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Medicine & Society 1 > Health Care Reform > Flashcards

Health Care Reform Flashcards

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1
Q

What does the patient want?

A

wants to see the best doctors and get the best treatment available

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2
Q

What does the insurer want?

A

wants to save money and send the patient to less-expensive doctors & providers

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3
Q

What does the physician want?

A

want to preserve autonomy and ensure they are getting paid fully for the services they provide

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4
Q

What does the competing pressure involve?

A

patients’ and physicians’ desire for autonomy; patients’ desire to be insulated from cost and society’s need to restrain health care spending

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5
Q

What is health policy?

A

The planning, development and implementation of interventions designed to maintain and improve the health of a group of individuals.

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6
Q

What do health policies affect or influence?

A

groups or classes of individuals or organizations

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7
Q

What does health policy inform and affect?

A

the various payment and care systems – the “business” of medicine

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8
Q

What are the factors impacting health care in America?

A
  1. Aging (increase in age = increased health care utilization to prolong life
  2. longer living with chronic illness (preventing death and disability using expensive technology continues to increase))
  3. Demand of aggressive treatment ( healthcare systems provide it across life span)
  4. Prescription (high utilization and cost)
  5. Medical technology (excessive use even when not necessary)
  6. fragmentation the US health care system (public/private insurer provide mix and excessive admin. cost)
  7. defensive medicine (need for medical tort reform)
  8. Autonomy (individuals demand personal responsibility for maintaining one’s own health status)
  9. specialist vs. PCP
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9
Q

What is the total number of professionally active physicians in the U.S as of March 2018

A

968,743
(467,477 - PCP and 501,296 Specialist)

ROUND OFF

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10
Q

The need for fundamental transformation of the U.S health care system involves?

A
  1. fragmented delivery system
  2. Need for better access/coverage (job based premium incr., gaps in coverage, and underinsured contribute to issue)
  3. shorter life span for Americans (disparities are pervasive, difference in access to care due to insurance status, income, race, and ethnicity)
  4. 30% of pop. is uninsured, unstably insured, or underinsured
  5. Inadequate access -> dec. work productivity and output
  6. Issue with safety and quality of care (medial errors and medical mistakes compromise quality of care)
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11
Q

What is the key concern for many working families?

A

Rise of health care

gaps in insurance coverage, high out of pocket cost = skipped test and treatment -> pain, suffering, and death

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12
Q

How does proper insurance affect the workforce?

A

majority of employers believe that health insurance positively affects employee health and morale and link health benefits to enhanced employee productivity

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13
Q

preventable morbidity and mortality associated with being uninsured translates into a loss of?

A

$65 billion to $130 billion annually

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14
Q

Whats the 3rd leading cause of death in America?

A

Medical Errors

250,000 death per year

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15
Q

What compromise the quality of care?

A

Inefficiencies, such as duplication and use of unnecessary services, (they are costly)

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16
Q

What percent of americans have access to health insurance according to the ACA?

A

85%

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17
Q

Which country is ranked first in per capita health care expenditures?

A

U.S

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18
Q

What is the U.s infant mortality rate ranking?

A

43rd (2009)

7 deaths per 1,00 live births (5.2 as of 2014))

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19
Q

Nearly all of the worlds highly industrialized nations have health care systems that provide what?

A

Universal access to health care for its citizens

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20
Q

What is a single player in universal healthcare?

A

The government provides insurance for all residents (or citizens) and pays all health care expenses except for co-pays and coinsurance. Providers may be public, private, or a combination of both

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21
Q

What is a Tow-Tier in universal healthcare?

A

he government provides or mandates catastrophic or minimum insurance coverage for all residents (or citizens), while allowing the purchase of additional voluntary insurance or fee-for service care when desired.

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22
Q

What is a Insurance mandate in Universal healthcare?

A

The government mandates that all citizens purchase insurance, whether from private, public, or non-profit insurers. In some cases the insurer list is quite restrictive, while in others a healthy private market for insurance is simply regulated and standardized by the government. ( insurers are barred from rejecting sick individuals, and individuals are required to purchase insurance)

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23
Q

How does healthcare work in Singapore?

A

all residents receive a catastrophic policy from the government coupled with a health savings account that they use to pay for routine care.

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24
Q

How does Universal healthcare work in countries like Ireland and Israel?

A

the government provides a core policy which the majority of the population supplement with private insurance.

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25
Q

What category if universal healthcare does the United states fall under?

A

Insurance Mandate

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26
Q

What is the US ranking for health care system performance?

A

11th

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27
Q

What is the proposed National Health Insurance Insurance Legislation?

A

Medicare for All Act Bill by Bernie Sanders

Expand medicare into a universal directions -> public systems of health care, paid for by higher taxes, no co-payments, younger than 18 receive universal medical cards, non-eligibles phased in within 4 years, employer insurances removed and employers req. to pay higher taxes, private insurance remains for specific procedure (cosmetics), doctors reimbursed by government, doctors sign yearly participation agreement

28
Q

What does the expanded and improved medicare for all act include?

A

!5 trillion over 10 years cost, saving 5 trillion
Lower pharmaceutical and device price, low rate of medical inflation.

These are in addition to the original reform.

29
Q

What are cost drivers?

A

Prices of labor and goods, including pharmaceuticals (1,443 in US) and administrative costs are major drivers

30
Q

What are the only two industrialized nations that allow pharmaceutical companies to engage in direct-to-consumer advertising of their drugs?

