Chapter One Health Policy And Management

Front 1

Access

Back 1

The ability of an individual to obtain health care services when needed

Front 2

Administrative Costs

Back 2

The costs of billing, collections, bad debts, and medical record maintenance; more in the US than any other national health care system

Front 3

Balance Bill

Back 3

when providers can bill the patient directly for the remaining costs of treatment not covered by their insurance/health plan

Front 4

Capitation

Back 4

a payment mechanism in which all health care services are included under one set fee/covered individual (PMPM-predetermined fixed payment per member per month)

Front 5

Defensive Medicine

Back 5

Because of our litigious society, many practitioners prescribe additional diagnostic tests, schedule check-up visits, and maintain copious documentation; all of these additional efforts are often unnecessary, costly and inefficient

Front 6

Demand

Back 6

driven by the prices prevailing in the free market; increases as price is lowered

Front 7

Enrollee

Back 7

(member) refers to an individual covered under an insurance plan

Front 8

Free Market

Back 8

multiple patients (buyers) and providers (sellers) act independently; unrestrained competition must exist between providers on the basis of price and quality; patients must have information on price and quality for each provider; patients must have information about the availability of various services; patients must directly bear the cost of services received; patients make decisions as consumers about their purchases

Front 9

Global budget

Back 9

used to determine total health care expenditures on the national scale and to allocate the resources within the budgetary limits

Front 10

Health Plan

Back 10

a part of managed care which uses selected providers from whom enrollees can choose to receive routine services

Front 11

Inpatient Care

Back 11

Health services predominantly associated with acute care hospitals/institutions; to receive health care services, patients are temporarily confined to an institution, such as a hospital or nursing home, where they stay overnight

Front 12

Managed Care

Back 12

A system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by such methods as gatekeeping, case management, and utilization review. A large variety of arrangements can fall under this rubric. It is a system of delivery that 1.seeks to achieve efficiencies through integration 2. employs mechanisms to manage utilization 3. determines the price at which services are purchased

Front 13

Medicaid

Back 13

The US government financed program that provides health benefits to the poor

Front 14

Medicare

Back 14

The US government financed program that provides health benefits to the elderly and certain disabled individuals

Front 15

Moral Hazard

Back 15

the tendency of individuals to use health care services to a greater extent after purchasing health insurance than before when they did not have insurance

Front 16

National Health Insurance (NHI)

Back 16

The government finances health care through taxes, but it is delivered by private providers

Front 17

National Health system (NHS)

Back 17

A tax-supported NHI where the government manages the infrastructure for the delivery of medical care

Front 18

Need

Back 18

the amount of medical care that medical experts believe a person should have to remain or become healthy

Front 19

Outpatient Care

Back 19

the process where health care is delivered in a non-institutional setting; health care services that are obtained without an overnight stay

Front 20

Package Pricing

Back 20

a bundled fee for a package of related services

Front 21

Phantom Providers

Back 21

providers that charge costs not anticipated/included in the cost of a surgery, such as anesthesiologists, nurse anesthetists, and pathologists

Front 22

Premium Cost Sharing

Back 22

In employer based health insurance, employers do not pay 100% of the premiums, but require their employees to pay a portion of the cost

Front 23

Primary Care

Back 23

continuous basic and routine care. Basic and routine health care that is provided in an office or clinic by a provider (physician, nurse, or other health care professional) who takes responsibility for coordination of all aspects of a patient's health care delivery that is the patient's first contact with the health care delivery system and the first element of a continuing health care process.

Front 24

Provider

Back 24

Any entity that delivers health care services and receives payments directly for those services; mostly serve those covered by insurance. Any individual or organization that provides services generally covered under health insurance (including Medicaid and Medicare), e.g. physicians, hospitals, dentists, laboratories, pharmacies, and providers of durable medical equipment

Front 25

Quad-function Model

Back 25

A model of a functional health care system; the four primary functional components: 1. FINANCING-helps obtain health insurance or pay for services 2.INSURANCE-protects insured from catastrophic risk and costly care, specifies how and where services received 3.DELIVERY-given by providers 4. PAYMENT-reimbursement of payment to providers for services delivered

Front 26

Reimbursement

Back 26

the amount insurers pay to a provider (portion of the actual charge); funds come from premiums paid to insurance companies or HMOs; the determination of how much to pay for a certain service

Front 27

Single-payer System

Back 27

another term for National Health Care system; a health care reform proposal to create a single organization, usually a government agency, to pay all medical claims

Front 28

Socialized Health Insurance

Back 28

health care is financed through government-mandated contributions by employers and employees

Front 29

Standards of Participation

Back 29

standards formulated by the government through health policy and regulation; providers must comply with the established standards to be certified in order to provide for Medicaid and Medicare patients

Front 30

Supplier-induced Demand

Back 30

Like provider-induced demand; when moral hazard induces a larger utilization which creates an artificial demand for services; physicians can only over prescribe care to their patients with their own economic interests in mind

