Exam 1 Flashcards
1
Q
Are American automatically covered by insurance
A
no
2
Q
Does a true system of healthcare exist?
A
no
3
Q
Why do you need to understand the healthcare system?
A
- be effective as possible in your role in the healthcare system
- have knowledge about payment systems
- learn about the diverse needs of patients
- improve the health outcomes of patients and communities
- identify strategies to reduce delays and lower costs
4
Q
As a consumer, what are we paying for?
A
health insurance premium every month
5
Q
Describe the healthcare spending growth in 2017
A
The healthcare spending growth in 2017 was similar to the average growth rom 2008-2013
6
Q
How much is the US health care spending per person approximately?
A
10,739$ per person
7
Q
How much did the federal government and households, private business, and state and local governments account for for shares of spending?
A
- federal government and households = 28% each
- private business = 20%
- state and local government = 17%
8
Q
Describe the spending for hospital care in 2017 and how it compared to 2016.
A
Spending for hospital care increased 4.6% in 2017 which was slower than the 5.6% growth in 2016
9
Q
List of stakeholders:
A
- providers
- inpatient and outpatient facilities
- payers, such as insurance companies
- government (federal insurance programs; regulations)
- patients (self-pay)
- suppliers (pharmaceutical companies, medical equipment companies, research and educational facilities)
10
Q
Providers
A
- The healthcare industry will continue to experience job growth (aging population and ACA with more individuals insured)
- Multiple employment settings in public and private sectors
- Rural areas continue to suffer physicians shortages
- shortage of nurses nationwide - mostly in the south and west
11
Q
Hospital systems
A
- Public hospitals
a. receives money from the government; aka teaching hospitals - Non-profit hospitals
a. Provides services to the community - often charity (Mercy) - Private hospitals
a. owned by private investors
12
Q
Outpatient services
A
The preferred method of receiving care.
- in 2015, there was over 900 million visits to doctor’s offices
- outpatient imaging centers, outpatient surgical centers, and outpatient therapy services
13
Q
Payers (insurance companies)
A
- Private Payers (private insurance companies)
a. Managed Care Organizations (MCO); Health Maintenance Organizations (HMO) - Public Payers (federal insurance programs
a. (medicare, medicaid, CHIP, VA (tri-care)) - Employee Sponsored Health Insurance
- Self-Pay
14
Q
Access to Health Services
A
- Coverage
a. health insurance, underinsured - Services
a. primary care provider, dentist, surgery, specialty clinics, therapy services) - Timeliness
a. onset of symptoms and seeing provider
15
Q
Access to health services: barriers
A
- cost
- inadequate or no insurance coverage
- lack of availability services
- lack of culturally competent care
16
Q
Access to health services: Consequences
A
- unmet healthcare needs
- delays in receiving appropriate care
- inability to get preventative services
- financial burdens
- preventable hospitalizations
17
Q
Health information Technology
A
Computerization of doc./charting
- electronic patient record (EMR, EHR)
- E-prescribing
- E-health
- Telemedicine
- Remote patient monitoring
18
Q
Describe the adoption of EHR
A
By year 2015, 80.5% of hospitals adopted at least a basic EHR system - Critical Access Hospitals (CAH) lagging behind
Reason: financial incentives from Medicare and Medicaid
Barriers: ongoing costs, obtaining physician cooperation, and up-front costs
19
Q
Ethics
A
- bioethics
- patient right and responsibilities
- advance directives
- DNR orders
- Licensure and Credentialing
20
Q
Trends and Directions in the Health System
A
illness –> wellness
acute care –> primary care
inpatient –> outpatient
individual health –> community well-being
fragmented care –> managed care
independent institutions –> integrated systems
service duplication –> continuum of service
21
Q
Prior to 1800, medicine in the US was referred to as a…?
A
“family affair”
22
Q
When and where did the first medical college open?
A
1765 - University of Pennsylvania
23
Q
When did private insurance emerge?
