Pharmacy And Health Care Systems Ii

Front 1

What is insurance?

Back 1

mechanism for managin or controlling the financial exposure to risk

Front 2

The mechanism for managin or controlling the financial exposure to risk though 2 basic prinicples

Back 2

tarnsferring or shifting risk from an individual to a group

and sharing losses on some euitable basis by all members of the group

Front 3

What are type of organizations providing PRIVATE health insurance

Back 3

commerical health, managaged care organizations or employers

Front 4

A concept in Health insruance is risk assement

Back 4

process of modeling and calculating expected expenses of one class of people relative to others

Front 5

Risk assessment is a function of age, gender, socioeconmic satus,and assesment by medical screenig, how is risk adjusted

Back 5

medical underwriting or redlining, co-payments

Front 6

What is medical underwriting

Back 6

assesing the likelihood of events in a population, and ajusts for risks to determine cost and coverage

Front 7

What is experience rating

Back 7

stratifes members acording to health risks and demographics of employer group

Front 8

What is community rating

Back 8

uses geographic area to predict utilizaiton

Front 9

What is redlining

Back 9

denying coverage to high risk goup of invidiuals

Front 10

What is a premium

Back 10

cost incurred to insured for their health care MONTHLY or annually

Front 11

What is a co-payment

Back 11

fixed amount paid for SERVICES or prescriptions, paid as the insured USES policy

Front 12

What is co-inurance (new trend)

Back 12

% of total expenses that must incured by the insured

Front 13

What is deductible

Back 13

amount that the insured must achieve before coverage becomes effective

Front 14

What are 3 types of benefits,

Back 14

indemnity benefit, service benefit, hybrid benefit

Front 15

WHat is indemnity benefit

Back 15

a fixed cash amount is paid for medial services, patietn is liable for any amount that exceeds that

Front 16

WHat is a service benfit

Back 16

reimbursement is paid on a percentage basis, patient pays co-insurance on a % basis

Front 17

What is a hybrid benefit

Back 17

combines both idenmnity and service

Front 18

Paymeny options for physicans are fee for service, preferred provider appraoch or capitation

Back 18

YES

Front 19

What is fee-for serice

Back 19

patient or insurer pays for services determined by physican

Front 20

What is perferred provider appraoch

Back 20

use of negotated discounts by individal physicans or a group

Front 21

Capitations doesnt exist anymore, is

Back 21

physican receive a pre-determined capiated annual amount for each patient who uses them.

Front 22

Are physicans are financial risk for the costs of their pateints care by capitation

Back 22

YES

Front 23

How does BCBS differ from commerical insurers

Back 23

not for profit, coverage on a service basis

Front 24

Blue corss NERVER refuses coverage, and based on community rating

Back 24

YES

Front 25

Commerical health insurace focues on marketing to

Back 25

large businness

Front 26

The link betwen emplyement and health insurance was forged by

Back 26

Taft-Hartley Act

Front 27

Did the Taft-Hartley act, establishe health benefits as a condition of employmeny

Back 27

YES

Front 28

Individual coverage is mostly offered by, and purchased by

Back 28

BCBS--individuals who are not covered by employer based HI

Front 29

Is individual more expensive as insurer ahs no way of spreading risk

Back 29

YES

Front 30

THe major source of HI is group, primarly though employers and union, core benfits offered

Back 30

medical, dentaland disability

Front 31

Commerical insurahce is expensive for small businesses b.c

Back 31

high premium spread overa small group

Front 32

How are employment based health benefits funded

Back 32

self-funded plans, commerical insureer and contracts with MCOs

Front 33

What are self-funded plans like CU

Back 33

employer pays fors its participants health care claims directly from its own income or assests

Front 34

What are empolyment based health froma commerical insurers

Back 34

employer plays premiums to purchanse health insurahce coverage directly from insurer (assumes risk)

Front 35

What are contracts with MCOs

Back 35

MCO provide health crae benefits to particiapnts, may share risk with providers

Front 36

Self-funeded plans mager theri own reserve fund and assume reposonsibility for definding a beifit

Back 36

YES

Front 37

Regulation of HI occurs at the STATE level by 3 federal statues

Back 37

ERISA, COBRA and HIPPIA

Front 38

What is ERisa

Back 38

federal framework for regulating employer sponsored health plans--regulates HI plans that are self-funded

Front 39

What is COBRA

Back 39

allows employees with group health coverage, who have lost jobs to reatin for 36 months

Front 40

HIPPA also guarantees extened HI coverage availabe to works when lose change, and

Back 40

prosecuting companies suspected of defrauding parties in the health care industry

Front 41

What was health maintenance act of 1973

Back 41

added dual chocie provision --empoloyers with 25 or more employers were required to offten indemnity plans

Front 42

What is Managed care

Back 42

is an organized effeort by health insurance plans to use financial incetives and organizaitonal arragements to alter provider and pt behavior

Front 43

Medicare, medicaid and employers all purchase

Back 43

manged care

Front 44

What is a PPO

Back 44

perferred provider organization

Front 45

Do PPO assume risk

Back 45

NO

Front 46

PPO are most generous--do they have negotiated and discounted payment rates

Back 46

YES

Front 47

WHat is POS

Back 47

point of service plans--combines key features of HMO and indemnity plans

Front 48

What plan does PCP act as a gatekeep for referrals

Back 48

POS

Front 49

THe most restricted plans are

Back 49

HMO (health maintenance organizations but cheapest

Front 50

Do providers assume risk for patient in HMO

Back 50

yes

Front 51

Docs can be employed by HMO (staff model) and HMO can contact with a multispeciality group practice

Back 51

YES

Front 52

What is IPA

Back 52

independent practice associatiton

Front 53

What does IPA do

Back 53

physcians in a practice VOLUNTAITY join of group of physicans, all indpepdnet and take part in large contact with HMOs

Front 54

How do HMOS compensate the IPA

Back 54

capitation basis

Front 55

IPA then compesnstaes its physcians base on

Back 55

a fee-for-service basis or primary care capitation

Front 56

IPA alllow sphyscian the benfits of indpendence and involvement in large scale contracting arragmdements

Back 56

YES

Front 57

Key principles of marange care, providers control utilziation, use of gatekeepers, promote team work

Back 57

YES