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Health Care Delivery > Block 1 > Flashcards

Block 1 Flashcards

1
Q

Enable all citizens to obtain needed health care sevices

A

Access

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2
Q

Services must be cost effective

A

Cost

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3
Q

Services must meet established standards

A

Quality

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4
Q

3 things considered to be acceptable healthcare

A

Access, Cost, Quality

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5
Q
  1. Cultural beliefs and Values
  2. Social Changes
  3. Technological Advances
  4. Economic Constraints
  5. Political Opportunism
A

5 factors that influenced our health care system

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6
Q

What are the 3 eras of US healthcare

A
  1. pre-industrial era
  2. post-industrial era
  3. corporate era
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7
Q

Care was provided by minimally educated physicians and some nurses

inexpensive: payment in cash or trade

A

Pre-industrial era

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8
Q

Development and growth of medical profession, nursing profession

Increased education
Urbanization led to concentration in cities and towns
Development and growth of hospitals

A

Post-industrial era

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9
Q

Post industrial era gave rise to what?

A

private health insurance

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10
Q

Explain employer based private health insurance

A

employers offered health insurance as a benefit instead of raising wages

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11
Q

What are the 4 main features of the corporate era?

A
  1. corporatization
  2. growth of non-physician workforce
  3. information revolution
  4. globalization
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12
Q

medical care is dominated by large corporation

A

corporatization

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13
Q

Many educated health professionals

A

growth of non-physician workforce

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14
Q

massive amounts of knowledge and information at everyone’s finger tips

A

information revolution

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15
Q

cross- border exchange of goods and services

A

globalizations

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16
Q

when was the Affordable Care Act passed

A

2010

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17
Q

Why do people have health insurance

A

run a risk of an accident or developing a disease to limit the high out of pocket cost

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18
Q

If a person applies for insurance they are automatically accepted

A

Guaranteed issue

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19
Q

as an employer you must supply insurance

A

employer mandate

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20
Q

Government says you must be covered by insurance (like school)

A

government mandate

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21
Q

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

A

underwriting

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22
Q

Underwriting is based on what?

A

judgement based on risk

23
Q

Explain Risk pool: adverse/favorable selection

A

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

24
Q

Explain the 4 make up of risk pools

A
  1. large pool: more healthy than sick=healthy large pool
  2. Small pool: more healthy than sick= healthy small pool
  3. Large pool: more sick than healthy= Large sick pool
  4. Small pool: more sick than healthy=small sick pool
25
Q

Out of the 4 pools which has the most adverse effect for health insurance companies?

A

Large sick pool then small sick pool

26
Q

out of the 4 pools which has the most favorable effect for health insurance companies?

A

Large Healthy pool then small healthy pool

27
Q

Which pool will have the highest premiums

A

the large sick pool will have the highest premiums because they are most at risk for spending alot of the insurance companies money

28
Q

How do insurance companies stabilize the risk pool?

A
  1. not market as much
  2. increase premiums
  3. maintain databases of group risk
29
Q

Us as a whole everyone has the exact same premium- no matter what their health status is

A

Community rating

30
Q

Bob as an individual are they gonna sell to him and at what premium

A

individual rating

31
Q

With individual rating can you charge people different premiums?

A

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

32
Q

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

A

rescission

33
Q

What were common practices prior to the ACA

A
  1. denying- ppl coverage with pre-existing conditions
  2. excluding- excluding coverage to care associated with pre-exisiting conditions
  3. charging- higher rates with people based on sex or gender
  4. limiting- limiting benefits on mental health, substance use, maternity care
  5. imposing- lifetime or annual caps on care
34
Q

What changes with ACA

A

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

35
Q

Can you charge someone more based on individual rating?

A

NO individual rating

36
Q

Can you remove someones policy after they are injuries and need insurance

A

NO rescission

37
Q

are you allowed to charge someone more because of their underlying condition

A

NO underwriting

38
Q

How does competition in the market impact premiums?

A

more competition in the market make premiums lower more competitive

small sick pools increase premiums
large healthy pools decrease premium

39
Q

How does guaranteed issue help ACA

A

increased pool size because everyone gets insurance who applies

40
Q

How does modified community rating help in the ACA

A

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

41
Q

Who are the players in the business of Health care? the 3 ps?

A

Payers/insurers-united health care, cigna, bc/bs, medicaid
providers-hospitals, pt clinics
patients

42
Q

Premiums

A

include payment from employer and employee every month

43
Q

Co-pay

A

portion is responsible for a certain cost at time of visit

44
Q

Co-insurance

A

80 20 plan

45
Q

deductible

A

you have to pay this price before insurance company pays anything

46
Q

How does employer-based private insurance work

A

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

47
Q

How does government insurance work

A

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

48
Q

Cost-sharing

A

pt pays copay and coinsurance at the time of visit that goes straight to provider

49
Q

providers has more info than consumer or patient
Ex: MD says you need surgery and pt has no idea if they do or not

A

information asymmetry

50
Q

What population has the greatest information asymmetry?

A

medicaid population

51
Q

provider has superior knowledge therefore society is dependent on this person

A

power asymmetry

52
Q

Explain the moral hazard theory

A

trend toward risky behavior because you know that you have insurance and someone else will pay for it

53
Q

Key point in moral hazard

A

over-utilization of services if cost sharing is low

insurance companies don’t like over-utilization

Health Care Delivery (19 decks)

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