A
Private insurance emerged prior to WW1, but Blue Cross was est. toward the end of the 1920s
24
Q
American Hospital Association (AHA) began supporting…
A
group hospitalization plans
25
Explain the medical plan that started during WW2
started by Henry J. Kaiser which featured a pre-paid program that paved the way for HMOs 40 years later
26
Timeline of major events: 1934-1939
NHI and the New Deal
27
Timeline of major events: 1945-1950
NHI and the Fair Deal
28
Timeline of major events: 1960-1965
Medicare and Medicaid
29
Timeline of major events: 1976-1979
Cost-containment
30
Timeline of major events: 1992-1994
The Health Security Act
31
Timeline of major events: 2010 - Present
Patient protection and affordable care act
32
1934-1939: NHI and the New Deal
The Great Depression (1929-1939)
* Calling for government relief
* Elements of reform – state-run system with compulsory health insurance for state residents; expanding hospitals, public health, and maternal and child services
* Strong opposition from AMA citing that physicians would lose autonomy
* Social Security Act passed in 1935 – only provided matching funds but no national health insurance
33
1945-1950: NHI and the Fair Deal
* During WW II, the War Labor Board ruled in 1943 that health insurance coverage should be excluded from the period’s wage and price controls
* After WW II ended, President Truman called upon Congress to pass a national program to ensure the right to medical care
* Proposed national health insurance but was defeated
34
1960-1965: Medicare and Medicaid
* Productivity expanded, as well as the middle class, with a well-educated workforce as a result of the G.I. Bill post WW II
* Increasing use of private insurance plans, but the elderly and the poor became of the focus of health care reform
* Medicare and Medicaid were incorporated into the Social Security Act, signed by President Lyndon Johnson, in 1965
* Health care costs increased the federal budget substantially
35
Medicare and Medicaid Milestones: 1972
Medicare eligibility was extended to individuals with long-term disabilities and to individuals with end-stage renal disease (ESRD)
36
Medicare and Medicaid Milestones: 1986
The Emergency Medical Treatment and Labor Act (EMTALA) required hospitals participating in Medicare that offer emergency services to provide stabilizing treatments
37
Medicare and Medicaid Milestones: 1997
The Balanced Budget Act of 1997 created the Children’s Health Insurance Program (CHIP)
38
Medicare and Medicaid Milestones: 2003
Medicare Prescription Drug, Improvement and Modernization Act: Created Part D prescription drug program
39
1976-1979: Cost-Containment Trumps NHI
* President Ford withdrew NHI for fear of worsening inflation
* Carter pledged as presidential candidate to support a comprehensive NHI plan
* National health insurance was not a priority so defeated once again in the face of economic recession, inflation, and uncontrollable health care costs
* Priority was on cost-containment
40
1992-1994: The Health Security Act
* Federal debt reached record levels – the Federal Reserve Board succeeded in acting to control inflation, unemployment decreased, but health care costs continued to escalate rapidly
* Fundamental health care reform needed
* President Clinton proposed universal coverage, employer and individual mandates, competition between private insurers, and regulated by government to keep costs down
* Once again, proposal defeated but bipartisan support for the Children’s Health Insurance Program (CHIP) in 1997
41
Affordable Care Act
Signed into law on March 23, 2010.
- On June 28, 2012, the Supreme Court rendered the final decision to uphold the law.
- put in place comprehensive health insurance plans
- working to make healthcare more affordable, accessible, and of higher quality
42
Who was the Affordable Care Act available to
Available to previously insured Americans, and Americans who had insurance which didn’t provide them adequate coverage and security
43
medicaid work requirements
January 2018, CMS issued new guidance for state Medicaid waiver proposals
- As of January 9, 2019, seven states have approved the waivers; 9 others pending
44
Purpose of medicaid work requirements
Meant to help enrollees find jobs
| ex. in Arkansas, everyone enrolled in Medicaid has to document work hours through state online portal
45
medicaid work requirement findings:
- Low-income may lose their health coverage
- Most people currently on Medicaid already work, go to school, have a disability, or are the primary caregiver for relatives
46
Why was the ACA again under assault by 20 republican states in 2018?
by asking the courts to rule the entire ACA unconstitutional
47
Describe the enrollment in health care exchanges in 2018
Enrollment in the health care exchanges just 4% lower than 2017
48
What was the proposed rule by HHS in 2018?
