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Health Care Delivery Flashcards

1
Q

What is Practice Management?

A

The coordination, promotion, and resource (financial and human) management of practice that follows regulatory and legal guidelines.

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2
Q

Who is responsible for the charges in a physical therapy clinic?

A

The Physical Therapist

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3
Q

Name some private insurers

A

Anthem BCBS, Kaiser, Cigna, Aetna, etc…

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4
Q

Name some governmental insurers

A

Medicare, Medicaid, workers , Tricare/VA, etc…

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5
Q

What happens when there is an increase in the national unemployment rate?

A

Decrease in state revenues, increase in Medicaid and CHIP enrollment, increase in uninsured, decrease in employer sponsored insurance

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6
Q

Name the sources of funding for uncompensated care

A

Federal $32.8 billion, 62%
State %19.8 billion, 37%
Private $0.7 billion, 1%
Total $53.3 billion

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7
Q

T/F: The US spends 2.5 times the OECD average

A

True

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8
Q

The US is worse than Germany, Japan, and Italy in terms of what?

A

Infant mortality
Life expectancy after 65
Maternal death per birth

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9
Q

What is the OECD?

A

Organization for Economic Cooperation and Development

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10
Q

What are issues that do not make health insurance in America a free market?

A

Public subsidies for health insurance payment
Adverse selection
Laws that protect vulnerable people

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11
Q

What is a collective good?

A

Public goods that could be delivered as private goods, but are usually delivered by the government for various reasons, including social policy and finances from public funds like taxes (similar to libraries, police, etc)

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12
Q

What happened when co-pays were increased?

A

Reductions in anti-depressants, anti-asthmatics, anti-diabetes drugs
Visits to the ER went up
Length of hospital stays increased

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13
Q

Who has a higher rate of not filling or delaying filling prescriptions, people with: Part D, employer-insurance, or insurance through the VA?

A

Part D

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14
Q

What are factors that are positively associated with receiving OP PT?

A

Having 7 or more ICD-9 Codes
Having a college or advanced degree
Residing in an urban area

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15
Q

What are factors that are negatively associated with receiving OP PT?

A 
Older than 65 years of age
Having no high school degree
Hispanic ethnicity
African-American race
Having public insurance or no insurance
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16
Q

What is guaranteed issue?

A

A requirement that insurance companies give insurance to anyone who applies. Pools are generally smaller until someone gets sick

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17
Q

What is important about a risk pool?

A

Insurance companies want smaller risk pools with favorable selection, but need larger pools to water the risk down because of adverse selection

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18
Q

What is Individual Mandated Coverage?

A

Everyone in the company is required to get insurance so the pool gets larger and then premiums won’t go up. Everyone is in the pool, whether insurance is obtained through employer or individually

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19
Q

What is The Exchange?

A

Newly formed health marketplace that the state or federal government created. People can search for health insurance based on their wants and needs

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20
Q

Who is exempt from the health insurance mandate?

A

Prisoners

Undocumented illegal immigrants

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21
Q

What is adverse selection?

A

A pool of people who are more sick

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22
Q

What is favorable selection?

A

A pool of people who are more healthy

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23
Q

In terms of premiums, what is the difference between adverse and favorable pools?

A

They both pay the same premium, however, adverse pools are considered a loss since more money is being paid out

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24
Q

What is Employer Mandated Coverage?

A

Employer lessens choice of health care plans, premiums, often stuck with select plans but employer pays 2/3rds of the premium

