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47 Cards in this Set
- Front
- Back
Many consulting firms offering: |
* Minimizing resources
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Both government and private enterprise involved in |
* Delivery of Health Services
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5 A’s of access |
avail, access, affordable, accommodates, accept |
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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 |
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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 |
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PPS (Prospective payment system) / DRGs (Diagnostic related groups |
* used to be a Fee for Service
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RBRVS - Resource Based Relative Value Scale |
fee schedule (how much to pay for Dx) long formula |
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PRO’s - peer review organizations |
determine if too much services were provided to control Practice Variations |
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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 |
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Supply Side Incentives (deal with competition) |
Antitrust laws (no monopolies) will promote competition in a “free” market |
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MCO |
managed care organization Different insurance providers contract with providers to limits/control allowed services Ex. HMO & PPO |
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What are the three major cornerstones of HC Delivery |
Cost of HC, Access of HC when needed Quality of services (Dimensions) |
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types of access |
1. effective and efficient access
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measurement of access |
individual level health plan level delivery system level |
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Clinical Aspects - |
outcomes facility quality quality of provider Processes/interventions provided Cost efficiency |
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Financing: |
Any mechanism that gives people the ability to pay for health care services |
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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 |
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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 |
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Premium |
The fee paid by individuals and/or employers Creates pool of resources that provides income or service benefits to holder |
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Beneficiaries: |
The holders of insurance contract |
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Underwriting |
Evaluates, selects/rejects, classifies, and rates risk. |
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Cost Sharing: |
Purpose: reduce misuse of insurance benefits |
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Deductibles |
Amount the insured pays first before benefits are paid by the plan Paid annually |
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Copayment |
* % share is referred to as coinsurance
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Indemnity plan |
reimburses the insured a predetermined amount per service insured is responsible for paying provider |
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Service plan |
* plan pays the provider directly except for deductible
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Benefits: |
Services covered by an insurance plan (medically necessary) |
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Fee-for-Service: |
Charges (prices) set by providers Each service is billed separately |
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Bundled Charges (package pricing): |
* Reduces provider-induced demand because fees are inclusive of all bundled services
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RBRVS) |
* Based on time, skill, and intensity
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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 |
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Group insurance |
* Cost and risk are distributed equally among the insured
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HDHPs) |
HDHP is combined with a health reimbursement arrangement. Employer-financed account. Tax exempt payments made for qualified medical expenses. |
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HDHP/HSA |
HDHP is combined with a health savings account. Mainly employee financed on a tax-deductible basis |
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Managed Care Plans |
Health Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) |
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Actuarial analysis |
process used to determine the premium fee |
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Premiums cover: |
the plan, profit, benefits, administrative expenses The analysis considers: demographics, past medical care use rates, known cost data |
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Why do we have managed care systems? |
* Weakened economic position of providers
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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 |
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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 |
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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 |
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PPO (Preferred Provider Organization) Plans |
Make discounted fee arrangements with providers (between 25-35% off providers’ regular fees) |
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Medicare tax: |
Paid by all working individuals. Paid on all income earned. Paid equally by both employer and employee.: |
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Covers |
Inpatient services, Short-term convalescence and rehabilitation in a skilled nursing facility (SNF), Home health Hospice |
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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. |
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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. |
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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. |