To test a new payment model to substantially lower the cost of prescription drugs
49
What did private companies such as Amazon, Berkshire Hathaway and J.P. Morgan Chase announce in 2018
announced the intent to form independent nonprofit health care company
50
What was the trend in 2018 of the growth in health care spending?
growth in healthcare spending slows.
51
PPACA stands for
Patient protection and affordable care act
52
When was the PPACA signed into law
March 23, 2010. Put in place comprehensive health insurance reforms - the first time since 1965
53
What happened following the 2010 mid-term elections?
The republicans gained control of the House of Representatives and voted 245-189 to repeal the ACA but on January of 2011, the repeal failed in the Democratic-controlled senate in a party-line vote. On June 28, 2012, the Supreme court rendered the final decision to uphold the law
54
By 2014, most American's would be required to what?
Most Americans would be required to carry a minimum level of health insurance or pay a penalty (individual mandate)
55
State had until what year to create health insurance exchanges?
2014
56
In 2014, eligibility requirements for Medicaid would be revised to cover what?
to cover anyone earning less than 133 percent of the poverty level (Medicaid expansion)
- 133% = minimum threshold for adults but children is much higher because they want to make sure children are covered
57
Businesses with how many workers would be assessed a penalty starting in 2014 if they did not offer benefits?
50 or more
58
Federal funds could not be used for abortions except in what cases?
rape, incest or when the mother’s life was endangered
59
Illegal immigrants would not be able to buy what?
insurance from subsidized exchanges – even if they paid the full cost themselves
60
Based on predictions by the Congressional Budget Office (CBO), the legislation would extend coverage to...?
32 million Americans by 2019
61
Coverage of the Federal Health Insurance Exchange
October 1, 2013 - first exchanged opened
8 million people enrolled during the first open enrollment period
Subsidies provided to allow low-income individuals to purchase health insurance
62
After the establishment of the ACA, how many people gained health coverage?
more then 20 million people; about half of the increase reflects gains in private coverage due to subsidies.
63
As the ACA took effect, Uninsured rates fell dramatically for
low income, all age groups, all race, ethnicity, all levels of education (almost all demographic groups)
64
Texas v. U.S. Decision
On December 14, 2018, a federal judge rules that the ACA's individual mandate is unconstitutional and that the entire law should be struck down as a result.
On July 2019, Texas will ask a federal appeals court in New Orleans to end the law in its entirety, without offering a replacement plan
Currently, waiting on decision from the U.S. 5th Circuit Court of Appeals on whether the law should stand
65
Steps in Accessing Health Services
1. Gaining entry into the health care system (usually through insurance coverage)
2. Accessing a location where needed health care services are provided (geographic availability)
3. Finding a health care provider whom the patient trusts and can communicate with (personal relationship)
66
Barriers in Accessing Health Services
1. High cost of care
a. premium, copay, deductibles
2. Inadequate or no insurance coverage
a. situational changes, eligibility issues, 5-year waiting period for immigrants
3. Lack of availability services
4. Lack of culturally competent care
67
What is the percent of adults who reported delaying or going without care due to costs (2016)
27%; those who delayed care or did not get care resulted in worse health
68
Trends over time of the insured vs. the uninsured
The insured – not a lot of fluctuation
| Insured – more fluctuation
69
Uninsured Population – Key Facts (4)
1. 20 million gained insurance coverage through the ACA – but in 2017, the number of uninsured increased by more than .5 million
2. Many people remain uninsured due to high cost of insurance, not having insurance through employer, and not knowing how to navigate exchanges
3. The uninsured are mostly low-income families and have at least one worker in the family (higher risk: adults and people of color)
4. Lack of access and medical debt
70
Insurance coverage gains particularly large among what groups?
Coverage gains particularly large among adults and poor
| and low-income individuals, Hispanics
71
Considering people living in the US, most of the uninsured are what percentages?
