Chapter 1 Overview of US Healthcare Delivery

Question 1

Access

Answer 1

Ability of a person to obtain healthcare services when needed, affordable, convenient, acceptable and effective in a timely manner.

Question 2

Administrative Costs

Answer 2

Costs that are incidental to the delivery of health services. Associated with management, financing, insurance, delivery and payment functions of health care. Include management of enrollment process, setting up contracts with providers, claims processing, utilization monitoring, denials and appeals of claims, and marketing and promotional expenses.

Question 3

Balance Bill

Answer 3

The practice in which the provider bills the patient for the leftover sum after insurance has only partially paid the charge initially billed.

Question 4

Defensive Medicine

Answer 4

Excessive medical tests and procedures performed as a protection against malpractice lawsuits, and otherwise regarded as unnecessary.

Question 5

Demand

Answer 5

The quantity of health care purchased by consumers based solely on the price of those services.

Question 6

Enrollee

Answer 6

A person enrolled in a health plan, especially a managed care plan.

Question 7

Free Market

Answer 7

A competitive market characterized by the unencumbered operation of the forces of supply and demand and where numerous buyers and sellers freely interact.

Question 8

Global Budgets

Answer 8

Allocation of pre-established total expenditures for a health care system of subsystem

Question 9

Health Care Reform

Answer 9

In the U.S. contest, expansion of health insurance to cover the uninsured.

Question 10

Health Plan

Answer 10

Contractual arrangement between a managed care organization and an enrollee, including the collective array of covered health services to which the enrollee is entitled

Question 11

Managed Care

Answer 11

System of health cre delivery that (1) seeks to achieve efficiencies by integrating the four functions of health care delivery

Question 12

Medicaid

Answer 12

Joint federal-state program of health insurance for the poor.

Question 13

Medicare

Answer 13

Federal program of health insurance for the elderly, certain disabled individuals, and people with end-stage renal disease.

Question 14

Moral Hazard

Answer 14

Consumer behavior that leads to a higher utilization of health care services because people are covered by insurance.

Question 15

National Health Insurance (NHI)

Answer 15

Tax-supported national health care program in which services are financed by the government but are rendered by private providers (Canada as an example).

Question 16

National Health System (NHS)

Answer 16

Tax-supported national health care program in which the government finances and also controls the service infrastructures (the UK as an example

Question 17

Need

Answer 17

Obtaining health care services based on individual judgement (in contrast to demand for health services) . The patient makes the primary determination of the need for health care and, under most circumstances, initiates contact with the system. The physician may make professional judgement and determine the need for referral to higher-level services.

Question 18

Package Pricing

Answer 18

Bundling of fees for an entire package of related services.

Question 19

Phantom Providers

Answer 19

Providers who generally function in an adjunct capacity; the patient does not receive direct services from them. They bill for their services separately, and the patients often wonder why they have been billed. Examples include anesthesiologists, radiologists and pathologists

Question 20

Premium Cost Sharing

Answer 20

Employers’ requirement that their employees pay a portion of the health insurance cost.

Question 21

Primary Care

Answer 21

Basic and routine health care provided in an office or clinic by a provider (physician, nurse or other health care professional) who takes responsibility for coordinating all aspects of a patient’s health care needs; an approach to health care delivery that is the patient’s first contact with the health care delivery system and the first element of a continuing health care process.

Question 22

Provider

Answer 22

Any entity that delivers heath care services and can either independently bill for those services or is tax supported. Examples of providers include physicians, dentists, optometrists, and therapists in private practices; hospitals; diagnostic and imaging clinics; and suppliers of medical equipment (wheelchairs, walkers, ostomy supplies, oxygen)

Question 23

Provider-Induced Demand

Answer 23

Artificial creation of demand by providers that enables them to delivery unneeded services to boost their incomes

Question 24

Quad-function model

Answer 24

Four key functions necessary for health care delivery; financing, insurance, delivery and payment.

Question 25

Reimbursement

Answer 25

The amount insurers pay to a provider. Payment may be just a portion of the actual charge.

Question 26

Single-payer system

Answer 26

National health care program in which the financing and insurance functions are take over by the federal government

Question 27

Socialized Health Insurance (SHI)

Answer 27

Healthcare that is financed through the government-mandated contributions by employers and employees and delivered by private providers (Germany, Israel, and Japan)

Question 28

Standards of Participation

Answer 28

Minimum quality standards established by the government regulatory agencies to certify providers for delivery of services to patients covered by Medicate and Medicaid.

