Final Exam Flashcards
What is insurance for?
Manage and redistribute financial risk of unexpected events
Manage trade offs that affect price (e.g. choice of provider, benefit package, cost split between sponsor and member)
History of US Healthcare
Out of pocket payment was the most common method, employers started offering insurance as a benefit during WWII
Cost/quality of healthcare skyrocketed as a result–> led to Medicare/Medicaid for people without jobs
Insurance Premium
The set amount the individual pays for health insurance every month even if you don’t use services (employer also contributes)
Insurance Deductible
The additional amount the individual pays for covered health care services before insurance starts to pay
Insurance Copayment
Fixed amount you pay for every health service you receive after you pay your deductible (i.e. $30 to see a dermatologist)
Co-Insurance
Percentage of costs you pay for after your deductible (i.e. being responsible for 20% of costs after deductible is met)
Affordable Care Act (ACA)
Medicaid coverage for everyone below 138% of the FPL
Health insurance exchanges for everyone above Medicaid eligibility threshold
Federal subsidies between 100-400% of FPL
Employer Sponsored Insurance
Federal tax policy subsidizes employer/employee- Used to collect, pool and redistribute money
Larger employers- effectively self-insured, risk pool is employees/dependents
Smaller employers- small carrier-based risk pools=high premiums
What are majority of bankruptcies in US caused by?
Inability to pay medical bills
Bronze Level Insurance
Lowest premium- highest cost sharing
Protects against catastrophic event, minimal coverage for routine care
Silver Level Insurance
Moderate premium- moderate cost sharing, tax credits based on 2nd lowest sliver plan
Gold Level Insurance
Lowest cost sharing- better deal for those expecting to use significant amount of care
Platinum Level Insurance
Highest premium, lowest cost sharing
Tax Cuts and Jobs Act of 2017
Trump’s approach to the ACA- made tax penalty for not having health insurance under the ACA $0
Key parts of the campaign- repeal ACA and replace it with something better (but it never happened)
California v Texas
Claimed Tax Cuts and Jobs Act rendered entire ACA unconstitutional
DOJ took many positions, key questions about “severability”, ended litigation for lack of standing
Standing- you have to be an aggrieved party to sue, argue that this doesn’t apply
Medicare
Eligibility- 65 and over or under 65 w/ permanent disabilities
2 yr waiting period for Social Security Disability Insurance & Medicare
No waiting period End-stage renal disease (ESRD) or ALS
Benefits of Medicare
- Providing insurance for people you least want in insurance pools (makes it more expensive for everyone else)
- Takes burden off of people would would have to care for family members
History of Medicare
AMA- dominant force in preventing major health form (“socialized medicine”)
Old Age and Survivors Insurance (OASI) strategy
1) Focus on elderly- political appeal, needy/deserving
2) Build on existing social security system
3) Restrict scope of benefits- move away from total health system reform and just focus on protecting the elderly
Medicare Part A- Hospital Insurance
Includes hospital care, skilled nursing, hospice and some home health care
$400/mo without work history, free if you or your spouse have 10 min years paying into SS from work
Long-term care: all costs out of pocket after day 101, doesn’t cover “unskilled” nursing home residency
Medicare Part B
Covers MD visits, preventative care, medical devices, ambulance, outpatient care and some home care (technically optional, most opt in)
Medicare Part C
Medicare advantage- private alt. to Parts A/B added later, broader benefits (dental, fitness, eye, prescription drugs)
- Feds negotiate premium w/ private plan sponsors, individuals still pay part of premium
-Higher cost for federal gov.