```
US citizens (75%)
Non-citizens (25%)
```
72
Individuals living in non-expansion
states most likely to
be _____.
uninsured
73
Consequences of Being Uninsured
1. Less likely to receive preventive care and services for major health conditions
2. Do not obtain the treatments that their health care providers recommended; end up paying a fortune or not doing it at all
3. More likely to be hospitalized for avoidable health problems because they didn’t get their preventative care
4. Safety net providers have limited resources and service capacity
a. public hospitals
b. Community health centers
c. free clinics
74
net providers
where people don’t have insurance/under insured go when they need care
75
Both farm and rural populations experience lower access to health care along what dimensions?
Along the dimensions of affordability, proximity, and quality, compared with their non-farm and urban counterparts.
76
Rural residents: to have quality health care access
- Financial means to pay for services
- Health literacy
- Confidence in quality of care
- Means to reach and use services
- Privacy
77
What is considered urbanized, urbanized cluster, and rural
Urbanized = 50,000 or more
Urbanized Cluster = at least 25 hundred up to 50,000
Rural = below 25,000
78
Barriers to Access in Rural populations
1. Structural
a. The number, type, concentration, location, and original configuration of providers (often predicted by the health care financing system)
- health care plan or provider refuses care
- inadequate supply of providers
- prolonged waiting times
2. Financial
a. The cost of care to individuals and families, including the presence and type of health insurance coverage (includes consideration of the underinsured)
- uninsured cannot afford care
- underinsured cannot afford co-pay or deductible
- absent coverage for certain conditions
3. Personal and Cultural
a. A set of either explicit or implicit rules that determine the behavior of social subjects in relations to their health
- unable to travel to care
- unable to communicate to providers
- disrespectful provider behavior
79
Causes and consequences to barriers to access to care in the rural populations
1. Rural hospitals close at a higher rate than urban hospitals
2. Losing hospitals creates a “domino effect”
3. For those underinsured, usually delinquent in paying providers
4. Small businesses are at a disadvantage
5. Health is affected
80
Estimated in 2017, almost what percentage of veterans are aged 65+
50%
81
Large cohort of younger veterans have registered for VA healthcare over the past 10 years come from what organizations?
Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND)
82
Compared to age-matched Americans, veterans enrolled in VA what?
poorer and have more complex medical conditions
83
Veteran population projections
overall veteran population will decline, increase in female veteran population, increase in minority veteran population
84
How many of the recent enrollees in VA had a mental health diagnosis?
more than half
85
What injury is more prevalent in the younger cohorts of the VA?
traumatic brain injury (TBI)
86
approaches to rehabilitation of combat-related injuries include:
- Systematic screening for TBI
- Incorporation of features of the patient-centered medical home model to include mental health services
- Integrated electronic medical record system
- Encourage family support in the form of informal caregiving
87
Where are many veterans treated?
in the community as well as military health facilities
88
Moral injury
“the lasting psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations”
89
VA Program to Address Homelessness (2009)
Systemic screening for homelessness, creation of multiple portals through which veterans can access services, housing first policies, and community partnerships
90
Youtube video: VA Pathways from Homelessness this video will have a short answer on the exam --> what were the different types of programs and services for veterans
veterans outreach program, emergency shelters, GI bill, home loans (to get ppl housed), working with community people to help get people jobs (Eddie got job at coffee shop)
91
What are some innovations that could be integrated to better improve the healthcare to veterans
1. Patient Centered Medical Home (PCMH) model
2. Integrated primary and mental health
3. Telehealth programs
4. Integrating chaplains into the healthcare team
5. Enhancing the delivery of programs designed to prevent chronic illness
6. Legislation (Choice Act; VA MISSION Act of 2018)
92
highest number of homeless are in what states
California, New York, Oregon, Hawaii
93
What factors might contribute to homelessness
Disability, simply not enough money, living in poverty, substance abuse, mental health issues, divorce, breakup, domestic abuse, losing a job,
94
3 different categories of homeless
1. Chronically homeless (older indiv, the ones sleeping under the bridge, ped mall, etc.)
2. Transitional homeless (more younger people, lost job, domestic abuse)
3. Episodic (younger generation, teenagers, early 20s, trouble with delinquency, substance use issues, couch surfers, overstay welcome, parents kick them out, can be a pattern)
95
point in time count
where you count the homeless
96
Total number of people experiencing homelessness per year: trends
1. Veterans homelessness has dropped by 38%
2. People in families has decreased by 23%
3. chronic homeless decreased by 19%
97
Health disparities exist among the homeless population
- severe and persistent mental illness
- substance abuse
- depression
- communicable disease
- temperature related illness
- chronic disease
98
There is an increased risk of suicide among homeless population by how much?