Question 29

System

Answer 29

Set of interrelated and interdependent components that are logically coordinated to achieve a common goal.

Question 30

Third Party

Answer 30

An intermediary between patients and providers, which carries out the functions of insurance and payment for healthcare delivery

Question 31

Uninsured

Answer 31

People who lack health insurance coverage

Question 32

Universal Access

Answer 32

The ability of all citizens to obtain health care when needed. It is a misnomer because timely access to certain services may still be a problem because of supply-side rationing.

Question 33

Universal Coverage

Answer 33

Health insurance coverage for all citizens

Question 34

Utilization

Answer 34

The consumption of health care services and the extent to which health care services are used.

Question 35

Why does cost containment remain an elusive goal in US health services delivery?

Answer 35

There is little standardization in a system that is functionally fragmented. There is no central agency (ie government) to oversee coordination of such a system. Problems with duplication, overlap, inadequacy, inconsistency and waste occur. System as a whole does not lend itself to standard budgetary methods of cost control. Individual and corporate entities seek to manipulate financial incentives to their own advantage (text pg 4-5 Kindle edition)

Question 36

What are the two main objectives of a health care delivery system?

Answer 36

(1) Enable all citizens to obtain needed health care services
(2) ensure that services are cost-effective and meet certain established standards of quality

Question 37

Name the four basic functional components of the US health care delivery system.
What role does each play in the delivery of health care?

Answer 37

(1) Financing - necessary to obtain health insurance or to pay for services
(2) Insurance - Protects the insured against financial catastrophe by providing expensive health care services when needed
(3) Delivery - Provision of health care services by various providers
(4) Payment- Reimbursement to providers for services delivered

Question 38

What is the primary reason for employers to purchase insurance plans to provide health benefits to their employees

Answer 38

Fringe benefit

Question 39

Why is it that, despite public and private health insurance programs, some US citizens lack health care coverage

Answer 39

Smaller businesses cannot get group insurance at affordable rates.
In some settings participation is voluntary, so employees are not required to join.
Some employees cannot afford the cost of premiums

Question 40

Why is the US health care market referred to as “imperfect”?

Answer 40

Does not pass as a free market. In practice prices are determined by payers such as MCOs, Medicare and Medicaid.
To be free, the market must have unrestrained competition

Question 41

Discuss the intermediary role of insurance in the delivery of health care

Answer 41

A bridge between those who finance, deliver, and receive health care

Question 42

Who are the major players in the US health services system? What are the positive and negative effects of the often conflicting self-interests of these players

Answer 42

Physicians - maintain incomes and have minimum interference with the way they practice medicine
Insurance companies and MCOs maintain their share of the health insurance market
Large Companies - contain costs incurred by providing health insurance
Government - tries to maintain or enhance existing benefits for those covered under public programs

Question 43

What main role does the government pay in the US health services system?

Answer 43

Finances health benefits for certain special populations including employees, elderly, disabled, low income and children with low income.

Question 44

Why is it important for healthcare managers and policymakers to understand the intricacies of health care delivery system?

Answer 44

Positioning the organization
Handling Threats and Opportunities
Evaluating Implications
Planning
Capturing New Markets
Complying with Regulations
Following the Organizational Mission

Question 45

What is the difference between national health insurance (NHI) and a national health system (NHS)

Answer 45

NHI - governement finances health care through general taxes, but actual care is delivered by private providers (Canada)
NHS - finances tax-supported NHI program and manages the infrastructure for the delivery of medical care

Question 46

What is socialized health insurance (SHI)?

Answer 46

Government -mandated contributions from employers and employees finance health care. Private providers deliver health care. Private, not-for-profit insurance companies (called sickness funds) are responsible for collecting contributions and paying physicians and hospitals (Germany)

Question 47

Provide a general overview of the Affordable Care Act. What is its main goal?

Answer 47

Reduce the number of uninsured
Mandated covering children to age 26
Manadated employers to provide health insurance

Question 48

What is meant by value-based care?

Answer 48

Provides financial incentives for achieving specified health outcomes.
Bundled-payment models and pay-for-performance are two applications

Question 49

What are the major and common challenges in health care reform around the world?

Answer 49

Strengthening primary care programs to deliver better health outcomes
achieving universal coverage while containing costs