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25
What are Underwritten Private Insurance Policies?
Insurance companies try to deny or rescind policies by going through health records to find red flags. Companies determine if you're eligible for health insurance. Usually happens after a claim is submitted. This is no longer legal
26
What four countries is health care coverage not universal?
US, Mexico, Chile, Turkey
27
In terms of uninsured adults, what regions have less uninsured and more uninsured?
Less uninsured: North, East More Uninsured: South, West 47.9 million ppl uninsured
28
T/F: pharmaceutical companies make much more than Fortune 500 companies
True
29
What are the modes for paying for healthcare?
Government sponsored health insurance Private Pay or Out of Pocket Private Health Insurance (employee based or individual policies)
30
What has happened since the cost of employment based insurance has increased?
Elimination of benefits Increased employee share Increased use of HSAs
31
Name some details about private health insurance (individual)
Higher risk to insurer (less of a risk sharing pool) Higher premiums More restrictions (pre-existing conditions) Rescission is legal
32
What is cost sharing?
Deductibles, copays, coinsurances, etc that you pay out of pocket Prevents pts from over-utilizing the healthcare system
33
What is the short term effect of cost sharing?
The insurer has a more favorable pool
34
What is the long term effect of cost sharing?
Delay in care, copays go up, people don't use preventative meds
35
HMO details
Most restrictive health plan Lowest out of pocket expenses Usually pay with co-pay Discounted rates leads to increased volume and decreased revenue per pt Small network, contract providers Lower premiums Need referrals from PCP to see a specialist Member pays higher percent of cost if seen by out of network provider
36
What is the difference between a co-pay and co-insurance?
Co-pay: flat amount for an appt | Co-insurance: percentage of the appt
37
PPO Details
Similar to HMO, creates a provider network Arent required to have a PCP No referral needed to see a specialist Less likely to have to use an in-network provider Richer benefits More expensive Larger network (more variety in picking in-network docs) Higher deductibles, co-insurance No co-pays
38
HSA Details (consumer-directed health plans)
Very high deductible Encourages responsible spending on healthcare More likely to discontinue chronic-illness meds More likely to delay seeing care due to cost Attract healthy people because less annual cost
39
Fee for Service
Paid by performed procedure (CPT) Negotiated fee for service- price is negotiated down by insurer Payment based on individual service
40
Payment by Episode
One sum for all services delivered in one illness Can span for multiple days+ Common in inpatient, rare in outpatient Diagnoses Related Grouping (DRGs paid by Medicare) Set amount, regardless of time it takes or procedures Incentive to d/c quickly
41
Payment per Diem
Flat amount paid per day Fairly common in IP with private insurers Becoming more common in outpatient PT Set amount per day regardless of time it takes Incentive to decrease services
42
Flat Rate per Visit
More common in outpatient clinics, similar to fee for service but paying for entire visit (not broken up by services)
43
Capitation
One payment is made for treatment for one month or year depending on contract More common for physicians
44
Payment per Patient
Payment for all services delivered to all patients within a certain time period Global budget reimbursement of hospitals such as Kaiser or VA Also includes salaried payment of providers Paid to institution, NOT physician More preventative care, aim to see the pt less over time All financial risk is on institution Increase utilization review, minimize waste
45
Payment for Institution (VA, Kaiser)
One flat budget | May be rushed to spend budget at end of year
46
Prospective Payment System (PPS)
Inpatient PT DRG (Diagnosis related groups) Home Health (payment per episode - OASIS)
47
Outpatient PT Payments
Flat rate per visit (rewarded for more visits, shorter visits. Usually capped by insurance as number of visits/year and/or number of visits/episodes for illness) Fee for service with negotiated fee schedule (many hospital based still have these)
48
VA, Kaiser, Military Payments
Budget for entire institution
49
Annual Benefit Maximum
Once you hit a certain amount for the year, insurance plan wont pay anymore money and you now pay for everything out of pocket Healthcare reform trying to eliminate ABM or LBM
50
Annual Out of Pocket Maximum
different with every plan, only allows you to pay a certain amount out of pocket. Includes copays, coinsurances, cost sharing, deductibles
51
Denials
Visits, equipment, etc get denied, often clerical problems
52
Appeals
Process to appeal a denial in order to get paid
53
Supervision Rules
Written by a payer, says certain jobs cant do certain things
54
Drug Formulary
Get a rx for a prescription and find out insurance company is not on the list for a certain drug. Insurance companies want generic drugs on list since theyre cheaper
55
COBRA
Federal law, meant to protect people who lost their job. Person can continue to pay health insurance premiums but has to pay whole premium (their part and employers) 90% of people don't take it Exchange is cheaper
56
What is No-Fault Auto Insurance? (AKA PIP Personal Injury Protection)
Coverage for certain medical and rehab expenses from injuries sustained in an automobile accident Pays benefits for injuries whether or not the insured person is negligent or at fault
57
Tort Auto Insurance
A tort is a civil wrong, not a crime Determination of fault in an automobile accident is made. Party at fault or their insurance company pays medical and rehab expenses to injured party, as well as property damage Injured party may also sue for other losses including lost wages and pain and suffering
58
Short Term Disability
Get injured and unable to work, get paid for a few months
59
Long Term Disability
Get injured and unable to work, get paid for a year - few years. The longer youre on it the more expensive it is
60
OWN Disability
Your own occupation, if youre unable to work as a PT you can be paid for disability More expensive than ANY disabiltiy
61
ANY Disability
Any occupation, if youre unable to work at all in any job, you can be paid for disability

HCD (5 decks)

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