Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
69 Cards in this Set
- Front
- Back
|
1.6 trillion
14% of GNP |
How much spent on healthcare in US ($ and GNP)
|
|
|
intensive care like a hospital but for long term
|
Subacute Healthcare Facilities
|
|
|
insurance of hospital care
-orginally community rate |
Blue Cross
|
|
|
provides insurance for professional care
-started by CA physician group |
Blue Shield
|
|
|
medicare, medicaid, BC/BS, commercial, VA, Tricare
|
Who pays?
|
|
|
45 million Americans
11 million children little access to primary and preventative care 4x more likely to have avoidable hospitalization |
Unisured
|
|
|
-thinking broader than the individual
-measure the outcomes for all with targeted condition |
Population-based perspective
|
|
|
-state of complete physical, mental, and social well-being- not merely just the absence of disease
|
Health
|
|
|
-Indices= life expectancy and Infant mortality
|
Health Indices
|
|
|
-no central agency
-access is selective (based on insurance) -imperfect market conditions -multiple third party payers -legal risks influence practice hospital care |
Challenges of the HCS
|
|
|
hospital care
-prescription drugs are growing in cost |
Largest expense of HCS
|
|
|
Individuals pay an advanced sum to a pool from which payments from numerous individuals offset the cost of possible future costly events
-way of distributing risk |
Insurance
|
|
|
-Individuals who purchase health insurance are more likely to use health services than if they were uninsured
-Requires the use of disincentives to control utilization i.e. |
Moral Hazard of Insurance
|
|
|
copayments and deductibles
-20% incur no health care costs at all -70% of pop. incurs 10% of total costs -1% of the pop. incurs 30% of total costs |
distribution of health care costs
|
|
|
payment before insurance benefits kick in
|
deductible
|
|
|
out-of-pocket expense each time health care servcies are received
|
co-payment
|
|
|
maximum out-of-pocket liability
|
stop-loss
|
|
|
employee pays a portion of the health insurance premium
|
Premium
|
|
|
premium based upon utilization in a defined geographic area
-adverse selection -everyone pays the same |
community rated risk management
|
|
|
premium based upon demographic characteristics and/or actual group experience
|
experience rated risk management
|
|
|
-required to have margin and mission as their goal
-do not have share holders -can be charitable or not |
Not-for profit Organizations
|
|
|
-only worry about margin
-have share holders |
For-profit organizations
|
|
|
-typically for-profit
-experience rated -idemnity plans (pay fixed amt) -service plans (pay % of bill) -managed care options (HMO, PPO, POS) -excessive coverage |
Commercial insurance
|
|
|
-shifting the risk back onto the pt
-instead of buying insurance, you get a lump sum of money to spend |
Health Savings Account
|
|
|
-Title 19 of SSA in 1965
-State program with federal funding (50-75%) -states set eligibility: below poverty line -states trying to cover more of the poor by MC enrollment -inpt and outpt coverage -reimburst <75% of what Medicare would -reimburstment based on encounters -many providers decline to see more than 10% of medicaid pts |
Medicaid
|
|
|
-Title 18 of SSA in 1965
-age 65 and over, disabled, and ESRD are covered -Part A, B, and C |
Medicare
|
|
|
-medicare will pay a % of the service, pt is responsible for the rest
-83% of Physicians participate |
Medicare Assignment
|
|
|
-started to finance trading expeditions
-primary function was to protect against loss of income when sick, not to help with healthcare costs |
History of Healthcare
|
|
|
-covers 99% of aged Americans
-limited nursing home coverage |
Medicare Part A
|
|
|
-covers Dr/PA servcies, outpt care, and DME
-have to buy it |
Medicare Part B
|
|
|
-3000 days/ 1000 people
|
Age 65 and older spend out many days in hospital?