-Elderly can forgo A &B for Medicare Advantage
Medicare Part D
Prescription drugs- Passed during Medicare Modernization Act of 2003
Run by private companies/no public option
Donut Hole
Original design of Part D created gap for prescription drug coverage
Catastrophic coverage threshold- Once initial limit is reached, beneficiary pays full cost until out-of-pocket costs reach a certain amount ($4750)
*Eliminated w/ recent policy changes
Medicare Coverage Limitations
1) high deductibles & cost sharing
2) no limit of out of pocket spending (A&B)
3) doesn’t cover long term care, dental, eyes, hearing aids
Medigap Insurance
Sold by private companies to fill gaps in Medicare coverage
Can pay remaining costs (copayments, coinsurance, deductibles), coverage outside of US, services not included in Medicare
Medicare Trust Fund
Hospital insurance trust fund financed through payroll taxes on earnings/income taxes on SS benefits (Part A)
Medicare Drug Provisions of Inflation Reduction Act
Feds can negotiate price of certain drugs in Medicare program- pick 10 drugs a year
Change Medicare Part D- get rid of paying 5% on catastrophic cost after $3250
Flaws:
1) Will take a long time to take effect (gives insurance a long time to figure out how to fight this/new president can roll it back)
2) 10 drugs a year is minimal- pharma can increase costs of drugs not picked
Great Social Policy Divide
Universal benefits vs particularistic benefits
Universal benefits everyone- inherently popular, seen as earned
Programs benefiting select people aren’t popular- seen as indigent (e.g. Medicaid)
Medicaid
Provides health coverage (all kinds of care) for the poor- jointly administered by the states and the federal government (mostly the feds, states cover the rest)
Long term institutional/community care for poor, elderly
Medicaid Eligibility
Low income (defined by each state), mostly children, pregnant women and sometimes parents
Low-income elderly/disabled often dual-eligible for things that Medicare won’t cover
Low-income adults w/o dependents in some states (post-ACA)
Federal Medical Assistance Percentage (FMAP)
Federal share of Medicaid payment varies by state
Formula relies on state per capita income (poorer states pay for less/richer states pay more), states report Medicaid costs & fed gov matches costs for each state- Lowest federal rate is 50%
Feds pay costs, but states manage as they see fit (while following basic requirements)
Poor southern states are hesitant to accept free $ for Medicaid expansion partly bc they benefit from FMAP
FMAP Requirements
Most provide certain benefits to certain populations
Services- physician, hospital, nursing home care
Populations- children and pregnant women
Feds will cover optional services (dental care) for optional groups (poor adults, elderly w/ massive medical costs)
ACA complicates basic requirements
CHIP
Medicaid offshoot for children- includes poor children in families that earn too much for Medicaid popular
Comprehensive coverage- free well child visits, copayments for other services
Refunding sometimes an issue, but quickly resolved bc politicians fear retribution
Medicaid Politics
Popular but contentious
1) Takes up large portion of state budgets
2) Provides for a group not historically seen as deserving (this is changing)
3) Concern that requirements are too prescriptive- can’t act in best interest of the state
4) Doesn’t pay well- many doctors don’t want to see Medicaid patients
Medicaid Waiver
Section 1115 of SS Act allowed federal government to waive provisions of major health programs (e.g. Medicaid)
States apply for them to try projects to improve Medicaid- ideal outcome would be program works and feds could change law nationally to improve Medicaid for everyone
ACA Medicaid Changes
Biggest change to Medicaid- mandated that all states expand Medicaid to 138% of FPL
Feds cover 100% of new costs for first 3 years and 90% moving forward
NFIB v Sebelius
Holding- most of ACA is constitutional except for Medicaid expansion
Deemed coercive under Dole Test- requiring states to expand or risk losing matching funds for former beneficiaries
Results: some states expanded or opposed expansion for political/economic reasons=coverage gap (people in-between get screwed bc not eligible for either program)
Gresham v Azar
Trump HHS pushed a work requirement for Medicaid
- Objective of Medicaid must be prioritized
- HHS waiver approvals are arbitrary/capricious
- Concerns over loss of coverage
Case blocked attempt to roll back Medicaid eligibility- if it leads to less people enrolling, it’s not doing what Medicaid aims to do
Block Grant Argument
Conservative states- federal rules are too limiting, want funds as block grants bc they know better how to distribute funds
Would eliminate waste and allow states to innovate
Opposition- what if a recession hits and block grants are too small? Allows states to make programs more meager
Harris v McRae
Does the Hyde amendment contradict liberty/equal protection as part of the Due Process Clause of the 5th amendment by denying public funding for abortions?
Should states be required to fund the cost of medically necessary abortions when federal reimbursement is unavailable under Title XIX?
