10/2c Healthcare Delivery Systems Part 1 (Integrated Care and Practice)

Question 1

delivery system is:

Answer 1

an interplay between access, cost, and quality healthcare

Question 2

Healthcare access

Answer 2

Public Sector - federal, state, local

Private Sector - for profit, non for profit

Question 3

examples of government sector healthcare

Answer 3

VA
Medicare
Medicaid
Not competeing against each other
Governed by las
steps to go through to access more care
health policies

Question 4

examples of private sector healthcare

Answer 4

corporations
nonforprofit
small businesses
capital banks
money from investors
shareholder/stakeholder/board of directors
consumer cost sharing

Question 5

out of pocket payments for consumer cost sharing

Answer 5

copayments and deductibles

Question 6

Define copayment

Answer 6

flat fee/dollar amount that the person who is consuming the healthcare good or service has to pay in addition to the insurance payment

Question 7

define deductible

Answer 7

how much the person consuming has to pay out of pocket before the insurance kicks in

• not a free market, so doesn’t depend on supply and demand
• the more that people are in the private sector, the more out of pocket payments will be there

Question 8

define coinsurance

Answer 8

• reported in GCP (overall amount the country consumes in goods and services)
• consumption has increase a lot over time

Question 9

healthcare financing - how are we giving money to healthcare?

Answer 9

• The flow of dollars (premiums and taxes) from individuals and employers to health insurance plan (private or government)
• Provider can get money in different ways:
  1. OOP
  2. Individual Private Insurance
  3. Employment Based Private Insurance

Question 10

health spending by major sources

Answer 10

• private = 34%
• medicare = 20%
• medicaid = 17%

Question 11

at the end of the day, what is health insurance?

Answer 11

• provides a mechanism to distribute health care more in accordance with human need rather than exclusively on the basis of ability to pay
• funds are redistributed from the healthy to the sick, a subsidy that helps pay the costs of those unable to purchase their own
• private insurance is mainly experience rated and employer based

Question 12

Government financing of health care

Answer 12

Medicare

Medicaid

Question 13

Medicare

Answer 13

• social insurance model
• allows only those who have paid a certain amount of SS taxes to be eligible for part a and only those who pay a monthly premium receive benefits from part b

Question 14

Original medicare

Answer 14

parts a and b

Question 15

medicare advantage pans

Answer 15

part c = HMOs and PPOs

-approve by medicare, but run by private companies

Question 16

medicare prescription drug coverage

Answer 16

part d

• formulary
• premium
• deductible
• co-pay
• brand
• coverage/gap

Question 17

medigap

Answer 17

• large deductibles, copayments, and gaps in coverage caused medicare to only pay for 58% of the average beneficiary’s health care expenses in 2012
• medigap is supplemental private insurance coverage purchased by employers or beneficiaries

Question 18

medicaid

Answer 18

• public assistance model
• tax payers (those who contribute) may not be eligible for benefits
• state children’s health program

Question 19

PDPM

Answer 19

• Patient Driven Payment Model
• long term care centers being reimbursed for their patients
• nursing driven payment model
• the process of using data to evaluate the performance of health plans and health care providers against recognized quality standards

Question 20

health policies

Answer 20

• public health policies are results of decisions made by an authoritative branch of government that are intended to influence the utilization of healthcare resources
• MOST > LEAST = communist > socialist > comprehensive > wellfare > entrepreneurial

Question 21

Patient protection and affordable care act (ACA)

Answer 21

tried to increase access to more individuals through Medicaid expansion

Question 22

Bundle payment systems

Answer 22

episode based payments

• fee for services reform towards a payment that rewards value rather than volume
• ends up being bad down the line, because they try to cut costs and avoid things they don’t deem “necessities”

Question 23

Accountable Care Organizations

Answer 23

ACOs

• groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to their medicare patients
• different types of ACOs
  1. medicare shared savings program
  2. advance payment aco model
  3. pioneer aco model
• they prove outcomes with their patients and are able to get bonuses