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29 Cards in this Set
- Front
- Back
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voluntary health insurance
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private health insurance tied to employment
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social health insurance
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govt entitlement program linked to current or past employment
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what are public welfare programs tied to?
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lack of employment or low income
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moral hazard
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the possibility that a party insulated from risk may behave differently than they would, were they exposed to the full risk
(i.e., asking for medical services that are not necessary just because you don't bear the full cost) |
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deductible
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the minimum amount that must be paid before the insurance policy kicks in
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indemnity benefit
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a fixed amount is paid to the beneficiary per procedure or day
(the difference between the charge and the benefit payment is the copayment--what the pt is responsible for) |
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service benefit
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a percentage of the charge is paid to the beneficiary
(difference b/w the charge and the benefit payment is the copayment) |
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hybrid benefit structure
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combines both service and indemnity features--a plan may pay a percentage of charges up to a ceiling amount, after which the pt is responsible
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adverse selection
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occurs when employees with a higher utilization enroll in a health plan with more generous benefits
(typically those prone to getting sick often; is more expensive bc of the high chance the services will be oft-used) |
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experience rating
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premiums are based on the demographics and actual utilization of the employer group
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community rating
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premiums are based on utilization of the wider geographic area
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HMO
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health maintenance organization
a type of managed care organization that provides a form of health care coverage in the US that is fulfilled by doctors/nurses at hospitals with which the HMO has a contract |
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types of voluntary health insurance
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Blue Cross, Blue Shield, HMO
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Medigap
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refers to various supplemental health insurance plans that are sold to Medicare beneficiaries that provide coverage for things only partially covered by Medicare
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workers' compensation
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cash replacement of a portion of wages lost due to disability, as well as payment for all or part of the medical care necessary
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health insurance basics pre-1980
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an insured person could seek care from whoever they chose as often as they wanted
-providers were reimbursed per SERVICE, so there was no incentive to constrain care -insurance companies paid providers |
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health insurance basics post-1980
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employers demanded that insurance companies constrain cost increases, since they were the main payers of health care
-led to growth of managed care |
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managed care
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-reimbursement, rather than fee for service (price ceiling)
-bulk purchasing for discounts -decreased # of providers approved to provide services |
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care delivery for insured
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from family physician in private practice who has a relationship with hospitals and specialists
local dental/pharm services stable care pattern w/ easy access |
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care delivery for uninsured
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no single source of care; mainly through public ERs, academic hospitals
limited dental/pharm/long-term care unstable/uncertain pattern of care with difficult access |
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care delivery for veterans
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a mixed bag--local physician w/ use of national VA hospitals for specialist care
basically stable with some uncertainty |
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why has nat'l health expenditures outpaced the GDP?
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-increased intensity in HC provision
-excess medical inflation -aging of population |
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why disproportionate growth between health expenditures and GDP?
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-rapid advancement of medical technology toward new treatments
-rising expectations about the value of HC services -gov't financing of HCS -nature of 3rd party reimbursement -more old people -lack of competition to increase efficiency |
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who is eligible for Medicare?
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-people age 65 and older
-disabled people entitle to Social Security -end-stage renal disease victims |
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factors driving US health care spending stratospheric
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1. high level of GDP per capita
2. comparatively high price of health services 3. inexpensive materials 4. administrative complexities, costs 5. unwillingness of americans to ration care |
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fee for service
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remuneration for medical service or procedure provided
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prospective payment system
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type of Medicare hospital reimbursement; pays based on a diagnosis, not a service
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top 2 personal health care expenditures
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1. private health insurance
2. federal govt |
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on what do people spend the most for personal health care?
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1. hospital
2. physician |
