Ethics Flashcards
Who funds medicare? eligibility?
Federal govt. >65 yrs- US citizens, perm residents, paid tax >10 yrs, ppl with ESRD on rx, ALS, perm disabilities
Medicare coverage
A- hospital insurance, B- medical, C- advantage, D- prescription drugs
Who funds medicaid? eligibility?
federal and state. Citizens. Financial criteria- Children and pregnant, < 65 years living in households with income ≤ 133% of the federal poverty level, >65 + disability receiving supplemental security income
Who can enroll in medicare and medicaid
> 65 yrs low income- with disabilities
CHIP eligibility
Kids from low income that is not low enough to qualify for Medicaid
Commercial health insurance plans
HMO, POS, PPO, EPO
Plans that require primary care provider and referral
HMO, POS
Out of network care covered for
POS, PPO
health insurance premium
Paid monthly to provider. Higher premium will have lower out of pocket expenses. Healthy- higher deductible, lower premium vice versa for a diagnosed patient
What is included in the out of pocket maximum
deductibles, copayments, coinsurance
Paying everytime while visiting a doc
Copayment
Coinsurance
% of expenses an individual pays after meeting deductible
Utilisation mx to cover for rx
Prior, concurrent, retrospective
Payment model- fee for service
Providers compensated for each service- assoc with high overall health care costs. Discounted and per diem payment
Pay for performance models
Compensation depends on providers meeting metrics for quality and efficiency
pay for perf programs
VBP, PQRS, MIPS
VBP
penalises for poor perf- reduced pay by 2%
PQRS
To assess quality of care by reporting data on quality of care across health care systems
MIPS
Integrates various programs into single system
Bundled payment
Fixed payment for all services during a clinically defined episode
Capitation
Fixed pay per pt irresp of services utilised
Global payment
Single pay for population of pts
Health care delivery models
IDS, ACO, PCMH
Social injustice types
Distributive, relational
