5. Economics of Health Care Delivery

Question 1

addresses health care disparities; places a greater emphasis on access to health care which leads to improvements in prevention of illness, patient outcomes, and population health; also provides a means to provide health insurance to more Americans

Answer 1

Affordable Care Act (ACA)

Question 2

Key provisions of ACA

Answer 2

• eliminate lifetime limits on benefits
• expand coverage for children on their parent’s health plans until 26
• prohibit discrimination due to pre-existing conditions
• increase medicaid coverage by states
• increase payment to rural health providers
• strengthening community health centers
• increased medicaid payment to PCPs
• link payments to quality not quantity
• mandate minimum coverage for certain conditions and prevention services

Question 3

What is the health care system turning to for future care?

Answer 3

primary prevention

Question 4

Benefits of primary prevention

Answer 4

• reduce money spent on health care

- increases quality of life

Question 5

Challenges of 21st century

Answer 5

• emergence of new and old communicable and infectious diseases
• chronic disease prevention programs
• complex technology (more expensive)
• hospital intensivists
• more care provided at home
• DNP
• emphasis on prevention and wellness

Question 6

What are the largest portions of health care spending

Answer 6

• hospital care and physician services

- home health care is expected to rise dramatically

Question 7

Factors that influence health care costs

Answer 7

• demographics
• technology and intensity
• chronic illness

Question 8

How is patient demographics affected health care

Answer 8

• aging population -> demands on medicare and medicaid increase
• with aging -> experience more chronic conditions that may be disabling

Question 9

most common medical condition treated

Answer 9

hypertension

Question 10

Why do chronic conditions cost more money

Answer 10

• number of bed days
• number of work-loss days
• activity impairments

Question 11

2 forms of public support to finance health care

Answer 11

Medicare and Medicaid (1965)

Question 12

Criteria for Medicare

Answer 12

• 65 y/o and older
• permanently disabled (24 months or longer)
• persons w/ ESRD

Question 13

Medicare Part A

Answer 13

everyone pays for this

• inpatient hospital care
• skilled nursing facility (must be getting skilled care; not long term nursing home)
• home health agency
• hospice

Question 14

Medicare Part B

Answer 14

services (tests, doctors, etc)

Question 15

Medicare Part C

Answer 15

medicare advantage (HMO)

Question 16

Medicare Part D

Answer 16

prescription plan

Question 17

Challenges of Medicaid

Answer 17

• recipients half as likely to obtain needed services
• lack of willing physicians
• reliance on emergency departments

Question 18

traditional health care payment where fees set after delivery and negotiated by payer and provider

Answer 18

retrospective reimbursement

Question 19

health care payment where price is set by organization and billed; client pays what insurance does not

Answer 19

charge method

Question 20

health care payment where third-party payer establishes fee before offering service; requires pre-approvals

Answer 20

prospective reimbursement