Ruling: violates liberty interest, financial need isn’t a suspect class
Essentially gov doesn’t need to remove obstacles to freedom of choice that it didn’t create ) :
Hyde Amendment
Restricts abortion funding under other health programs (Medicaid) funded through HHS
Health Care Provider Examples
1) Hospitals and outpatient centers (e.g. Academic medical centers, community hospitals, safety net providers)
2) Physicians (e.g. primary care, specialists)
3) Other providers (e.g. nurses, PAs, home health aids)
Health Care Purchaser Examples
1) Employers- choose which insurance plans to offer their employees
2) Patients- choose private plans, eligible for public plans, or uninsured
HMO v PPO
Health Maintenance Organization (HMO)- lower cost, less flexibility
Preferred Provider Organization (PPO)- higher cost, higher flexibility
How is money spent to deliver care?
1) By governments and insurers
-directly to providers on behalf of patients/for facility fees, indirectly through taxes
-to intermediaries enrolling members/negotiating with providers
-to individuals paying out of pocket and need reimbursements
2) By individuals
-Deductibles, copayments, coinsurance, out of pocket to providers
-Premiums to insurers
Fee for Service (FFS)
Payer pays provider for each individual service provided to payer’s member based on negotiated price for each service (Or has fee schedule under Medicare)
Alternative Payment Methodologies (APMs)
Alternative payment structure agreed upon through payer-provider contract that financially incentivizes efficiency
(e.g. global/capitation risk budgets, bundled or episode-based payments, pay for performance)
What factors contribute to medical spending?
Medical spending=price x utilization
1) Prices- spending goes up if prices increase
2) Utilization- spending does up if patients use more services
3) Service mix- spending goes up if patients use more $$ services (e.g. Surgery vs PT, MRI vs X-Ray)
4) Provider mix- spending goes up if patients choose more $$ hospital over less $$ hospital
Major Hospital Ownership Changes
1) Governed by Board or Board of free-standing leaders instead of free-standing independent
2) Doctors in private practice
3) Multi-hospital systems employing physicians in community settings, owning/operating dispersed outpatient or imaging facilities
Key Payment Terms: Charge
Amount set by hospital, not usually what they get paid
Key Payment Terms: Price/Reimbursement
Payer- what they pay the hospital, own negotiated rate varies
Patient- what it costs them out of pocket
Key Payment Terms: Cost
Resources needed to provide a service, inputs, fixed and variable
(consumers and hospitals often have no idea, not a constant)
Hospital Consolidation Pros
1) Costs can do down- purchasing power
2) Quality will improve- tech improvements, coordinated care
3) Access- long term stability, patient trust due to name recognition
Hospital Consolidation Cons
1) Lower cost- more likely to close, smaller/weaker/non teaching hospitals, risk of price hikes
2) Quality could go down- improvements aren’t guaranteed/clear cut
3) Access- rural/inner city more likely to close
Pay for Performance
Based on bonuses and penalties- hospital is evaluated for each program using hospital data compared to what would be expected for a hospital with a similar patient-mix
How is the ACA changing hospital payment?