10x higher
99
What is the percentage of homeless teens that struggle with depression?
40%; 12 percent higher than housed peers
100
LGBTQ youth experiencing homelessness are how much as likely to commit suicide than heterosexual youth who are homeless?
twice as likely to commit suicide
101
Case study - Suitcase Clinics
Uses the principles of community-based participatory research (CBPR)
- Direct service, advocacy, and community engagement
- Formation of a “healthcare for the homeless” coalition
- Targeted needs assessment (windshield tours and direct observation)
- Suitcase clinics held at five local shelters staffed by volunteer providers, nursing case manager, and numerous volunteers
102
Most prevalent diseases found during the suitcase clinics
hypertension, diabetes, COPD or asthma
103
Refugee
someone who is in fear of being persecuted, is outside the country of his/her nationality, and is unwilling to avail him/herself to the protection of that country
104
How do refugees poses a challenge to the countries they go to?
Poses a challenge to host countries to provide access to health services
105
What is the worldwide displacement level of refugees
Worldwide displacement is at the highest level ever recorded (59.5 million)
106
Health concerns for refugees
- mental health
- chronic disease
- physical problems and disabilities
- malnutrition and anemia
- complicates the delivery of maternal obstetric care
107
Ethical concerns for refugees
- medical screening only
- Asylum seekers have restricted access to health care (emergency medical care, pregnancy and childbirth care, immunizations)
- Many host countries often impose waiting periods
- According to the Organization for Economic Cooperation and Development (OECD), access to health care services is conditional on confinement in detention facilities
108
Improving Access to Health Services for refugees
- should be a fundamental human right
- donor countries should support efforts to improve access to secure essential health-care services
- Greater efforts needed to strengthen the resilience of health systems to foster equity and efficiency in refugee health
109
A high overall ranking indicates _____ prevalence
| of mental illness and _____ rates of access to care. What is Iowa ranked
lower; higher
Iowa ranked 6th
Massachusetts ranked #1
Nevada ranked #51
110
How can we ENSURE access to quality healthcare
1. Addressing the social determinants of health
2. Adopting new and innovative virtual care strategies
3. Designing global budgets
4. Using inpatient/outpatient transformation strategy
111
Nurses
The largest group of healthcare professionals
- Registered nurses (RN)
- Licensed Practical Nurses (LPN)
- Certified nursing assistant (CNA)
112
Projections indicate there will be a deficit of how many nurses by 2030?
918,232
113
What comprise the largest group in nursing occupations?
registered nurses
114
Trends in the nursing workforce of the US
- older RNs over 50 comprised 44.7% pf the total population up from 33% (2000)
- increasing percentage of internationally educated nurses
- Racial/ethnic minority representation increased
115
Employment settings of registered nurses
```
#1: hospital (62.2% )
#2: ambulatory care (10.5%)
#3: public and community health (7.8%)
```
116
Physicians
Generalists and specialists
| - work settings and practice patterns
117
Physicians: expanding the role of hospitalists
- grew out of increasing complexity of patients requiring hospital care; dedicated physicians
- do not have a relationship with patient prior to hospitalization
- increasing use to reduce inpatient costs, increase efficacy without compromising quality or patient satisfaction
118
Issues in medical practice, training, and supply: Medical training
Graduate Medical Education (GME) – Medicare primary funding source to offset a portion of direct costs associated with training physicians
119
Issues in medical practice, training, and supply: Supply of medical professionals
Labor force increasing but still not meeting demand
120
Labor force increasing but still not meeting demand: unequal distribution
- geography
| - Specialty (general practice, internal medicine, pediatrics, mental health)
121
mortality rate
number of deaths per 100,000 population
122
Physician Supply and Demand through 2025
Study commissioned by the Association of American Medical Colleges
Categories: primary care, medical specialties, surgical specialties; other
```
By 2025, demand for physicians will exceed supply by a range of 61,700 to 94,700
Primary care physicians (14,900-35,600)
Medical specialists (3,600-10,200)
Surgical specialists (25,200-33,200
```
123
What is affecting the supply of physicians?
