Delivering Healthcare in America

Question 1

an acceptable healthcare delivery system should have two primary objectives:

Answer 1

• enable all citizens to obtain needed health care services

- ensure that services are cost-effective and meet certain established standards of quality

Question 2

quad-function model

Answer 2

financing, insurance, delivery and payment

Question 3

financing

Answer 3

employers, government (medicare, medicaid) and individual self-funding

Question 4

insurance

Answer 4

• protects the insured against financial catastrophe by providing expensive health care services when needed
• determines the package of health services that the insured individual is entitled to receive
• specifies how and where health care services may be received
• claims processor and manages the disbursement of funds to health care providers

Question 5

delivery

Answer 5

• provision of health care services by various providers
• provider - any entity that delivers health care services and either independently bills for those services or is supported through tax revenues

Question 6

payment

Answer 6

• reimbursement to providers for services delivered
• insurer determines how much is paid for a certain service
• funds for actual disbursement come from the premiums paid to MCO or insurance company
• at time of service, patient is usually required to pay an out-of-pocket amount
• in gov’t insurance plans, tax revenues are used to pay providers

Question 7

medicare

Answer 7

for elderly and certain disabled individuals

Question 8

medicaid

Answer 8

for indigent

Question 9

Children’s Health Insurance Program (CHIP)

Answer 9

for children from low-income families

Question 10

predominant employment-based financing system in US has left some employed individuals uninsured for two reasons:

Answer 10

• some small businesses simply cannot get group insurance at affordable rates and therefore, are bit able to offer health insurance as a benefit to their employees
• in some work settings, participation in health insurance programs is voluntary, so employees are not required to join (so some don’t join because they cannot afford the cost of premiums)

Question 11

premium cost sharing

Answer 11

employers rarely pay 100% of the insurance premium, instead, most require their employees to pay a portion of the cost

Question 12

health care reform

Answer 12

expansion of health insurance to cover the uninsured - those without private or public health insurance coverage

Question 13

Affordable Care Act of 2010

Answer 13

• insurance companied were mandated to start covering children and young adults younger than age 26 under their parents’ health insurance plans
• -mandate for employers to provide health insurance
• required all US citizens and legal residents to be covered by either public or private insurance
• relaxed standards to qualify additional numbers of people for Medicaid
• failed to achieve universal coverage that would enable all citizens and legal residents to have health insurace

Question 14

utilization

Answer 14

quantity of health care consumed