-Medicare: P4P for readmissions/value/complications, some hospitals in ACOs, bundled payments
-Loss of funding for uninsured/vulnerable populations due to Medicaid shift
-Medicaid expansion increased % of insured people
-Exchange plans may not cover all hospitals
No Surprises Act of 2020
Patients pay what they would have if care had been performed in network (other than ambulances)
Situation 1) emergencies
Situation 2) Non-emergencies where patients are treated at in-network hospitals but receive care for out of network ancillary providers
Ambulatory/Outpatient Care Structure
1) Physician offices
2) Hospital outpatient/ambulatory centers (diagnostic, therapy, surgery)
3) Free standing centers (CHCs, retail mini-minute clinics, surgical centers, imaging centers)
Community Health Centers
Safety-net centers for low-income, uninsured patients, sliding scale payment based on income
Comprehensive medical, dental, support
Patient Centered Medical Home
Team based delivery model- providing continuous medical care to meet patient needs
Patient-centered, coordinated care, accessible service, quality, safety
Non-Medicare ACA Changes to Primary Care
1) Increase workforce (increased training slots, increased national health service corps, loan forgiveness
2) Increased % insured and removing cost sharing for preventative care
3) More $$ to Federally Funded Community Health Center (CHC)
4) Increased Medicaid reimbursement for PC visits
Patients v Consumers
Patients:
-Goal- prevent hard, protect health
-Assumes unequal knowledge and skill
-Fiduciary duty on providers
-Resource use based on need
Consumers
-Goal: permit voluntary choices
-Assume equal bargaining positions
-No fiduciary duty of seller to buyer
-Entitlement to goods
Patient Rights
- Reasonable care by providers
- Informed, voluntary choice of medical care
- Medical care
- Right to refuse treatment (Jacobson v MA)
Tort Liability
Includes:
1) Allocation: Responsibility for injury
2) Compensation to injured party
3) Prevention of harm (deterrence, incentive to prevent risks/improve quality)
Battery
Intention and offensive touching without consent (e.g. operating on wrong part of the body, adding a surgical procedure not previously agreed to)
Negligence
Failure to perform duty of care- causing harm to the person receiving services
Types of Negligence
Ordinary negligence- informed consent
Professional negligence- malpractice
Breach of confidentiality
Plaintiff must provide which 4 points when proving negligence?
1) Defendant had a duty of care to the plaintiff to act reasonably (Duty)
Duty of reasonable care for malpractice, duty of disclosure for informed consent
2) Defendant breached that duty by not acting with reasonable care (Breach)
3) Plaintiff suffered actual injury (Harm/injury)
4) Defendant’s breath of duty was the proximate cause the plaintiff’s injury (Causation)
What is the goal of informed consent?
Give patients opportunity to make autonomous choices
Creates minimum conditions for making a medical choice possible
Health Care Practitioner’s Duty and Standard of Care
1) Duty to exercise same degree of knowledge/skill that a competent practitioner would exercise in similar circumstances
2) Duty of care is a legal principle
3) Standard of care- duty of care is constant, but standard of care varies based on case/circumstances
Malpractice Examples
Failure in:
Diagnosis- failure, delayed or incorrect diagnosis
Treatment recommendation- incorrect recommendation, failure to refer
Performance- incorrect performance of prescribed therapy
Follow-Up- failure to monitor, follow-up, incorrect follow up
Cobbs v Grant
Ulcer surgery leads to many other medical problems (spleen injury, subsequent ulcer, hospitalization, etc.)
Charged with medical malpractice
Jury reversed judgement to focus on negligence and not battery- requirement to share potential risks and complications
Scope of Duty to Disclose
1) Full and complete disclosure
2) What doctors in good standing would disclose
3) Information for the decision the patient has to make (patient-centered decision)
4) What the doctor determines should be disclosed at that time
What must be disclosed?
1) Patient’s medical condition/risks of going w/o treatment
2) Recommended treatments
a) Potential benefits and probability of success
b) Risks/Complications
c) potential benefits/risks of alternative
treatments
IN LAY TERMS
Sine v Vega
Implied consent in emergency situations where patient/family member can’t consent
Competent patient’s refusal to consent can’t be overridden just bc the patient is in a life-threatening position
4 C’s of Competent
1) Conscious
2) Comprehends relevant info (medical condition, treatment options)
3) Chooses- capable of making an affirmative decision
4) Communicates a decision
Children Patient Rights
Parents have duty to provide necessary medical care to patients
Some minors can consent to their own medical care- emancipated minors, mature minors
Rights for Incompetent Adults
Same rights as competent adults, just exercised by rep.
-Informal- knowledgeable family member
-Formal- health care proxy, legally appointed guardian
“Substituted judgement”- be voice of the patients and make decision the patient would want
Cruzan v Director, Missouri Dept. of Health
Car crash, parents wanted life-sustaining treatment withdrawn
No clear and convincing evidence about withdrawal of treatment in a life or death situation
Court ruling- MO has a clear interest in keeping its residents alive
Washington v Glucksberg
Is Washington’s prohibition against causing/aiding a suicide a violation of the 14th amendment?
