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32 Cards in this Set
- Front
- Back
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What are the modes of financing health care?
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Out-of pocket payment - 16%
Individual Private Insurance - 3% Empolyment Based group Private Insurance - 33% Goverment Financed Programs - 44% |
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How are people covered in the US?
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Uninsured - 16%
Individual Private Insurance - 3% Employment Based Private Insurance - 55% Goverment Financing - 27% NOTE: 1/3 of US Citizens are covered by goverment insurance! |
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Describe Medicare Eligibility?
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Covers Americans 65+ who are eligible for social security
- they DO NOT have to be retired - They must pay into social security for the past 10 years - Covers the spouse too COVERS AMERICANS who are younger then 65 if they have a permanant disability - Must have payed into social security for 24 month [2yrs] - The 2 yr requirment is waved for people who are: On dialysis, transplant patients, end-stage renal disease. |
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What does MediCARE A covers?
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- Hospitalization
- Skilled Nursing Home - Home Care - Hospice Care * People also enroll in Medigap or and 16% of mediCARE people enroll in mediCAID. |
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Who is eligible for MediCARE B?
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Anyone who is eligible for MediCARE A, but there is a 70$ fee for MediCARE B.
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Medicare C and D are?
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C: alternative to medigap, offers incentives such as extra hospital days.
D: The Medicare Drug Prescription Plan |
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What are the two main categories of people w/out health insuracne?
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Employed Uninsured
& Unemployed Uninsured |
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Why has lack of insurance been increaseing in the past 15 years?
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Cost of health care insurance has gone up causing employers to stop covering their employees.
Employees pay part of the cost of job-based health insurance, and they may not be able to afford it Us economy is moving from high-wage full time manifucturing workforce toward low-wage, part-time service workforce without health insurance. |
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What is the impact of uninsurance?
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Uninsured children are 4 times more likely to go w/out needed medical serivce then insured children.
insured adults recive 90% more hospital care then uninsured. 55% of uninsured says they postpone their health because they cannot afford it. Huge drag on health care economy. |
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Describe Capitation Payment?
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The insurer pays per patient. The IPA assumes the risk and spreads that risk to all participating physicians.
The capitation-plus-bonus payment may lead to incentives for less frequent use of diagnostic and specialist services. If physician does not use the servies for his patients, he will recive a bonus at the end of the year. |
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Describe the disperced health care model?
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US health model: multiple access points by patient choice or doctor referral
fewer requirments for GP gatekeeping less clearly defined roles of providers less distinction in hospital care |
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Describe the regionalized health care model?
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Population based planning
Regionalized Hospitals w/ distinct functions <<stepwise>> patient flor thru the tiers --> primary --> secondary --> tetiary |
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What is the first Generation of HMO?
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Vertical Integration: Consists of a health plan, hospital, medical group, physicians... all under one roof. Hospitals are on a global budget
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What is the second Generation of HMO?
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Virtual Integration
Group Model Virtual Integration Involved contracting out between the HMO and provider (i.e. physicians, hospitals, etc). |
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Describe what is the PPO? [preffered provider organization]
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PPO recives monthly premiums from subscribers and employers.
Patients are requried to select a physician and hospital from a preffered ('approved') list The insurance can deny / approve care required by the physician. |
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What is an IPA?
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IPA is independent physician association, they are a group of doctors who decide how payments is redestributed within a practice.
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Describe the German Health Care System?
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Sick Funds [come from employers] --> Concerted Action at Regional Level ---[
1. Regulated Rates --> Hospitals 2. Expenditure Cap --> Physicians -------------------------- Control build into the system It remains occupational fund Room for physician maneuver Rapid Cost increase Preassure of private system Pressure of demographic change ------------------------------ |
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Describe the Canadian Health Care System?
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review lectures:
----------------- - Everyoen is insured via gov. - Financed by provincial and fed taxes - Hospitals are on global budget - Hospitals have independent boards (not gov owned) - Hospitals are voluntery - Physicians are fee-for-service payment. |
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Describe the NHI system:
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-NHI are more effective at cost control
-Monopoly Buyers, negotiated fees, lower administrative costs -NHI are unversal and comprehansive -NHI needs to be accompanied by primary health care model Problems: -Rationing of non-urgent care -Burden on Public Purse -Need extensive regulatory mechanism |
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What are the problems for physicians in managed care?
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Risk Sharing:
- Financial Risk for care providers - Ethical conflicts vs. Efficient Care Gatekeeper Function: - Problem of case managment |
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In Canada, hospitals are payed based on:
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On a global budget.
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Doctors in Canada are payed:
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Fee-For-Service
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Canada per capita costs are, compared to US costs?
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60%
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What are some concerns for Canadians?
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Fee-For-Service Inflationary potential.
Need for primary care reform. Integrative health care services. 100% Coverage for insured yet 30% of costs are outside public system and may or may not be covered by supplemental insurance. Non-urgant care waiting lists Physician Supply and Distribution. |
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In germany Dr. are payed how?
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Fee-for-service
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In Germany, Hospitals are payed how?
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DRG Funds...
Note: there is a yearly cap on what each sickness fund will pay doctors and hospitals. |
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Germany -- Private Insurance:
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Sickness fund enroll about 90% of all Germans. Private Insurance covers about 8% of the population.
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What are the pros fo Goverment Fianced National Health Insurance?
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Cost Control is build in & Lower Admission fees.
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What are the 'players' in the health care reform?
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Purchesers - your consumers
Insurers - recive money from purchesers Providers - provide the care Suppliers - the pharma and medical supply industry |
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What is the source of conflict in the US ?
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Fundemental conflic between purchasers and other actors:
purchasers want to reduce the costs while the health care industry wants to increase them. |
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What are the impact of costs on health care?
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Risings costs make health care indurance unaffordable for greater number of individuals and firms.
premiums payed on these policies have risen over 10% per years since 1999. As a result of increased patient costs, access to care is declining -- more people are uninsured and many more are underinsured. |
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What is the ER room situation in the United States?
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two out of every five Americans visit an ER every year.
More then half are at or above capacity From 1993 to 2003 emergency room visits increased by 27% in the US, while at the same time, 425 emergency department closed. ER patients have access issues, in terms of medical needs & insurance coverage. |
