Exam 3.4 Flashcards
Public health professionals
usually financed by tax dollars, available to everyone, primarily serve economically disadvantaged, public health physicians, environmental health workers, epidemiologists, health educators, public health nurses, research scientists, clinic workers, biostatisticians
Health care facilities
physical settings where health care is provided, inpatient care and outpatient care
Inpatient care facilities
hospitals, nursing homes, assisted living
Clinics
two or more physicians practicing as a group, do not have inpatient beds, for and not-for profit, tax funded
Outpatient care facilities
care in a variety of settings but no overnight stay, practitioner’s offices, clinics, primary care centers, ambulatory surgery centers, urgent care centers, services offered in retail stores, dialysis centers, imaging centers
Rehabilitation centers
work to restore function, may be part of a clinic or hospital, or freestanding facilities, may be inpatient or outpatient
Long-term care options
nursing homes, group homes, transitional care, day care, home health care
Home health care
growing due to restructuring of health care system, technological advances, and cost containment
Affordable Health Care Act
goal to put American consumers back in charge of their health coverage and care
Structure of the health care system
US structure, complex, expensive, many stakeholders, intertwined policies, politics, major issues: cost containment, access, quality
Major goal of ACA
to increase the number of Americans with health insurance and decrease costs, unfortunately premiums are going up dramatically for most Americans as a result
Quality health care should be
effective, safe, timely, patient centered, equitable, efficient
Sources of health care payments
consumers, third party payments
1st party payment
consumer pays the provider for services rendered using cash, flex plans, medical savings plans
3rd party payment
government or private insurance pays the provider for services rendered
Fee for service
patient pays a % of care
Packaged pricing
bundled services
Resource based relative value scale
Medicare’s scale for reimbursement
Capitation
prearranged agreement made between provider and insurer
Prospective reimbursement
payments made ahead of need
Premiums
regular periodic payments
Deductible
amount of money that the beneficiary must pay before the insurance company begins to pay for covered services
Co-insurance or co-payment
the portion or % of an insurance company’s approved amounts for covered services that the beneficiary is responsible for paying
Fixed indemnity
maximum amount an insurer will pay for a certain service
Exclusion
a specified health condition that is excluded from coverage, the Health Insurance Portability and Accountability Act of 1996
Pre-existing condition
a medical condition that has been treated six months before starting a health policy
Health Insurance Portability and Accountability Act (1996) and ACA (2010)
insurance companies can’t make a pre-existing condition an exclusion for coverage
Types of health insurance coverage
hospitalization, surgical, regular medical, major medical, dental, disability
The ACA mandates that
employers with 50 or more employees provide insurance coverage or pay a tax
Trends due to ACA
employers reducing full-time jobs, increasing part-time jobs, increased worker share of premium, raising deductibles, increasing prescription co-payments, increasing number of exclusions
Self-funded insurance programs
created for/by employers rather than using commercial insurance carriers, many benefits to employer, generally for larger companies unless low-risk employees
Health insurance provided by the government
medicare, medicaid, CHIP, VA, IHS, federal employees, uniformed services, prisoners
Medicare
covers more than 47.5 million people, 65+, permanent kidney failure, certain disabilities, through FICA tax
Four parts of medicare
hospital insurance (A), medical insurance (B), managed care plans (C), prescription drug plans (D)
Medicare part A
hospital, inpatient, mandatory, 100% coverage for hospital stays, hospice, and some health care, no premium, deductible, some co-pays
Medicare part B
medical, voluntary but those with part A automatically enrolled, coverage for doctor services, outpatient hospital care, physical therapy, durable medical supplies, ambulance, diagnostic tests, blood screening, and preventive care, premium, deductible, copays
Medicare part C + Choice plans (Medicare Advantage)
alternative to A & B and medigap plans, managed care plan, preferred provider plan, private fee-for-service plan
Mediare part D
prescription drug coverage, voluntary, 2 parts: discount card based on income, prescription insurance with premium, deductible
Medicaid
for the poor, costly budget item for states, noncontributory
Medicaid under ACA
eligibility based solely on income, extended to more low-income people, nearly everyone under 65 with income below 133% of poverty level could qualify, increases burden on states
CHIP
joint state-federal program, created in 1997, funding by increase in federal excise tax rate on tobacco, 8 million children enrolled
Problems with medicare and medicaid
some providers do not accept, fraud, cost of programs escalating and will become insolvent unless tax revenue increased or benefits reduced, many concerned federal government overextended
Supplemental health insurance
helps cover out of pocket costs, medigap, specific disease insurance, long-term care insurance
Managed care
goal to control costs by controlling health care utilization, provider panels, limited choice, gatekeeping, risk sharing, quality management, utilization review
Types of managed care
PPO, HMO, Independent practice association (IPA), POS, medicare advantage
National health care
a system in which the federal government assumes responsibility for health care costs of entire population, primarily paid with tax dollars, US only developed country without
National health service model
entire system owned and operated by government, UK, Spain
Social insurance model
government is the only 3rd party payer, Canada, Germany
Consumer directed health plans
responsibility for health care decisions lies with the individual
High deductible health plan
brings down monthly payments, pay more out of pocket, incentive not to seek needed care or preventive care
Health savings accounts
individual invests and the account grows tax free, money withdrawn tax free to pay for care
Health reimbursement arrangement
employer funded health savings account for employees
Flexible spending account
employers allow employees to set aside tax free money for medical expenses in a given year
Archer medical savings accounts
account funded by both individual and small business employer
Affordable Care Act
1000 pages and passed without any bipartisan support, very controversial, goals to reduce costs and increase number insured, step toward national healthcare, profoundly increases the authority of DHHS
President’s 8 principles of reform
protect families’ financial health, make health coverage affordable, aim for universality, provide portability of coverage, guarantee choices, invest in prevention and wellness, improve patient safety and quality care, maintain long-term fiscal sustainability
You can’t have everything
pick two: good, fast, cheap
Why costs are increasing
increasing population, aging population, increasing technology, changing patient expectations, service/cost detachment
For every dollar spent on newer medicines in place of older medicines
total healthcare spending is reduced by $6.17
Every additional dollar spent on healthcare in the US over the past 20 years
has produced health gains worth $2.40 to $3.00
Medical malpractice suits
encourage defensive medicine
Chronic illness
75% of health care spending, receive 56% of all clinically recommended care, substantial share of growth in healthcare spending
Nearly 60% of healthcare spending
happens during the last 2 weeks of life
