2: Paying for Healthcare Flashcards
Why was there growth in employment based insurance after WWII?
Attracted commercial for profit insurance companies (Aetna or United) to the healthcare field.
Who created BCBS, when and why? Method to set premiums?
BC: Initiated in New Jersey by American Hospital Association as an experiment
BS: two years later by the AMA to protect doctors
The Blues: created in all states and merged into a single organization offering coverage for hospital and physician expenditure
Offered community rating
What does Bloche mean when he discusses the “soul of BCBS”? What is the identity of BCBS in the early periods?
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Why did doctors oppose BCBS plans? What changed their minds?
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Basic characteristics of insurance system in the U.S.? Does the ACA change these features?
- Direct risk adjustment: medical underwriting and redlining
- Indirect risk adjustment: limiting the benefit package by excluding certain services or drugs from coverage or placing caps on the level of services
ACA banned direct risk adjustment
What factors explain the rapid growth of employment based insurance in the aftermath of the WWII?
The government allowed health insurance to be tax exempt if sponsored by employers, employers offered health insurance as a fringe benefit to attract good workers, advantages of group insurance over individual insurance. Companies competed for workers began to offer health insurance (Great Depression, no wage increases)
What is the basic function of insurance according to B&G? Are Americans protected against finical loss due to illness?
A mechanism to protect against unpredictable loss
How did insurance companies calculate risk of a patient before the ACA?
Direct risk adjustment: pre-existing conditions, job, hobbies,
Community rating
Health plans with a flat rate (premium) for everyone in a given geographic area
Redlining
Refusing coverage to certain people on the basis of geographical location, involvement in high risk groups/lifestyles or history of excessive claims
Experienced rating
Different premiums paid based on differences on demographics, past utilization, medical status
Out of pocket payments
Direct payment you have to pay until a you hit a limit before insurance kicks in. Resets every year
Managed Care
An organized system of healthcare that attempted to reduce services that deemed ineffective/unnecessary
health services buildings managed under a fixed budget
Managed care restricts the autonomy of physicians
Actuarial Value
the percentage of total average costs for covered benefits that will be paid by a health insurance plan
(Bronze plans, for example, pay on average 60% of the medical costs of covered benefits. Silver plans pay 70 percent, Gold plans pay 80 percent and Platinum plans pay 90 percent.)
Preauthorization
Health insurer decides if what you need is necessary, or gives you permission to use services when you ask
Utilization Review
Systems that monitor provider prices and quality of healthcare by enrollees
Premium
an amount paid periodically to the insurer by the insured for covering his risk.
Out of Pocket Maximum
The most you have to pay for covered services in a plan year
Deductible
is the amount paid out of pocket by the policy holder before an insurance provider will pay any expense
Co Payment
a fixed amount for a covered service, paid by a patient to the provider of service before receiving the service.