Exam 1 - Powerpoint 2 Flashcards
Classic economic market
Buyer has a budget Multiple buyers and sellars Easy entry and Exit for Sellars and Buyers Good Information Buyer Decides Buyer pays the prices
Health care in US characterized by
Excess and deprivation
Ways to think of “excess”
seeing specialist when NP might’ve been enough
Taking expensive brand drug vs cheap generic
Deductible
Amount you must pay for healthcare or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay
Coinsurance
amount you may be required to pay as your share of the cost for services after you pay any deductible. Coinsurance is usually a percentage
Copayment
Set amount, rather than a percentage. Example, you may $10 or $20 for a doctor visit or prescription, regardless of cost
Value-based insurance plans
have different payment structure that varies the cost-sharing amount depending on the value of the service
great value = health benefit or “payoff” is high, and cost is low, ie very cost-effective services, ex hypertension meds provided for free to patient
Medicare
Passed in 1965
All Americans over 65, and 10 yrs of FICA taxes
in 1972, added End Stage Renal Disease and Long term disabilities (2 yr waiting period)
2001 Added ALS
2018 covered about 60mil, 84% are 65+
Federal program, same benefit all states
Medicare Part A
Hospital insurance, automatic w/ 10yr FICA
Hospital, skilled nursing care, home care related to hospitalization, hospice
No premium for almost all enrollees
Medicare Part B
Medical insurance, provider coverage (voluntary)
Physician visits, outpatient services, preventive, home care
Physician admin drugs
required premium, vary by income but also subsidized
Medicare Part C
Medicare Advantage
Managed care version of Medicare, covering A,B, and optionally D
Only through private plans, mostly HMOs and PPOs
Formerly known Medicare+Choice
Medicare Part D
Outpatient drug coverage (voluntary)
Only through private plans
Requires premiums, vary by income and can be subsidized
Supplements (Medicare)
Not part of medicare
Medigap private plans
Employer-sponsored employee + retiree benefits
Medicare Part A Cost sharing
Days 1-60 Max $1408 OOP
Days 61-90 $352 per day OOP
After 90, can use up to 60 reserve days at $704 per day, then anything after that is all OOP. This if its all one visit
Diagnosis-Related Groups
Phased in the early to mid 1980s
Pre-determined payment based on the reason for hospitalization
caused length of stays to drop
shifted patient surgeries from inpatient to outpatient
How is Part A funded
Medicare portion of FICA payroll taxes, no premium
How is Part B funded
Monthly premiums (~27%, rest from US Gov tax revenue)
Fee schedule Part B
Defined fees for specific services
Medicare Supplement plans
known as Medigap
beneficiaries pay the full premium
additional coverage, reduced cost sharing
Retiree Health Benefits
Declining over time
Usually these are Medicare supplemental plans
Medicare Advantage (Part C)
little or no additional premium (past part B)
plans receive a capitation from CMS = a per member per month amount
private plans with hospital/doctor networks.
enrollment in Medicare Advantage has nearly double in past decade
Prescription Drug Plans (Part D)
Passed GW Bush 2003, into effect 2006
All private plans
How is Part D funded
Mostly General revenue taxes and premiums
Medicaid
enacted along with Medicare
Varies state, jointly financed by federal and state gov
Entitled eligible individuals to a defined set of benefits
Medicaid Highlights
Federal share is about 60%
Wealthiest states pay up to 50% costs, poor states 25%
receive rebates reducing drug prices by ~45%
major source of coverage for low-income children and families
Supplemental coverage for poor Medicare Beneficiaries
Primary payer of longer term care - nursing home
Supports safety net hospitals
Medicaid growth
Growth due to population growth, program expansions, erosion of other sources of coverage, and wage stagnation
Medicaid Funds
Pulls federal funds to states
“automatic stabilizer” = money flows to states during economic downturn because poverty and eligibility increase
Enrollee and Expenditure
Disabled ( 15% enrollee, 42% of costs)
Elderly (9% enrollee, 21% costs)
Adults (27% enrollee, 15% costs)
Children (48% enrollee, 21% costs)
Dual Eligibles
dual enrollees
Have both medicare and medicaid coverage
are sicker compared to others on just in Medicaid and Medicare
Medicaid Benefits
Mandatory Benefits
Hospital, outpatient/doc, birth and family planning, nursing home, home care, transportation, smoking cessation
Optional Benefits
Rx coverage, dental, case management, hospice
All states currently cover Rx
Medicaid cost sharing
$0 premiums under 150% FPL
>150% FPL premiums possible bust must be <5% income
