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47 Cards in this Set

  • Front
  • Back

Many consulting firms offering:

* Minimizing resources

Both government and private enterprise involved in

* Delivery of Health Services

5 A’s of access

avail, access, affordable, accommodates, accept

Demand side:

Cost-sharing by consumers


A self-rationing mechanism (reduces moral hazard)


RAND experiment (1974-1981): study resulted in lower HC costs with cost-sharing mechanisms in place

supply side

US Antitrust Laws prohibit business practices stifling competition among providers


Examples include price fixing, price discrimination, exclusive contracting arrangement, and mergers.


It forces health care organizations to be cost-efficient.


Health Planning


CON

PPS (Prospective payment system) / DRGs (Diagnostic related groups

* used to be a Fee for Service

RBRVS - Resource Based Relative Value Scale

fee schedule (how much to pay for Dx)


long formula

PRO’s - peer review organizations

determine if too much services were provided


to control Practice Variations

Demand Side Incentives

cost-sharing (co-pays, co-insurnce, deductibles, premiums, Pay % of visit)


This developed from RAND Health Ins Experiment


study showed that if individuals had to pay for services, demands went down

Supply Side Incentives (deal with competition)

Antitrust laws (no monopolies)


will promote competition in a “free” market

MCO

managed care organization


Different insurance providers contract with providers to limits/control allowed services


Ex. HMO & PPO

What are the three major cornerstones of HC Delivery

Cost of HC,


Access of HC when needed


Quality of services (Dimensions)

types of access

1. effective and efficient access

measurement of access

individual level


health plan level


delivery system level

Clinical Aspects -

outcomes


facility quality


quality of provider


Processes/interventions provided


Cost efficiency

Financing:

Any mechanism that gives people the ability to pay for health care services

Health Insurance:

A financial mechanism that shares and disperses risk of financial loss due to occurrence of an adverse event within a population of people

Risk:

The possibility of a substantial financial loss from an event of which the probability of occurrence is relatively small


I.e. from textbook: Car accidents are common; however, the risk/likelihood is quite small that a specific individual will have one in a given year

Premium

The fee paid by individuals and/or employers


Creates pool of resources that provides income or service benefits to holder

Beneficiaries:

The holders of insurance contract

Underwriting

Evaluates, selects/rejects, classifies, and rates risk.

Cost Sharing:

Purpose: reduce misuse of insurance benefits

Deductibles

Amount the insured pays first before benefits are paid by the plan


Paid annually

Copayment

* % share is referred to as coinsurance

Indemnity plan

reimburses the insured a predetermined amount per service


insured is responsible for paying provider

Service plan

* plan pays the provider directly except for deductible

Benefits:

Services covered by an insurance plan (medically necessary)

Fee-for-Service:

Charges (prices) set by providers


Each service is billed separately

Bundled Charges (package pricing):

* Reduces provider-induced demand because fees are inclusive of all bundled services

RBRVS)

* Based on time, skill, and intensity

Risk pool

collection of premium fees from each member (potential beneficiary) which can be dispersed to individuals who actual incur an event covered by the contract


Beneficiaries are not guaranteed to receive benefits equal to the amount contributed to the risk pool

Group insurance

* Cost and risk are distributed equally among the insured

HDHPs)

HDHP is combined with a health reimbursement arrangement.


Employer-financed account.


Tax exempt payments made for qualified medical expenses.

HDHP/HSA

HDHP is combined with a health savings account.


Mainly employee financed on a tax-deductible basis

Managed Care Plans

Health Maintenance Organizations (HMO)


Preferred Provider Organizations (PPO)

Actuarial analysis

process used to determine the premium fee

Premiums cover:

the plan, profit, benefits, administrative expenses


The analysis considers: demographics, past medical care use rates, known cost data

Why do we have managed care systems?

* Weakened economic position of providers

Staff Model

Employs own fixed salary physicians


At end of year, pool of money distributed as bonuses based on physician’s productivity and HMO’s profitability


Least popular type of HMO

Group Model

Contracts with multispecialty group practice and one or more hospitals


Physicians employed by practice, not HMO


HMO pays all inclusive capitation fee to practice

Network Model

HMO contracts with one or more medical group practice


Good for large metropolitan areas and widespread geographic regions


Able to offer more choice


Less utilization control


PPO (Preferred Provider Organization) Plans

Make discounted fee arrangements with providers (between 25-35% off providers’ regular fees)

Medicare tax:

Paid by all working individuals.


Paid on all income earned.


Paid equally by both employer and employee.:

Covers

Inpatient services,


Short-term convalescence and rehabilitation in a skilled nursing facility (SNF),


Home health


Hospice

The timing of benefits is determined by a benefit period.

It begins on the day a beneficiary is hospitalized.


It ends when the beneficiary has not been in a hospital or a skilled nursing facility for 60 consecutive days.

Hospital benefits:

Deductible is paid for the first 60 days.


Copayment required from 61 to 100 days.


Higher copayment required after 100 days and reserve days must be used.

SNF benefits:

Eligibility begins after 3 consecutive days of hospital stay.


100 days maximum in SNF.


First 20 days at no charge to the beneficiary; copayment applies from day 21.