Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/202

Click to flip

202 Cards in this Set

  • Front
  • Back
try to spend less on RX to avoid paying 100% of cost of RX while in hole
Part D - Medicare
# of cases of disease or injury at a particular pt in time
prevalence
# of NEW cases of a disease that occur in a pop that is at risk for disease
incidence
$1000 benefit more valuable than $1000 raise
employee's w/ health benefits
$37 dollar premium and a $250 deductible
Part D - Medicare
$600 credit if income is below $12,569
Medicare RX Discount Cards
$78.20 monthly premium, $110 deductible
Part B - Medicare
45 million and 11 million are children
uninsured
501-c-3 Corporations
Not for Profit - charitable
501-c-4 Corporations
Not for Profit - not charitable
65 and over, disabled, ESRD
Medicare
75% discount on drugs until you spend $2,250 on drugs
Part D - Medicare
accepting this form of Medicare = more patients
Medicare assignment
added in addition to Fee for Service under part A and B plans
Part C - Medicare
all excess revenue goes to community/institution
Not for Profit - not charitable
allows unemployed to buy insurance from previous employer
cobra
allows you to go to services outside of the HMO plan
Point of Service
amt of risk of acquiring a disease increases with exposure to risk factor
Relative risk
Arcadia, Church, synagogue
Not for Profit - charitable
as long as you pick a participating provider you pay 10% they pay 90%
PPO
because patients became sicker/ hospitalized and unable to pay for care
Tenncare
Beyond $2,250 = no benefits until you spend $3,600
Part D - Medicare
bought by those who have Medicare - covers costs over $3,600
Catastrophic Coverage
cannot manage the elderly and make a profit
HMO
Care after 30days of hospitalization
Subacute care
care is fragmented and differs by state
Medicaid
care that takes place in a hospital
Acute care
causes ER care to be wasted - b/c doesn’t cover primary care
Medicaid
Charitable organization - tax exempt
Not for Profit - charitable
comprehensive inpatient and outpatient coverage
Medicaid
contract with many HMO's
IPA
contract with more than one group practice
Network HMO
contract with muti-speciality physician group practice
Group Model HMO
covers physician/PA services
Part B - Medicare
Deontological approach - its an individual resp to do what is right
market justice
determines a rate for service
Medicare assignment
disabled Americans
Medicare
discount cards - 15 - 25% off
Medicare RX Discount Cards
does not keep up with reimbursement or hospital costs
Medicaid
does not reimburse the provider enough to cover their costs
Medicaid
does not use preventative medicine
Indemnity Health Care
doesn't care how much a physician charges for a visit
Medicare assignment
doughnut hole - between $2,250 and $3,600
Part D - Medicare
drug companies raised the price of RX to nullify the 75% discount
Part D - Medicare
each state receives diff amts of $$ depending on service/pop
Medicaid
eligibility req. change state to state
Medicaid
emphasis on prevention along with social/enviro determinants of disease
Public Health
employee pays a portion of the health insurance
premium
equitable distribution of health care is a societal responsibility
social justice
everyone in the community has the same premium
community rating
expanded kinds of private health care = managed health care
Part C - Medicare
extra money to community/institution
Not for Profit
Federal and state program
Medicaid
Federal Poverty Level - $20,00 for family of 4
Medicaid
Federal Poverty Level - $9,800 - for one person
Medicaid
Federal prgm/no state involvement
Medicare
focus is on populations
Public Health
for profit and experience rated
Commercial insurance
freedom to see any physician you want
Indemnity Health Care
general population is sicker
community rating
get the HMO benefits but can see any other provider within the plan
Point of Service
government cannot help regulate cost of RX made by drug company
Part D - Medicare
Greatest saving exist here - practitioner is at risk
HMO - Capitation
Group Health of Puget sound
Staff Model - HMO
group which pays or physician services
Blue Shield
has share holders
For Profit
Have community boards/Board of trustees
Not for Profit
have to make below poverty level
Medicaid
health care is delivered using a prepaid sys where costs are contained
Medicaid Managed Care
health care plan for indigent
Medicaid
health care plan for seniors
Medicare
health care provider comp BC/BS
BS
health care system in most countries around the world
Universal health care
healthy people subsidize the cost for the unhealthy
adverse selection
healthy young people have lower premiums
experience rating
highest life expectancy
Switzerland
HMO employs the physicians and PA's
Staff Model - HMO
hospital component of BC/BS
BC
illegal to waive the copay
Medicare
includes PPO's
Part C - Medicare
increases with a decrease in insurance
Relative risk
independent physicians join and form a group which contracts with HMO's
IPA
indigent move to states with better benefits
Medicaid
indigent pt is treated by primary care early in the illness
Medicaid managed care
individual contribution toward part B premium
Medicare
insurance companies and pharmacies cannot disclose the cost of RX
Part D - Medicare
Insurance plan of greater NY
Network HMO
insurer wants provider to treat patient - no referral to specialist
HMO - Capitation
it is your own responsibility to be able to afford health care
market justice
Kaiser = HMO = insurance company
Group Model HMO
Kaiser Permanente
Group Model HMO
keep patients away from hospital, ER, and specialists
Managed Care
large gaps contribute to significant out of pocket expenses
Part D - Medicare
look patients which have shared health care needs
Population Based Health Care
manage the population - dec use of services/provider makes more $$
Managed Care
manage the population - i.e. diabetics with diabetic educator
Managed Care
managed care, medical savings accounts, private fee for service plan
Part C - Medicare
manages health care for enrolled population not just individuals
Managed Care
mandated part - hospital insurance
Part A - Medicare
