality

Front 2

Quad-Function Model

Back 2

four key functions necessary for health care delivery: financing, insurance, delivery, and payment

Front 3

Financing

Back 3

necessary to obtain health insurance or to pay for health care services

Front 4

Insurance

Back 4

protects the insured against catastrophic risks when needing expensive health care services

Front 5

Delivery

Back 5

provision of health care services by various providers

Front 6

Provider

Back 6

any entity that delivers health care services and can independently bill or is tax supported

Front 7

Payment

Back 7

reimbursement to providers for services delivered

Front 8

Uninsured

Back 8

those without private or public health insurance coverage

Front 9

Employed individuals don't have insurance for 2 reasons

Back 9

1. employers are not mandated to offer health insurance to their employees
2. participation in health insurance is voluntary and does not require employees to join

Front 10

Premium Cost Sharing

Back 10

a portion of the insurance premium that employees pay

Front 11

Medicare

Back 11

health program for elderly and certain disabled individuals

Front 12

Medicaid

Back 12

health program for the poor, jointly administered by the federal and state government

Front 13

Children's Health Insurance Program (CHIP)

Back 13

health program for children from low income families, jointly funded by federal and state

Front 14

Utilization

Back 14

the quantity of health care consumed

Front 15

Managed Care

Back 15

1. seeks to achieve efficiencies by integrating the 4 functions of health care
2. employs mechanisms to control utilization of medical services
3. determines the price at which the services are purchased and how much the providers get paid

Front 16

Enrollee

Back 16

individual covered under the health plan

Front 17

Health Plan

Back 17

contractual arrangement between the MCO and the enrollee

Front 18

10 Characteristics that the US health care system is different from other countries

Back 18

1. no central agency governs the system
2. access to health care is based on insurance coverage
3. health care is delivered under imperfect market conditions
4. 3rd party insurers act as mediator between financing and delivery functions
5. existence of multiple payers makes the system complicated
6. balance of power among various players prevents any single entity from dominating
7. legal risks influence practice behavior of doctors
8. development of new technology creates an automatic demand for use
9. new service settings have evolved along a continuum
10. quality is no longer accepted as an unachievable goal in health care

Front 19

Global budgets

Back 19

controls cost by determining total health care expenditures on a national scale and to allocate resources within budgetary limits

Front 20

Standards of Participation

Back 20

providers must comply with the standards established by the government to be certified to provide services

Front 21

Access

Back 21

ability of an individual to obtain health care services

Front 22

Access is restricted to people who?

Back 22

1. have health insurance through employer
2. covered under a government program
3. can afford to buy insurance with private funds
4. able to pay for services privately

Front 23

Primary Care

Back 23

continual basic and routin care

Front 24

Universal Coverage

Back 24

health insurance is available to all citizens

Front 25

Universal Access

Back 25

ability of all citizens to obtain health care when needed

Front 26

Free Market

Back 26

multiple patients and providers act independently and patients can choose to receive services from any provider. Prices are governed by the free and unencumbered interaction of the forces of supply and demand

Front 27

Demand

Back 27

quantity of health care purchased

Front 28

Phantom Providers

Back 28

providers that bill you separately for their services. e.g. anesthesiologist, nurse anesthetists and pathologists

Front 29

Package Pricing

Back 29

bundled fee for a package of related services

Front 30

Capitation

Back 30

reimbursement mechanism which the provider is paid a set monthly free per enrollee regardless if the enrollee sees them on a regular basis

Front 31

Moral Hazard

Back 31

consumer hazard that leads to a higher utilization of health care services becuase people are covered

Front 32

Need

Back 32

amount of medical care that medical experts believe a person should have to remainor become healthy

Front 33

Provider-Induced Demand

Back 33

artificial creation of demand by providers that enables them to deliver unneeded services to boost their incomes

Front 34

Third Party

Back 34

the insurance and payment functions

Front 35

Single-Payer System

Back 35

one primary payer, the government in a national health care system

Front 36

Balance Bill

Back 36

Provider provides the patient with a bill of the remainder balance the insurance didn't cover

Front 37

Administrative Costs

Back 37

costs associated with billing, collections, bad debts, and maintaining medical records

Front 38

Defensive Medicine

Back 38

prescribing additional diagnostic tests, scheduling return checkup visits, and maintaining copious documents to prevent from litigation

Front 39

National Health Insurance (NHI)

Back 39

government finances health care through general taxes, but the actual care is delivered by private providers

Front 40

National Health System (NHS)

Back 40

government finances health care through general taxes, manages infrastructure for delivery of medical care

Front 41

Socialized Health Insurance

Back 41

government-mandated contributions by employers and employees finance health care, private providers deliver health care

Front 42

System

Back 42

set of interrelated adn interdependent, logically coordinated components designed to achieve common goals

Front 43

Outpatient Care

Back 43

health care services delivered in noninstitutional settings, not overnight

Front 44

Inpatient Services

Back 44

institutional health services provided in hospitals, nursing homes, and rehab institutions