3) Health Care Financing, Access, Payment, and Formats Flashcards
What are the types of payment for health care?
- Out-of-pocket
- Individual private insurance
- Employer-based private insurance
- Govt financing
As of 2013, the highest percentage of the national health expenditure went towards what type of payment?
Government financing
Out-of-pocket payment
2 party-deal involving cash or barter
- Was the most common payment type until the mid-20th century
Individual Private Insurance
Third-party system where the insurer acts as the third party and is included in transactions btwn the two basic parties (pt/consumer & provider)
- Requires 2 transactions:
- Consumer premiums to insurance company
- Insurer reimburses the provider
Employment-Based Private Insurance
Type of third-party payment system where the employer pays the premiums to the insurance company
Describe the purpose of govt-financed health care
- Redistributes the funds from wealthy to the poor, elderly, and people who can access insurance through their job
How does govt-financed health care work?
An individual enrolls and taxpayers subsidize and then the govt pays the provider
Medicare Part A
Inpatient hospital insurance plan financed through social security
Medicare Part B
For outpatient/physician services; Financed by federal taxes and monthly beneficiary premiums
- You have to pay into it
Medicaid
State-run programs for low-income peeps; Funded by federal and state taxes
- Have to qualify for this
Medicare Part D
Prescription drug coverage
- Optional
CHIP
Companion program to Medicaid to make it easier for kids to get coverage
- Implemented in the 1990’s
Describe the 3 types of health care financing
Progressive - Pay more as you make more based on tax brackets
Regressive- Pay a fixed percent; Not based on income
- Most common in US
Proportional- Proportional to income
Access
The timely use of personal health services to achieve the best health outcomes; A person’s ability to obtain health care services when needed
Availability
Can you get the (special) services you need?
Accessibility
Payment options, Convenience, Physical access to the office
Affordability
Individual’s ability to afford coverage and meet cost-sharing requirements
Acceptability
Bedside manner; Cultural competance
How does lack of insurance affect access to health care?
It delays the seeking of care, the condition worsens, and then more skilled/costly care is needed
True or false: Uninsured kids can access care more easily than uninsured adults?
True
Market Justice
Free market where health care is an economic good and based on people’s ability to pay
- Tends to be the school of thought for the politically conservative
Social Justice
Runs under the belief that health care is a right so the government assists w/allocation
- Tends to be the belief for democrats
Moral Hazard
People are more likely to seek care when someone else is paying for it
Health Disparity
A higher burden of illness, injury, disability, or morality on one group relative to another
Health Care Disparity
Differences btwn groups in health coverage, access to care, and quality of care
What are the types of payment methodologies?
- Self-pay
- Fee for service
- Bundled
- Per diem/per visit
- Per episode
- Capitation
Self-Pay
Cash-based services where the pt directly pays the provider for services
- Bill is given directly to the pt
- Pt can submit to insurance
- Maximizes cash flow and minimizes administrative burden on the provider
- Limits market to those who are willing/able to pay
Fee for Service
Provider reports each service delivered w/a fee for each
- Basis of payment for outpatient PT
- Uses CPT codes
- Fees/charges are set by the provider
- Leads to overutilization
Per-Visit/Per Diem
Bundled payment where one lump sum payment is given for each visit regardless of a number of services provided
- Moving more towards this trend
- Can require CPT codes
Per-Episode Payment
One lump-sum payment is given for an episode of care
- Not based on charges→Quality measures are attached to this
- Allows the provider freedom to select which services will be provided
- Associated w/reduced administrative costs
- Basis for diagnosis-related groups
- Issues=Accuracy of dx/px, outliers, definition of “episode”
Capit
A monthly/yearly lump-sum payment that covers all subscribers
- Incentivizes to keep the population healthy
- High risk to provider
Describe risk pattern for self-pay
High risk to pt; Low risk for provider
Describe the risk pattern for fee-for-service
High risk to payer
Describe the risk pattern for bundled services
High risk for provider
What payment methods are used for hospitals?
Fee-for-service and Per-diem
Diagnostic Related Group
A type of per-diem payment under medicare part A where payment rates are based on the resources needed to care for each DRG
What payment methods are used for inpatient rehab?
Per-diem, Private managed care, or prospective payment system (PPS)
PPS
Utilizes info from the pt assessment instrument to classify pt’s into groups and payment is linked to the pt’s fxnl level
What payment methods are used for SNF’s?
Contract, Per-diem, or Medicare PPS
- Part A rates based on case mix using a resident classification system
What payment methods are used for long-term care hospitals?
PPS
What payment methods are used for home health?
Medicare, Medicaid, Fee-for-service, Managed care, or Private Pay
Describe Medicare Part A: Home Health
- PPS
- Predetermined base payments are given to the agency based on case mix adjustments for pt’s conditions and needs of pt
- Rates are adjusted to geography
- Based on the OASIS
- Consolidated billing for nursing, therapy services, medical supplies, home health aides. & medical social services
What is the basis of payment for Medicare Part B?
Physician Fee Schedules
Medicare pays the provider 80% of the fee schedule amount and the pt is responsible for the remaining 20%
