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53 Cards in this Set
- Front
- Back
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Medicare originally consisted of what?? (2 parts)
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Part A: primarily for inpatient care
(in-hospital care, skilled nursing care, hospice, and home health care) Part B: ambulatory care (health care not involved with hospitalization) |
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What does part A cover?
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inpatient care
Covers in-hospital care, skilled nursing care, hospice, and home health care. Part A benefits are financed by Social Security taxes, require no premium payment by the beneficiary, and are automatic for those 65 and older. |
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Medicare provides health care coverage without a premium cost, but.....
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it is not free health care!
(includes deductibles and co-insurance provisions) |
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What is the purpose of deductibles and coinsurance?
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Mechanisms designed to limit costs and to give greater responsibility for use of services to the insured
(insured will not likely go to a doctor if it is unnecessary because of what they have to pay) |
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What is the waiting period known as?
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The Blue Cross Equalizer
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What year is considered marking the start of modern health care?
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1929
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Who were the fortunate recipients of the first health insurance plan established?
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School teachers
-started by Justin Ford Kimball |
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What is the difference between Blue Cross and Blue Shield?
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Blue Cross: hospital and surgical coverage
Blue Shield: physician services coverage |
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What was the first major, national health insurance plan called?
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Blue cross
-evolved out of Justin Ford Kimball's plan (Baylor Plan) -late 1930s |
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Why were doctors fearful of the early Blue Shield insurance plans?
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concerned that non-medical people would tell them how to practice
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Medicare
(before any payment by Medicare is authorized) |
There are a considerable number of restrictions and requirements the patients must meet by Medicare Part A and Part B before any payment by Medicare is authorized
(Medicare can deny payments if they see something wasn't necessary during past history and make the patient have to pay all costs) |
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Medicare---Health insurance program for persons 65 and older...
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Regardless of income or wealth
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What was the first state that required medical licensure?
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Georgia
(had to graduate from medical school--before, all the training was apprenticeship, hands on, atmosphere) |
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AMA and AAMC
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AMA: American Medical Association
AAMC: Association of American Medical Colleges =They are separate bodies but WORK TOGETHER for the same thing |
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What is a deductible?
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-predetermined amount of money that a patient MUST pay before the insurance policy provides any benefits
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What is coinsurance?
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A % of the cost of each service that must be paid by the insured along with the insurance policy payment.
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What is a co-pay?
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A flat, pre-determined fee that must be paid for each type of service
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What year is the official beginning or birth of modern health insurance?
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1929
Justin Ford Kimball school teachers |
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Kimball designed an acceptable plan that who did want to turn down?
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-school teachers
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What does Blue Cross cover?
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Hospital and Surgery coverage ONLY
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What does Blue Shield cover?
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Physician/PA services ONLY
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AMA's position was based on fear that it would be accused of restraint of trade...
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they were afraid that non-medical people would be telling doctors how to practice medicine
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What year is considered marking the start of modern health care?
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1929
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Who were the fortunate recipients of the first health insurance plan established?
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school teachers
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What was the first major, national health insurance plan called?
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blue cross: evolved out of Justin Ford Kimball's plan (Baylor plan)
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Why were doctors fearful of the early Blue Shield insurance plans?
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concerned that non-medical people would tell them how to practice
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What is the Flexner Report?
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Carnegie foundation: agreed to conduct an independent investigation as to the quality of medical education
-Flexner: not a physician but an educator (educational survey) 1. entrance requirements 2. size and training of faculty 3. financial resources and expenditures 4. quality and adequacy of labs provided for instruction for the first 2 years 5. relations between medical school and hospitals Formal report published by The Carnegie Foundation in 1910 "Medical Education in the US and Canada" |
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Results of the Flexner Report
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Named schools, assets, liablilities and offered a prescription for each school, for each state and region, and for country as a whole
-caused some schools to close and some to consolidate -Flexner recommended that # of schoole be reduced from 155-->31 -donations went to better medical schools and education (this was direct result of the Flexner Report and the influence it had) |
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What was the first state to establish a state board of medical examiners?