Holding- banning physician-assisted suicide doesn’t violate Due Process Clause of the 14th amendment
Justifications for Research on Human Subjects
-Some scientific questions can’t be answered w/o testing in humans
-Study design is scientifically sound
-Subject selection is based on justice and relevant to research question
-Risk to subjects is reasonable/minimized
-Subjects participate w/ voluntary, informed consent
Info Necessary for Informed Consent Research
-Study purpose, design, and procedures
-Interventions, standards of care
-Nature of investigational intervention
-Anticipated benefits/risks
-Subjects can withdraw at any time
-Care/compensation in case of injury
Researchers v Physicians
Duty: properly conduct research v quasi-fiduciary duty to patient
Confidentiality: No duty v active duty
Intervention: Prescribed by research protocol v patient need
Consent: Must obtain in writing v not required
Goal: Obtain valid results v successful treatment chosen by patient
International Bill of Rights
- Universal Declaration of Human Rights
- International Covenant on Economic, Social and Cultural Rights
- International Covenant on Civil and Political Rights
*US hasn’t signed and ratified all of them
Universal Declaration of Human Rights
All human beings are born free and equal to dignity and rights….
-No cruel treatment
-No arbitrary interference
-Right to standard of living adequate for health (food, clothing, shelter)
International Covenant on Economic, Social and Cultural Rights
Equal gender rights, right to work, fair wages, right to SS, right to education, etc.
Factors Impacting Health Systems
-Form of gov
-Population demographic, homogeneity
-Geography (large v small country)
-History
-Ideology
-Culture
-Economic prosperity
-Local burden of disease
Goals Across Health Systems
Access and quality of care, sustainable costs
4 Methods of Health Care Finance
1) Out of pocket
2) Individual private health insurance plans
3) Employer sponsored health insurance
4) Public insurance- gov pays for insurance
2 Methods of Care Delivery
Private providers- Canada, Germany, Japan
Public providers- UK
GINI Index
Measures degree of inequality in the distribution of family income in country
Scale of 0 (perfect equality)-100 (perfect inequality)
Beveridge Model
National Health Service- Care provided to all citizens through tax payments (Socialized medicine), gov. controls all aspects of the system
E.g. UK, Cuba
Bismark Model
Social insurance w/ competing plans- jointly financed by employers and employees, doctors/hospitals tend to be private
E.g. Germany, Japan
National Health Insurance
Publicly funded, privately delivered
E.g. Canada, Medicare in the US, India
Germany- Health Care History
Health and other benefits tied to employment- people pay for insurance through taxes in addition to companies
Public coverage covers everything including those not working
Health insurance is mandatory
Canada- Health Care History
Path of voluntary employment-based health insurance, universal coverage is recent
Canada Health Act- care will be universal, comprehensive, accessible, publicly administered, portable
Long wait times, drugs/eyeglasses covered by private insurance
UK- Health Care History
Socialized medicine
Pros: Costs are low, happy people, better health outcomes
Cons: Doctors not paid as well, less nice hospitals, longer wait times
Prevention
Aimed at reducing incidence of disease/disability or slowing the progression and exacerbation of illnesses
Primary Level Prevention
Focus on preventing disease, promoting better standard of living (and save $$)
E.g. immunizations, physical activity, better wages, seatbelts, fluoridated water
Secondary Level Prevention
Focus on identify/reduce incidence of illness in population, focus on high risk individuals
E.g. hypertension screening/treatment, smoking cessation programs
Rarely cost saving, maybe cost effective
Tertiary Level Prevention
Focus on maintaining function/soften impact of ongoing illness
E.g. long term disease management, rehabilitation (mode of transport for trauma patients)
Cost Saving
Cost of prevention is less than cost of treatment
Cost effective
Doesn’t save $ in medical treatment, but there is significant benefit to population or individual for cost of prevention
4 Categories of ACA Mandated Coverage for Preventative Services
1) Evidence-based screenings and counseling
2) Routine immunizations
3) Childhood preventative services (e.g. autism screening, blood screenings)
4) Preventative services for women (e.g. birth control, STD screening)
Braidwood Management Inc v Becerra
Christian owned businesses and individuals argue that USPSTF is unconstitutional, requirements to cover PrEP violates RFRA
Argued that USPSTF officers not nominated my president
Being appealed to 5th Circuit Court of Appeals
