Chapter 1 Delivering Healthcare part 1 Flashcards
How is the United States’s healthcare system unique compared to everywhere else?
Americans are not automatically covered by health insurance
Different people obtain healthcare through different means
Why is US healthcare delivery complex?
Many organizations and individuals are involved in healthcare.
It is also a massive system with a vast array of health care institutions
Various types of healthcare professionals are involved
Multitudes of government agencies are involved
Does US healthcare delivery function as a rational and integrated network of components designed to work together coherently?
No
What are the characteristics of the US system?
A multiplicity of financial arrangements for health care services
Numerous insurance agencies or MCOs that employ various mechanisms for insuring against risk
Multiple payers that make their own determinations regarding how much to pay for each type of service
A diverse array of settings where medical services are delivered
Numerous consulting firms offering expertise in planning, cost containment, electronic systems, quality, and restructuring of resources.
Negative aspects of the US healthcare system
Little standardization
Problems of duplication, overlap, inadequacy, inconsistency, and waste due to lack of a central government agency to oversee coordination.
A complex and inefficient system due to lack of system-wide planning, direction, and coordination.
Cost containment remains an elusive goal d/t everyone’s individual interests needing financial incentives
Which country consumes more healthcare services as a proportion of its total economic output than any other country in the world?
The United States
What are the two primary objectives of an acceptable healthcare delivery system?
Enable all citizens to obtain needed healthcare services
Ensure that services are cost-effective and meet certain established standards of quality
What are the components of the quad-function model?
Financing
Insurance
Delivery
Payment
What is the source of insurance for most Americans?
Employer-based
Why is financing necessary?
To obtain health insurance or pay for healthcare services.
What is the purpose of insurance?
To protect the insured against financial catastrophe by providing expensive healthcare services when needed.
To what does the term delivery refer?
The provision of healthcare services by various providers.
Define the term provider
Any entity that delivers healthcare services and either independently bills for those services or is supported through tax revenues
What does the payment function deal with?
Reimbursement to providers for services delivered
From where do the funds to pay the provider come?
The premiums paid to the MCO or insurance company, with the exception of the out-of-pocket amount charged immediately to the pt
With gov’t insurance plans, the money comes from tax revenues
Who is covered under Medicare and under what gov’t is it run?
The elderly and certain disabled individuals
Federal gov’t
Who is covered under Medicaid? Under what gov’t is it run?
The indigent
Jointly by federal and state gov’ts
Who is covered under CHIP? Under what gov’t is it run?
Children from low-income families
Federal-state partnership
What are the two main reasons some employed individuals remain uninsured?
Some small businesses cannot get group insurance at affordable rates
In some work settings, participation is voluntary, and many people do not join because they can’t afford the cost of health insurance premiums.
Define premium cost-sharing
When employees are required to pay a portion of the cost of health insurance premiums
Define healthcare reform
The expansion of health insurance to cover the uninsured
What was the most sweeping healthcare reform in recent US history?
The Patient Protection and Affordable Care Act of 2010, or the ACA
What was one of the main objectives of the ACA?
To reduce the number of uninsured
What was a requirement of the ACA in terms of insurance?
All US citizens and legal residents must be covered under public or private insurance
Define universal coverage
Coverage that enables all citizens and legal residents to have health insurance
Trends in insurance coverage after the ACA
Uninsured rate declined among all race-ethnicity categories
Females experienced a greater decline in uninsured rate compared to males
Consequences of Trump’s repeal and replace ACA
Uninsured rates soared
When was there a fundamental change in healthcare delivery and what was it?
The 1990s
Involved a tighter integration of the basic functions through managed care
Define utilization of health services
The quantity of healthcare consumed
Describe managed care
A system of healthcare delivery that
1. Seeks to achieve efficiency by integrating the 4 functions of healthcare delivery
2. Employs mechanisms to control utilization of medical services and
3. determines the price of services and consequently, how much the providers are paid
Define enrollee
The individual covered under the health plan
Define health plan
The contractual arrangement between the MCO and the enrollee, including the collective array of covered health services that the enrollee is entitled to
What is managed care good at?
Implementing effective cost-saving measures without compromising access and quality
What external influences shape the basic character of the health services delivery system?
National political climate
Economic development
Technological progress
Social and cultural values
Physical environments
Population characteristics
What are the 10 basic characteristics that differentiate the US healthcare delivery system from most other countries?
- No central agency governs the system.
- Access to health care services is selectively based on insurance coverage
- Healthcare is delivered under imperfect market conditions
- Insurers from a third party act as intermediaries between the financing and delivery functions
- The existence of multiple payers makes the system cumbersome
- The balance of power among various players prevents any single entity from dominating the system
- Legal risks influence the practice behavior of physicians
- Development of new technology creates an automatic demand for its use
- New service settings have evolved along a continuum
- Quality and value are fast becoming the hallmarks of care delivery
Definition of global budgets. Does the US have them?
Allocation of pre-established total expenditures for a healthcare system or subsystem.
No, because the US healthcare system is not administratively controlled by a department or agency.
What is the implication of private delivery of health care?
The majority of hospitals and physician clinics are private business, which operate independently of the government
What is the role of federal and state governments in healthcare delivery?
Determine public-sector expenditures and reimbursement rates for services provided to Medicare, Medicaid, and CHIP beneficiaries.
Formulates standards of participation through health policy and regulation
Define standards of participation
Providers must comply with the standards established by the gov’t to be certified to provide services to Medicare, Medicaid, and CHIP beneficiaries
Define access
The ability of an individual to obtain healthcare services when needed
How can Americans access healthcare services?
- Health insurance through their employers
- Covered under a gov’t healthcare program
- Can afford to buy insurance with their own private funds
- Can pay for services privately
- Can obtain charity or subsidized care
