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Health Care Systems Exam #1

Health Care Systems Exam #1

by theresa4947, Jul. 2009

Subjects: arcadia care health

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232 Cards in this Set

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	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
	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
	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

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232 Cards in this Set