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Texas in 1873
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What is HIPAA?
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Health Insurance Portability and Accountability Act
-federal law that changed insurance rules including giving people the right to change jobs without fear of losing coverage -provisions regarding patient privacy |
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Medigap coverage?
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The private insurance that Medicare beneficiaries can purchase that covers the portion of the bill not paid by Medicare
(deductibles and copays) |
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What is Occupancy?
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the number of inpatients at any given time, usually expressed as a percentage
(patients divided by total beds) -not refer to Hilton or Paris Hotel |
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What is Qualified Medicare Beneficiary?
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A Medicare beneficiary whose Part B premium and coinsurance is covered by Medicaid, because they are at or below poverty level
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What is AAPCC?
(Adjusted Average per Capita Cost) |
Federal calculation that determines how much Medicare pays a managed care company each month to cover Medicare beneficiaries living in a certain area
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What is the dominance of physicians in health care explained by?
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1. division of labor in health care delivery that requires that all other health care professionals work under "orders" given by the physician
2. amt of knowledge physicians have (in comparison to the patients they treat) 3. capitalist economy -promotes freedom of practice and economic dominance of physicians |
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What is deprofessionalization?
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occurs with reduction in the knowledge gap between physicians and consumers
-fostered by increase in consumer education/computerization of knowledge -physicians assuming salaried positions in organizations and as new professions emerge with authority to treat patients independently of physicians |
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Which of the following occupations is NOT a physician?
-ophthalmologist -osteopath -allopath -psychologist -psychiatrist |
-psychologist (they don't require going to medical school)
-you need to go to medical school to be considered a physician |
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Prior to the 1990's, little attention was paid to health, wellness, prevention, or treatment of chronic illness. What was the focus?
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focus was on cure and "sick care" rather than health care
-no system; everyone worked independently |
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What is horizontal integration?
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an attempt to provide the same services to a larger number of persons
the same service by the same hospital corporation in a new area of the surrounding area |
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What is vertical integration?
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an attempt to provide a greater variety of services to the same patient base or the immediate community
example: new services |
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Why was the Baptist Memorial Health Care systems so successful?
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-they have always "put the interests of the patients as their priority"
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What is the Public sector paying for?
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-since 1929, government expenditures have risen
-in 2000, government at all levels was responsible for 46.5% of all health expenditures (constant since 1980, but on the rise again) |
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What happened in 1970?
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a sharp rise in government expenditures
-implementation of Medicare and Medicaid -subsequent years growth due largely to expenditures for these 2 programs |
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What is the health care sector?
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Patients
-does not include: hospitals, nursing homes, or managed care groups=part of health care system) |
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What does accepting medicare assignment mean?
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Patient must pay deductible
Physician agrees to accept 80% of what medicare determines to be a reasonable fee. MUST bill the patient only for the balance (20% of the fee set by medicare) |
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Medicare does not pay for "custodial care." what must a physician or PA need to do in order to have Medicare patient covered for extended skilled nursing?
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Medicare patient must have been in an acute care hospital for at least 3 full days
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How much of nation's resources hould be allocated to health care?
What happened in 1998? |
13.5% of nation's GDP was spent in the health care system
-brought high quality health care services which contributes to its health and quality of life |
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Health care industry is huge employer of both skilled and unskilled labor
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heavy purchaser of supplies and drugs and equipment
health care workers pay taxes and spend money thus fueling the economy |
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I-Thou and I-it attitude
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I-thou:
-attitude of true caring and valuing the other person I-It: regards the other person as a thing to be assessed, evaluated, and/or used |
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What does medicare NOT pay for?
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custodial care
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What is selective medical underwriting?
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when insurance company SELECTIVELY excludes people with health problems from enrolling in small employee groups or charge higher rates than for the rest of the members
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US Health expenditures in 1998
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Hospital care accounts for 382.8 billion dollars or 37.6% of all personal health care costs
In 2007: 39.5% |
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When did the first health insurance company begin?
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1847
-rail/steamboat accidents 1864 -coverage for every type of accident |
