Chapter 5 Flashcards
Insurance
Mechanism for managing the financial exposure to risk via two basic principles:
- Transferring risk from an individual to a group.
2. Sharing loses on an equitable basis by all members of a group.
Principles of insurance
A loss is slowed to be something out of the ordinary as well as something to be avoided.
Ex: shot on the head
4 employment benefits
Medical
Dental
Vision
Prescription drug
Indemnity
Pay more money out of pocket
Comprehensive deign
Pocket maximum is reached
Capitation deign
Cheaper to prevent a disease than to cure a disease.
Health savings account
Give consumers financial incentives to choose their health care providers and manage their own health expenses.
Long term care coverage
For abuelos
Indemnity product offering a fixed daily reimbursement payment for LTC services.
Short-term programs
Coverage for loss of income due to illness. 5-7 days
Ex: pregnant on bed rest.
Long-term programs
Are often entirely employer-finances
Long-term disability maintains a waiting period before employees are eligible for coverage.
7 objectives of managed care?
- Enhance cost containment
- Implement some forms of rationing
- Promote administrative & clinical efficiency
- Reduce duplication of services
- Enhance appropriateness of care
- Promote comprehensive contracting mechan
- Manage care process by managing provider and consumer behavior.
PPO
Preferred provider organizations
Don’t need s referral as long as they’re in the book
HMO
Health maintenance organizations
Have to go to family physicians
The staff model
Employs its own physicians
Ex: BMW healthcare clinic
Managed care areas of management AREAS U CAN WORK IN
Provider contracting and network management Utilization management Quality management General administration Health info system Sales and marketing management
The gatekeeper concept
One phys provides all primary care for a patient to control the use of expensive resources, to reduce patient-initiated use of specialists, and insure overall coordination of care.