retiring, supply for GME growth, millennial hours, and people retiring earlier
124
Affordable Care Act - Physicians
In 2013, $12 million in ACA funding was awarded to train more than 300 new primary residents during the 2013-2014 academic year
- Loan repayment for pediatric medical, mental health, and surgical sub-specialties in exchange for providing care in medically-underserved areas
- Authorizes grants to increase training in geriatrics
125
Affordable Care Act - Physicians
Advanced Nursing Education Expansion Program
- Allocated $30 million to support academic
training programs for nurse practitioners and
certified nurse-midwives
- Funds pay for instructor and for students’
housing and living expenses
126
National health services corps
Federal program established in 1972 to strengthen and grow the primary care workforce.
127
National health services corps Awards scholarships and loan repayment to?
primary care providers in eligible disciplines
128
National health services corps: Since 1972, more than _____ primary care medical, dental, and mental and behavioral health professionals have served
50,000
129
Becoming a member of the National Health Service Corps requires
commitment of at least two years at an NSHC-approved site located in a Health Professional Shortage Area (HPSA)
130
Health Professional Shortage Areas (HPSAs): geographic area
shortage of providers for the entire population
131
Health Professional Shortage Areas (HPSAs): population groups
shortage of providers for a specific population group
132
Health Professional Shortage Areas (HPSAs): facilities
- Public or non-profit medical facility serving a population or geographic area designated as a HPSA
- Correctional facility
- State mental hospitals
- Federally qualified health centers; Indian health facilities, IHS and Tribal hospitals; CMS-Certified Rural Health Clinics
133
National Health Service Corps eligibility
- US citizen or US national
- enrolled as a full-time student
- Attending - or accepting to attend - an accredited school or program in one of the 50 states, D.C., or a US territory
134
National Health Service Corps disciplines
Physician, dentist, nurse practitioner, nurse midwife, physician assistant
135
Mid-level providers
Do not have a MD or a DO degree
- receive less training than physicians but more than RNs
- can often substitute for physicians (NP, PA, certified nurse midwifes)
136
Allied Health Professionals
Therapists, OTs, dietician, EMTs etc.
137
The Resident Physician Shortage Reduction Act of 2019
Increase the number of residency positions eligible for Medicare DGME and IME support by 15,000 slots above the current caps
- 3,000 each fiscal year from 2021-2025
- A hospital may not receive more than 75 slots in any fiscal year unless the HHS Secretary determines there are eligible slots for distribution
- One-third of the new residency slots available only to hospitals that are already training at least 10 residents in excess of their cap
- Slots would be fill slots based on priority
138
To determine which hospitals receive slots, the HHS Secretary would have to consider the likelihood of a hospital filing the positions and would be required to prioritize hospitals in the following order:
1. hospitals in states with new medical schools
2. hospitals in training partnerships with Veterans Affairs medical centers
3. Hospitals that emphasize training in community-based settings or hospital outpatient departments
4. non-rural hospitals that operate a training program in a rural area or a program with an integrated rural track
5. all other hospitals
139
Bodenheimer and Smith conducted a literature review on the primary care shortage (50 articles). Most of the articles proposed...?
An increase in the number of clinicians. Others suggested adding capacity through different professionals
140
Reform proposals giving attention to the non-clinician components can move primary care toward a...?
a balance of demand and capacity
141
What are the components of balance and capacity
- non-clinician licensed practitioners
- non-licensed personnel
- patient self-care
- technology
142
Non-clinician Licensed Practitioners are who?