Front 31

System

Back 31

the main organizations and individuals involved in health care (educational and research institutions, medical suppliers, insurers, payers, and claims processors); very little standardization and components are functionally fragmented; two primary objectives of any health care system: 1. enable universal access 2. services must be cost effective and meet standards of quality

Front 32

Third Party

Back 32

The intermediary role of insurance; creates a wall between financing and delivery functions so that quality of care becomes a secondary concern. Under the current system, the payers for covered services, e.g. insurance companies, government. They are called third parties because they are neither the providers nor the recipients of medical services

Front 33

Uninsured

Back 33

those without private or public health insurance

Front 34

Universal Access

Back 34

Health insurance coverage for all citizens, as in a national health care program.

Front 35

Utilization

Back 35

Extent to which health care services are actually used. For example, the number of physician visits per person per year is a measure of utilization for primary care services.

Front 36

Why does cost containment remain an elusive goal in US health services delivery?

Back 36

Cost containment remains and elusive goal in US health services delivery because the system does not lend itself to standard budgetary methods of cost control. Each individual and corporate entity within a predominantly private entrepreneurial system seeks to manipulate financial incentives to its own advantage without regard to its impact on the system as a whole.

Front 37

What are the two main objectives of a health care delivery system?

Back 37

The two main objectives of the healthy care delivery system are to one, enable all citizens to access health care services and two, these services must be cost-effective and meet certain established standards of quality.

Front 38

Name the four basic functional components of the US health care delivery system. What role does each play in the delivery of health care?

Back 38

The four basic functional components of US health care delivery & functions:
a.Financing- helps obtain health insurance or pay for services
b.Insurance- protects insured from catastrophic risk and costly care, specifies how and where services received
c.Delivery- given by providers
d.Payment- reimbursement of payment to providers for services delivered

Front 39

What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees?

Back 39

The primary reason for employers to purchase insurance plans to provide health benefits to their employees is that its in their best interest to keep their workers healthy and performing optimally; employers also get discount pricing because of group rates offered by insurance companies.

Front 40

Why is it that despite public and private health insurance programs, some US citizens are without any coverage?

Back 40

5. Despite public and private health insurance programs, some US citizens are uninsured because their low wages are enough to make them ineligible for federally funded programs, but they cannot afford premium cost sharing through their employers, if their employers even provide insurance.

Front 41

What is managed care?

Back 41

Managed care is a system of health delivery which, 1. Seeks to achieve efficiencies through integration 2. Employs mechanisms to manage utilization 3. determines the price at which services are purchased

Front 42

Why is the US health care market referred to as "imperfect"?

Back 42

The US health care market is imperfect, or quasi-market, because costs are fixed by the government, buying power is consolidated in the hands of private health plans, which forces providers to form alliances, patients do not have adequate information about services and their price/quality, patients do not directly pay for their services, and finally, patients do not make the decisions about the purchase of health care services, they are directed by their physicians.

Front 43

Discuss the intermediary role of insurance in the delivery of health care.

Back 43

The intermediary role of insurance in the delivery of health care is that of a third party. This intermediary influence creates a wall between financing and delivery functions so that quality of care becomes a secondary concern.

Front 44

Who are the major players in the US health services system? What are the positive and negative effects of the often-conflicting self-interests of these players?

Back 44

The major players in the US health services system are physicians, administrators of health service institutions, insurance companies, large employers, and the government. One positive effect of their opposing self-interest is that they prevent any single entity from dominating the system. On the negative side, each player has a large stake in health policy reforms. In an environment where everyone is competing for their own self advancement, achieving comprehensive systemwide reforms and cost containment are nearly impossible.

Front 45

What main roles does the government play in the US health services system?

Back 45

The main roles of the government in the US health services system is as a financer through Medicare and Medicaid the government finances medical costs for those unable to pay. The government also serves as a sort of regulator through certification and standards of participation with Medicare/Medicaid.

Front 46

Why is it important for health care managers and policy makers to understand the intricacies of the health care delivery system?

Back 46

It is important for health care managers and policy makers to understand the intricacies of the health care system because it can help officials be more attuned to their own positions/role/relationship to the rest of the health care environment. It can help to better understand changes and their potential impact on their own practices.

Front 47

What kind of a cooperative approach do the authors recommend for charting the future course of the health care delivery system?

Back 47

A multifaceted system will be needed to plot the future progress of the American health care system. It will need to be a joint undertaking that involves a balanced representation of the key players in health service delivery.

Front 48

What is the difference between national health insurance (NHI) and a national health system (NHS)?

Back 48

13. Both National Health Insurance, NHI, and National Health System, NHS, are tax-supported, but in NHS the government manages the infrastructure for the delivery of medical care and in NHI health care is delivered by private providers.

Front 49

What is socialized health insurance (SHI)?

Back 49

14. Socialized Health Insurance is health care financed through government-mandated contributions by employers and employees