Health Care Delivery Flashcards
What are the three eras of US health care change?
pre industrial
post industrial
corporate era
What are the 4 main features of the corporate era?
corporatization
growth of non-physician workforce
information revolution
globalization
What is the strucutre of the ACA passed in 2010?
What were common occurences prior to ACA?
denying–people with pre-exisitng conditions or in certain occupations
excluding – people with pre-existing condition
charging– higher premiums to people based on gender or health
limiting– limited benefits to people with pre existing conditions, mental health etc..
imposing– lifetime or annual benefit caps
What is guaranteed issue?
concept that if an individual applies for healthcare policy then company must sell them a policy (everyone needs to be insured)
What is the insurance mandate?
when government requires everyone to have insurance
What is underwriting?
idea that individual applies for a policy and company looks at their risk factors (pre-exisint conditions and refuses to sell) can either not sell, increase rates (avoid the sick, choose the healthy)
What is a risk pool?
how risky the group of people you are insuring are
adverse selection – normally increase the rates of premiums, large pool with more sick than healthy= MOST risk
favorable selection– large pool, with more health than sick
What is community rating ?
idea that the US as a whole, that each individual will have the same premium regardless of preexisting conditions of individual factors– spreads the risk
What is an individual rating?
based on age, gender, ethnicity, or health staus– exclusive prior to the ACA
What is recision>
recission is when an insurer takes actions retroactively to cancel a policy holder’s coverage by citing omissions or errors in application– in order to revoke their policy
What is modified community rating?
can charge different rates based on characterisitcs of the community rather than the individual– get more people into the pool
What is a premium and how is it determined?
is your monthly payments – paid regardlness if using care or not
competition– holds prices in check
Who are the players of healthcare?
providers
payers/insurance
patients
pharmacy (suppliers)
What are the types of cost-sharing
co-pays= flat amount of $
co-insurance – dependent on policy
deductible
What is power asymetry?
idea that people have certain reverebce for providers having more knowledge
provider is the superior knowledge therefor is the decision maker
What is shared decision making?
idea that there is no large power differential
inherently assymes that patients are capable of taking in complex information from health care providers
What is the moral hazard theory?
trend towards more risky behavior because the individual knows that he/she won’t have to cover the full cost
someone else will pay for my mistake, so more likely to take risk
What are the types of managed healthcare?
HMO
PPO
Consumer directed health plans (HSA)
What are the components of an HMO?
exclusive provider organization (EPO)– more restrictive
network size=small
must see a PCP before specialist
provider reimbursement= negotiated fee/ contracted rate w/ a co-pay
cheaper premiums than a PPO
cost sharing is lower out of pocket cost to member
What are the components of a PPO?
have a larger network size than HMO
do not require PCP visit
provider reimbursement =negotiated fee/ contracted rate w/ typically co-insurance
less reestrictibe
more expensive premium
higher out of pocket cost
What are the components of an HSA?
created by a provision in the Medicare prescription drug improvment and modernization act
typically very large network
full access to specialist
provider reimbursement= pt paying majority
premium is very low
cost sharing= very high deductible
max= $6650 for self
What is fee for service?
CPT codes used for determining payment amount
encourages overutilization
What is payment by episode/ prospective payment system?
pre-determined amount paid by insurance to provider
CPT used for charging but do not impact payment amount
Medicare like to pay of IP using payment by episode – diagnosis related groups (DRG) in acute care