Nurses, pharmacists, psychologists, licensed clinical social workers, physical and occupational therapists, and health educators
- Extremely underused in their capacity to fill roles generally performed by clinicians
143
Non-Licensed Personnel are who?
Medical assistants, front desk staff, health coaches, patient navigators, and lay educators (community health workers)
- also underused
144
health coaches and health educators can provide care for patients with
chronic illnesses
| - non-licensed personnel
145
Medical assistants can recognize and coach patients with
depression resulting in significant improvement compared to those receiving physician-only care
- non-licensed personnel
146
How do patients feel about reallocation?
The patient-provider relationship is already in a fragile state
---> 78% of physicians believe they are providing compassionate care compared to 54% based on patient perspective
147
Participating in self-care
self-care helps balance primary care demand and capacity by reducing demand instead of increasing capacity
148
Examples of participating in self-care
- Home pregnancy tests, HIV testing, Cologuard
- Monitoring glucose and insulin doses
- Blood pressure monitoring, self-treatment with OTC medications
- Serve as peer coaches for patients with the same condition
149
insurance is the mechanism for ...?
protection against risk
150
Risk
the possibility of a substantial financial loss from an event of which the occurrence is relatively small
151
4 fundamental principles of insurance
1. Risk is unpredictable for the insured
2. Risk can be predicted with a reasonable accuracy for a large group or population
3. Insurance mechanism transfers risk from the individual to the group through the pooling of resources
4. Members of insured group share actual losses on some equitable basis
152
In 2017, private health insurance
| coverage continues to be more prevalent than...
than government coverage
153
Percentage of people by type of health insurance coverage and change from 2013 to 2017: Between 2016 and 2017,
Medicare coverage increased by how many percentage points
0.6 percentage points
154
Percentage of people by type of health insurance coverage and change from 2013 to 2017: Military coverage rate increased by how many percentage points?
0.2 percentage points
155
Percentage of people by type of health insurance coverage and change from 2013 to 2017: Employment-based, direct-purchase coverage, and Medicaid
did not
| statistically change
156
Types of Private Insurance: Group Insurance
Gained through employer (pre-taxed), a union, or professional organization
157
Types of Private Insurance: Individual private insurance
Directly with insurance company, marketplace exchanges
158
Types of Private Insurance: Self-insurance
The employer acts as its own insurer instead of obtaining insurance through an insurance company
159
Types of Private Insurance: Managed care plans
HMOs, PPOs
160
Types of Private Insurance: Short-term stop-gap coverage
Consolidated Omnibus Budget Reconciliation Act (COBRA)
161
Types of Private Insurance: Medigap (Medicare Supplemental Insurance)
- Eligible only to those enrolled in the original Medicare program
- Does not cover extended long-term care, vision, dental, hearing aids, or private nursing
162
Open enrollment for health insurance runs from...?
November 1 – December 15, 2019
163
The health insurance marketplace is for people who don’t have health coverage. What you pay if you have job-based insurance or medicare
If you have job-based insurance, you will pay full price
If you have Medicare, you can’t switch to marketplace insurance
164
Types of Public Insurance
Public financing supports programs benefiting certain categories of people:
a. Medicare for elderly and disabled individuals
b. Medicaid for the indigent
c. Department of Defense programs for active service members and their families
d. Department of Veterans Affairs (VA) health care for military veterans
165
When was Medicare first implemented
1966 - covering more persons 65+
166
In 1973, Medicare benefits expanded to include those entitled to...
...Social Security or Railroad Retirement disability cash benefits for at least 24 months and most persons with end-stage renal disease
167
Medicare Traditionally consisted of two parts:
Hospital Insurance (HI), aka Part A (inpatient care, SNF, hospice, some home health)
Supplementary Medical Insurance (SMI), aka Part B (doctors’ services, outpatient care, PT, OT, some home health)
168
Prescription Drug Coverage (Part D) -->
Goal to lower prescription drug costs and help protect higher costs in the future
169
Prescription Drug Coverage (Part D) --> describe the monthly premium
Monthly premium for this coverage – began in January 1, 2006
170
Prescription Drug Coverage (Part D) --> estimated national average
Estimated national average, 2017, was $42.17
171
Stand-alone prescription drug plans provide what coverage
Prescription Drug Coverage (Part D)
172
If a beneficiary does not enroll in a drug plan when they are first eligible, what happens?
they may pay a penalty if they choose to join later.
| - certain low-income beneficiaries are automatically enrolled without having to pay a premium.
