Block 1 Flashcards
Enable all citizens to obtain needed health care sevices
Access
Services must be cost effective
Cost
Services must meet established standards
Quality
3 things considered to be acceptable healthcare
Access, Cost, Quality
- Cultural beliefs and Values
- Social Changes
- Technological Advances
- Economic Constraints
- Political Opportunism
5 factors that influenced our health care system
What are the 3 eras of US healthcare
- pre-industrial era
- post-industrial era
- corporate era
Care was provided by minimally educated physicians and some nurses
inexpensive: payment in cash or trade
Pre-industrial era
Development and growth of medical profession, nursing profession
Increased education
Urbanization led to concentration in cities and towns
Development and growth of hospitals
Post-industrial era
Post industrial era gave rise to what?
private health insurance
Explain employer based private health insurance
employers offered health insurance as a benefit instead of raising wages
What are the 4 main features of the corporate era?
- corporatization
- growth of non-physician workforce
- information revolution
- globalization
medical care is dominated by large corporation
corporatization
Many educated health professionals
growth of non-physician workforce
massive amounts of knowledge and information at everyone’s finger tips
information revolution
cross- border exchange of goods and services
globalizations
when was the Affordable Care Act passed
2010
Why do people have health insurance
run a risk of an accident or developing a disease to limit the high out of pocket cost
If a person applies for insurance they are automatically accepted
Guaranteed issue
as an employer you must supply insurance
employer mandate
Government says you must be covered by insurance (like school)
government mandate
an individual applies for an insurance and the insurance company looks at the risk factors and depending on those risk factors will change them more or less
underwriting
Underwriting is based on what?
judgement based on risk
Explain Risk pool: adverse/favorable selection
Insurance companies have a certain number of people apply to purchase a insurance and the people that make up the risk pool can either be good or bad for the insurance company
Explain the 4 make up of risk pools
- large pool: more healthy than sick=healthy large pool
- Small pool: more healthy than sick= healthy small pool
- Large pool: more sick than healthy= Large sick pool
- Small pool: more sick than healthy=small sick pool
Out of the 4 pools which has the most adverse effect for health insurance companies?
Large sick pool then small sick pool
out of the 4 pools which has the most favorable effect for health insurance companies?
Large Healthy pool then small healthy pool
Which pool will have the highest premiums
the large sick pool will have the highest premiums because they are most at risk for spending alot of the insurance companies money
How do insurance companies stabilize the risk pool?
- not market as much
- increase premiums
- maintain databases of group risk
Us as a whole everyone has the exact same premium- no matter what their health status is
Community rating
Bob as an individual are they gonna sell to him and at what premium
individual rating
With individual rating can you charge people different premiums?
yes you can charge people different premiums but it must be based on the community not the individual and their risk factors- modified community rating
An insurance company takes action to cancel a policy holders coverage by citing omission or error in the customer application even if the policy holder has been diligently keeping their policy current
rescission
What were common practices prior to the ACA
- denying- ppl coverage with pre-existing conditions
- excluding- excluding coverage to care associated with pre-exisiting conditions
- charging- higher rates with people based on sex or gender
- limiting- limiting benefits on mental health, substance use, maternity care
- imposing- lifetime or annual caps on care
What changes with ACA
guaranteed issue
insurance mandate
stabilizing risk pool
NO individual rating based on age sex geography only can do community rating based on the area
No Rescission- removing policy when patient needs insurance
NO underwriting
Can you charge someone more based on individual rating?
NO individual rating
Can you remove someones policy after they are injuries and need insurance
NO rescission
are you allowed to charge someone more because of their underlying condition
NO underwriting
How does competition in the market impact premiums?
more competition in the market make premiums lower more competitive
small sick pools increase premiums
large healthy pools decrease premium
How does guaranteed issue help ACA
increased pool size because everyone gets insurance who applies
How does modified community rating help in the ACA
premiums are moderated based on location so that it helps those in high risk groups such as older people, women who are child bearing age, those living in areas with high numbers of existing conditions
Who are the players in the business of Health care? the 3 ps?
Payers/insurers-united health care, cigna, bc/bs, medicaid
providers-hospitals, pt clinics
patients
Premiums
include payment from employer and employee every month
Co-pay
portion is responsible for a certain cost at time of visit
Co-insurance
80 20 plan
deductible
you have to pay this price before insurance company pays anything
How does employer-based private insurance work
patient (employee) doesnt have a choice in insurance- employer pays a portion of the premium to the payer/insurance then the insurance company pays the providers who gives the service to the patient
How does government insurance work
government is involved in all of it so people pay taxes, then taxes go to the insurance/payers and the providers adn the patient also pays taxes
examples are medicare, medicaid, VA
Cost-sharing
pt pays copay and coinsurance at the time of visit that goes straight to provider
providers has more info than consumer or patient
Ex: MD says you need surgery and pt has no idea if they do or not
information asymmetry
What population has the greatest information asymmetry?
medicaid population
provider has superior knowledge therefore society is dependent on this person
power asymmetry
Explain the moral hazard theory
trend toward risky behavior because you know that you have insurance and someone else will pay for it
Key point in moral hazard
over-utilization of services if cost sharing is low
insurance companies don’t like over-utilization
