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67 Cards in this Set
- Front
- Back
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capitation
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fixed payment to HCP per member per month
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moral hazard
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having insurance means we consume more than we would if paying out of pocket
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national health insurance
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financed by gov't, delivered privately, i.e. canada
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national health system
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financed and delivered by gov't, i.e. great britain
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socialized health insurance
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financed through gov't via mandatory employer/ee contributions, private delivery, sickness funds, i.e. germany
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utilization
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quantity of healthcare consumed
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demand-side rationing
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production of healthcare depends on consumers' willingness and ability to pay; market justice
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deontology
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it's individual's duty to do what's right; ignores societal responsibility
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market justice
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1. emphaisis on individual
2. healthcare is distributed through supply-demand, 3. based on ability/willingness to pay, 4. no gov't interference |
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social justice
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1. healthcare distributed by gov't
2. societal responsibility 3. need based rather than ability to pay |
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utilitarianism
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greatest good for the greatest number; ignores the individual
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6 payers in the healthcare system
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Medicare
Medicaid BC/BS Commercial companies VA Tricare |
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3 things that shape today's economics of healthcare
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uniformed consumer
perverse incentives intermediaries |
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4 ways technology has an impact
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drugs
imaging surgery genetics |
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3 major health indicators
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life expectancy at birth
life expectacy at age 65 infant mortality |
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5 challenges to US healthcare system
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1. no central agency
2. access based on coverage 3. imperfect market 4. multiple 3rd parties 5. legal risks influence practice |
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community rating=
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premium is based on utilization in geographic region- healthy people pay for sick people
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experience rating=
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premium based on demographics or experiences
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Blue Cross/Blue shield: which is hospital and which is physician
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BC- hospital
BS- physician |
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key differences between non-profit and for profit
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Non Profit: governed by community boards, owned by the community, tax exempt
For Profit: has shareholders, excess revenue beyond expenses doesn't have to go back to institution. |
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who finances/operates medicaid?
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financed by federal and state, operated by state
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who finances/operates medicare
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federal for both
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who's eligible for medicare
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>65 y.o
ESRD disabled |
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who's eligible for medicaid
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below the poverty level- $9800 individual or $20,000 for family of 4
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what year were medicare and medicaid established
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1965
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What does part A medicare cover?
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hospital expenses, no nursing home coverage
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who pays for Medicare part A
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it's included for free- automatic coverage
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what does MEdicare part B cover
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supplementary- physician, outpatient, DME
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who pays for part B
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Medicare pays 80% of "assigned" rate and pt. pays 20%
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what is assignment
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docs agree to a predetermined rate set by medicare- which may be lower than the going rate
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What does medicare part c (Medicare + choice) cover?
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MCO participation
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who pays for part c?
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Medicare pays 95% of the community rating; only for very healthy elderly people
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what does part d cover?
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prescriptions
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do medicaid participants pay a premium?
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no
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what is managed care?
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insurers and providers collaborate to use financial incentives to alter provider/patient behavior to lower costs and increase effectiveness
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what is retrospective payment
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provider receives a payment after services have been provided
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what is prospective payment
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provider recieves payment before-hand, regardless of services rendered
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which type of payment offers incentive for providers to keep pts healthy
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prospective
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with capitation, who does the risk lie with
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providers
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3 keys to success with MCOs
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Limit:
1. hospital stays 2. ER usage 3. specialists |
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3 types of cost-sharing
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premiums
deductibles co-payments |
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what is stop loss provision
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the maximum out of pocket liability an insured person pays in a given year
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What are the types of MCO's?
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HMO, PPO, EPO, POS
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whats the most common type of MCO
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HMO
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what distinguishes HMOs from other types
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wellness care, capitation, and using in-network providers
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describe the staff model HMO
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an HMO employs its own fixed salaried docs, i.e. puget sound
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describe group model HMO
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HMO contracts with multi-specialty group practices to provide comprehensive services, i.e. Kaiser
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describe network model HMO
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HMO contracts with more than one medical group practice, i.e. Health Insurance Greater NY
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describe Independent model HMO
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independent docs form groups that contract with HMOs
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which model of HMOs is most common
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IPAs
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what's the relationship between choice, cost and provider control
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the more choice, the higher the cost, and the less provider control
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What is a PPO
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employer health benefit plans and health insurance carriers contract to purchase health care services
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distinguising features of PPOs
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can pay higher fee for out of network providers if you want, and arrange discounted fees with providers rather than capitation
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What is a POS plan?
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a hybrid of a PPO and HMO- free choice of providers, increased out of pocket costs, and tighter utilization
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3 key measures of health care
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access, quality and cost
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what are barriers to access
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1. Financial- lack of insurance
2. Structural- shortage of doctors, needing referrals,etc. 3. Personal- religious, cultural |
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what is the 10/90 gap
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10% of the worlds population uses 90% of all healthcare resources
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what are key indicators to look at when comparing healthcare systems
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-population health
-inequalities/disparaties -system responsiveness -distribution of responsiveness -distribution of financial burden |
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what are the 4 varieties of healthcare financing globally
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-out of pocket
-individual private insurance -employment based private insurance -government |
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financing in Germany
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govt' mandated, employment based private
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delivery in Germany
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mostly private
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financing in Canada
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gov't
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delivery in Canada
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mostly private
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financing in UK
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gov't
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delivery in UK
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public
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financing in Japan
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gov't, some employee contributions
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delivery in JApan
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mostly private
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