173
Medicare has established two main trust funds
1. Hospital Insurance (HI) trust fund provides the money pool for Part A services
2. Supplemental Medical Insurance (SMI) trust fund provides the money pool for Parts B and D
Taxes, premiums, and other revenues are credited to the respective trust funds but benefit payments and administrative costs are the only purposes for which disbursements from the funds can be made
Area of concern: Trustees predict depletion of the HI funds by 2027
174
Medicaid became law when?
1965 as a cooperative venture jointly funded by the Federal and State governments
175
For medicaid, each state...
- Establishes its own eligibility standards
- Determines the type, amount, duration, and scope of services
- Sets the rate of payment for services
- Administers its own program
176
Eligibility of Medicaid
Federal law requires states to cover certain groups of individuals:
- low income families
- qualified pregnant women and children
- ind. receiving Supplemental Security Income (SSI)
- disabled adult children
- Ind. with TB
- many others listed on the "List of Medicaid Eligibility Groups"
177
Children's Health Insurance Program
Created in response to the 10 million children whose families’ incomes exceeded the Medicaid threshold levels
- eligibility varies by state
178
Children's Health Insurance Program provides coverage through
both medicaid and separate CHIP programs
179
Children's Health Insurance Program (CHIP) medicaid expansion:
- Provides the standard Medicaid benefit package
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services
- Mental health services
- Dental services
180
Military Health System - TRICARE is a health insurance program for...?
- Uniformed service members and their families
- National Guard/Reserve members and their families
- Survivors
- Former spouses
- Medal of Honor recipients and their families
- Others registered in the Defense Enrollment Eligibility Reporting System (DEERS)
181
Military Health System - VHA
Operates the largest integrated health services system in the United States
182
Congress requires VHA to...?
provide services on a priority basis to veterans with service-connected illnesses and disabilities, low incomes, or special health needs
183
VHA is funded through
the annual appropriations process (discretionary budget)
184
VHA suffers from
capacity and financing constraints
185
TRICARE Benefits
- your services may vary depending on you health plan
| - your TRICARE health plan's rules and costs will apply
186
VA benefits
Your eligibility and copayment depend on:
- discharge
- service-connection
- income
187
VA and TRICARE Benefits and plans will vary depending on your...
- Prime plans or traditional TRICARE plans
| - Choosing between TRICARE or VHA Benefits
188
GO LOOK AT TRICARE AND VA BENEFITS IN PPT
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189
Indian Health Services
Federal program that provides comprehensive health care services directly to members of federally-recognized American Indian and Alaska Native tribes and their descendants
190
Indian Health Services are eligible to participate in what
all public, private, and state health programs available to the general population – but challenging due to geographic barriers
191
Indian Health Services serve how many people and where?
IHS serve almost 2.6 million AIANs residing on or near reservations – and in rural communities
192
What was established in 1935?
Social security
193
What was established in 1965
medicare and medicaid
194
How did the Balanced Budget Act impact hospitals?
They put a cap on residency slots in teaching hospitals
195
Marketplace plan category: bronze
a. the insurance company pays how much?
b. you pay how much?
a. 60%
| b. 40%
196
Marketplace plan category: silver
a. the insurance company pays how much?
b. you pay how much?
a. 70%
| b. 30%
197
Marketplace plan category: gold
a. the insurance company pays how much?
b. you pay how much?
a. 80%
| b. 20%
198
Marketplace plan category: platinum
a. the insurance company pays how much?
b. you pay how much?
a. 90%
| b. 10%
199
Where does the funding come from for public insurance
mandatory budget
200
How are TRICARE and VA related?
TRICARE is the insurance arm of the VA system, the VA is the entire system
201
Marketplace plan category: catastrophic
| age and reason
people under 30
| - people of any age with hardship exemption or affordability exemption