|
|
|
-HMOs
-POS plans -PPOs |
Types of MC
|
|
|
-HMO employs Dr/PA
-have lowest prices |
Staff Model HMOs
|
|
|
-HMO contracts with a multi-specialty physician group practice to provide all physician and PA services to the HMO’s members
|
Group Model HMOs
|
|
|
-HMO contracts with more than one group practice to provide physician services to the HMO’s members
|
Network Model HMOs
|
|
|
-Independent physicians join to form a group which contracts with HMOs
-most common model |
Independent Practice Association (IPA)
|
|
|
-hybrid of HMO and PPO
-member retains some coverage for services by nonparticipating providers (will pay 70%) |
Point of Service Plans (POS)
|
|
|
-employers purchase health care services for covered beneficiaries from a selected group of participating providers
-more expensive (bc of choice) |
Preferred Provider Organizations (PPO)
|
|
|
-perceived loss of autonomy
-organizational demands exceed that of a private practice (increased bureaucracy, different proceedures for different plans, hard to rid of difficult pts) |
Providers view of MC
|
|
|
-Distributive Justice
-Market Justice -Social Justice |
Distribution of Healthcare
|
|
|
-who should receive services
-what type of services should they receive -what quantity of services should be provided -overall: where do we limit? |
Distributed Justice
|
|
|
-Healthcare is like any other good or service
-service distributed on the basis of one's ability to pay -it is the individual's responsibility to do what is right |
Market Justice
|
|
|
-Equitable distribution of healthcare is a responsibility
-Utilitarianism -requires significant govt intervention |
Social Justice
|
|
|
-the greatest good for the greatest number
|
Utilitarianism
|
|
|
-access, -quality, -cost
|
Measures of Healthcare
|
|
|
-financial (not having insurance, or financial means)
-structural (lack of PCP or facilities, live in rural area) -personal (spiritual differences, language barriers) |
Barriers of Access to Healthcare
|
|
|
-adults with insurance are 2x more likely to receive a routine checkup than those w/o
-1/3 adults under 65 and below poverty level do not have insurance -uninsured children are 4x more likely to go w/o needed medical care -40 million Americans do not have a particular center to receive services in |
Health insurance factoids
|
|
|
-women are 50% more likely to leave their physician bc of dissatisfication
-women are 2x as likely to report that their physicians talked down to them |
Gender issues of healthcare
|
|
|
-African Americans and Latinos receive fewer services than whites with the same level of income/insurance
-disparities are attributed to bias, communication, and providers, |
Race issues to health care
|
|
|
-preventing disease, prolonging life, promoting health through education, control, and organization
-insure a adequate standard of living for all -emphasis of prevention -focus on population not the individual |
Public Health
|
|
|
- 20%
-bc most are paid by a 3rd party |
What % do consumers pay for health care costs directly and why?
|
|
|
-uninformed consumer (is Dr reliable?)
-MD/PA as intermediary (can't just go get a chest x-ray) -perverse financial incentives (intermediary is not always fair and unbiased) |
Economics of health care
|
|
|
-failure to complete a planned action as inteded or the use of the wrong plan to achieve an aim
-98,000 killed annually -more deaths than MVAs or breast cancer |
Medical errors
|
|
|
-medicaid: 40% higher risk than privately insured
-uninsured: 50% higher risk than privately insured |
What % of risk do medicaid prescribers have of death from breast cancer over the privately insured? what about the uninsured?
|
|
|
-covers Rx
|
Medigap
|
|
|
-receive a 15-20% off Rx card
-$30 monthly premium -$600 credit if income is below $12,569 |
Medicare Rx Improvement Act of 2003
|
|
|
-$37 premium, $250 deductible
-75% off Rx up to $2250 -catastrophic coverage > $3600 -Problem: no coverage between $2250 and $3600 |
Medicare Part D
|
|
|
-Rx companies raised their prices to account for the deduction
-no help for generic Rx -prevents states from negotiating lower prices for Rx |
Problems with Rx Act
|
|
|
-Organized effort by health insurance plans and providers to use financial incentives and organizational arrangements to alter provider and patient behavior so that health care services are delivered in a more efficient and lower cost manner
|
Managed Care
|
|
|
85%
|
Number of Americans with MC
|
|
|
-Physicians accept financial risk
-mostly prospective payment -Physicians provide for enrolled population not just individual -preventing injury/disease is financially beneficial |
Principles of MC
|
|
|
-payment before services are rendered and even if services aren’t rendered at all
|
Prospective payment
|
|
|
-service and then payment
|
Retrospective payment
|
|
|
-Specified amount paid periodically to a health provider for a group of specified health services regardless of quantity rendered
-get paid a certain amt a month no matter how many times the pt comes in -shifts financial risk from insurer to provider |
Capitation
|
|
|
-MC org withholds 20% of capitated money
-provider can get it at the end of the year based on how well they provide for their pts, etc |
Witholds of Capitation
|
|
|
-get extra money at the end of the month for good bx
|
Bonuses of Capitation
|
|
|
-for certain services, MC will pay more to providers
-preventative care, AIDS, specialties |
Carve outs of Capitation
|
|
|
-keep pt out of hospital
-keep pt out of ED -keep pt away from specialists |
Keys to success for MC
|
|
|
-includes PPOs
|
Medicare Part C
|