Mass offers limited services - gets little money
Medicaid
maximum $30 monthly premium
Medicare RX Discount Cards
maximum out of pocket liability
stop-loss
means tests established by states
Medicaid
measure outcomes for all patients
Population Based Health Care
measuring a chronic disease
prevalence
measuring an acute disease
incidence
Medicaid may buy this part if you are eligible for Medicaid = buy in
Part B - Medicare
medical care distributed based on the ability and willingness to pay
market justice
medical care is an inherent right b/c you are part of the community
social justice
Medicare pays the physician directly and the patient pays you
Medicare assignment
more evident around July1st or January 1st
deductible
more likely to use Pas and NPs to deliver primary care
Group Model HMO
more likely to use Pas and NPs to deliver primary care
Staff Model - HMO
most common model
IPA
municipal fee - NYC
Medicaid
no desire to keep you well - the sicker the pt the more money 4 provider
Indemnity Health Care
no individual premium contribution
Medicaid
no means test
Medicare
not mandated but an option
Part B - Medicare
not penalized for sending someone to an ophthalmologist
HMO - Capitation
NY offers many services gets a lot of money
Medicaid
only concerned with what keeps you well for the next 3 years
Managed Care
Only get full capitation if providers costs stay down $45 per head -> $36
HMO - Capitation
only permitted 5 RX's patients became sicker
Tenncare
originally community rated
Blue Cross
out of pocket expense each time service is received
co-payment
outpatient care and durable medical Equipment
Part B - Medicare
overall nursing home care
Medicaid
paid a certain amt of money per person - usually in primary care
HMO - Capitation
paid smaller salaries and pay less income tax
employee's w/ health benefits
partially funded through SS
Medicare
patient pays full bill - insurance company partially reimburses
Indemnity Health Care
patient receives more health care benefits
HMO
patient receives some coverage for services given by nonparticipate docs
Point of Service
payment before insurance benefits kick in
deductible
pays 95% for a patients to be enrolled in an HMO
Medicare
Permanente = who the physicians work for
Group Model HMO
person chooses more benefits over raise
employee's w/ health benefits
physician doesn't get paid by Medicare
Medicare no assignment
physicians accept financial risk
Managed Care
physicians have practices in places where patient pays bill in full
Medicare no assignment
plan is highly complex - hard for seniors to understand
Part D - Medicare
plan which pays a fixed amount
Indemnity plans
plan which pays a percentage of the bill
Service
point of service
POS
practice preventatively - get paid if you provide service or not
Managed Care
practioner gets paid the same amount regardless of # of visits
HMO - Capitation
Practioner wants to keep you well - prospective payment
HMO - Capitation
preferred provider options
PPO
premium based on demographics/actual group
experience rating
premium based on utilization in a geographic area
community rating
premium is based on the people being insured
experience rating
prescription drug plan
Part D - Medicare
Prevention - has a long term life cycle b4 you see return - ie mammogram
Managed Care
private health insurance - fills gaps of Medicare
Medigap Plans
program before 1974
Indemnity Health Care
program made the cut because there were people who had no coverage
Tenncare
promote social welfare
Not for Profit - not charitable
prospective - payment provided even before you provide service
Managed Care
providers decline to see more than 10% of these patients
Medicaid
provides insurance for hospital care
Blue Cross
pts with end stage renal disease
Medicare
quality of care and pt satisfaction determine amt paid
HMO - Capitation
radical departure from fee for service
Managed Care
receive list of participating providers
PPO
receives payment directly from patient
Medicare no assignment
rehabilitative nursing home care
Medicare
reimbursements less than 75% of Medicare reimbursements
Medicaid
requires significant intervention
social justice
retrospective payment - practitioner provides services then is paid
Indemnity Health Care
risk is on practitioner/provider
Managed Care
run by individual states = 50 different systems
Medicaid
run less tests/but must run some to prevent sickness which dec ur $$
Managed Care
Salaries not based on amt of $ made
Not for Profit
San Joaquin County Foundation
IPA
shift of financial risk from insurer to provider
HMO - Capitation
shows how disease and drugs/treatments affects a population
Relative risk
started in 1939 by a California physician
Blue Shield
study of a disease and how it is distributed within a population
epidemiology
study of which factors influences the distribution of disease within pop.
epidemiology
Supplemental medical insurance
Part B - Medicare
takes the risk back to the patient
consumer driven health care
tax exempt - no share holders
Not for Profit - not charitable
tend to enroll the healthiest of the elderly population
HMO
term for not paying for the total cost for service
subsidized
the more the patient comes the more it costs the practitioner
HMO - Capitation
Tightest control = minimal amt of cost
Staff Model - HMO
to qualify you have to be at poverty level ie - $9000
Tenncare
treats health care like any other commodity
market justice
understanding how a disease exits in the community
epidemiology
up till 2003 RX drugs were not covered at all
Part D - Medicare
use hospitals more than any other group
Medicare
usually has prospective payment
Managed Care
Utilitarianism - the greatest good for the greatest number
social justice
Vermont and Massachusetts health care system
Universal health care
very little risk falls on the practitioner - practitioner sees you a lot
Indemnity Health Care
very profitable
Medicaid managed care
walker, commode, O2
Part B - Medicare
way of pooling/distributing risk
insurance
who should receive what services, how many, and what type
distributive justice
Withholds part of capitation - gives bonuses
HMO - Capitation
you pay 30% HMO pays 70%
Point of Service