A

US and New Zealand

That added to the cost of Big Pharma lobbying efforts has greatly drug costs

31
Q

Administrative cost account for what percent of GDP in the US.

A

8% compared to 1-3% in other countries

32
Q

True of False?

Doctors and make less in U.S than in other countries

A

False

More

33
Q

What is the National Health Expenditure (NHE) for 2015?

A

$3.2 trillion for 2015

$3.35 trillion for 2016

Predicted to be 5.7 trillion in 2026

34
Q

How much did medical spending grow?

A

646.2 billion in 2015

575 billion in 2017

35
Q

What percent of the US population accounts for nearly half of all health care expenditures in a given year?

A

5%

36
Q

What is the historic role of health insurance?

A

a method of mediating and redistributing the financial risk associated with major illness from individuals to collectives administered by insurance companies

37
Q

What is the purpose of health insurance companies?

A

serve as conduits between individuals, doctors, hospitals or other health care providers by taking a predetermined amount of money per person covered (premium) and paying it out as beneficiaries costs of utilization are incurred

38
Q

What are the three type of Health Care Coverage you can access in the U.S

A

Employer-based

Individually Purchased

Government Subsidized

39
Q

What is the primary source of annual health insurance coverage information in the U.S.?

A

CPS supplement

40
Q

Majority of U.S insurance in 2015 is what type of coverage?

A

Employer based healthcare (49%)

41
Q

What is employer based insurance?

A

Employer usually pay all or part of premium
Tax deductible business expense
Not taxable income for employee (so it is subsidized, apron. 260 Billion/year)

42
Q

According to the Bureau of Labor Statistics, health insurance accounts for what percent of employers personal compensation?

A

7.6-12.1%

43
Q

What are the cost saving strategies companies use (according to Aflac)?

A
  • increased employee co-payments (26 percent)
    – increased their employee’s share of the premium (25 percent)
    – implemented a health care plan with a deductible of $1,000 or more (22 percent)
    – reduced the number of health insurance plans they offer (19 percent)
    – eliminated coverage for spouses and partners (12 percent)
44
Q

Traditional Idemnity Insurance includes?

A

Inpatient Care
Outpatient Care
Specialty Care

(Managed Care Organization)

45
Q

The provision of health services through a single point of entry and through a formal enrollment mechanism where the patient care is managed by a gatekeeper, PCP or physician extender (nurse practitioner, physician assistant, etc) with an emphasis on: quality preventive and primary care, reduction in inappropriate utilization, control & leveraging of costs and the overall management of risk

This describes?

A

Managed Care

Provide high quality care

Dominant healthcare delivery vehicle

46
Q

What are the common elements of managed care organizations?

A
  • Aggressive negotiation of contract w/ select panel of provides
  • explicit standard of selection
  • employ financial capitation models
  • pre-authorization and review of services
    defined formularies and pharmacy benefit management companies (PBM)
  • stringent cost control (efficiency of management)
  • quality assurance, utilization analysis and review program
  • financial incentive (value based, outcomes/evidence based care)
  • penalties to providers to reduce cost, maximize efficiency and to improve clinical outcomes
47
Q

What are the types of managed care organization?

A
  • Staff or group Model
  • Independent Practice Association (IPA)
  • Exclusive Provide Organization (EPO)
  • Preferred Provider Organization (PPO)
  • Point of Service (POS)
48
Q

What is the staff or Group Model?

A

a type of managed care plan in which the plan has contracted with a multispecialty physician group to care for plan members; a type of managed care plan in which physicians who care for plan members are employees of the plan

49
Q

What is the Independent Practice Association?

A

a type of managed care plan which contracts with many physicians or physicians groups in an area to provide care to plan members.

50
Q

What is the exclusive provide organizations?

A

Managed care plans that provide benedicts to subscribers who are required to use this group of network providers exclusively for care.

51
Q

What is the Preferred Provider Organization?

A

a large group of hospitals and physicians under contract to a managed care plan. Health care providers in the PPO serve plan members for negotiated fees and copayments. Plan members who use providers not in the PPO (network) face higher out of pocket costs.

52
Q

What is Point of Service?

A

you can use out of network managed care providers, but at a much higher cost.

53
Q

What is the number 1 Insurance Company?

A

UnitedHealthcare Group

54
Q

In 1935 the Social Security Act was amended for what?

A

To pay for health services for Medicaid and Medicare

55
Q

What is Medicare?

A

the exclusively federal program that pays for health services for individuals 65 or older or people with severe and permanent disabilities

In 2012, Medicare spending accounted for 16% of total federal spending and 21% of total national health spending. Covered 52.3 million Americans as of 2013

56
Q

What is Medicaid?

A

a federal/state cost-sharing program, that pays for certain health services for persons who meet certain eligibility criteria as determined by the states (low income)

1 in 5 Americans

57
Q

Medicare Part A

A

covers inpatient hospital stays, skilled nursing facility stays, home health visits (also covered under Part B) and hospice care

Part A benefits are subject to a deductible ($1,184 per benefit period in 2013) and coinsurance.

58
Q

Medicare Part B

A

covers physician visits, outpatient services, preventive services, and home health visits

Part B benefits are subject to a deductible ($147 in 2013) and cost sharing generally applies for most Part B benefits

59
Q

Medicare Part C

A

refers to the Medicare Advantage program, through which beneficiaries can enroll in a private health plan, such as a health maintenance organization (HMO), and receive all Medicare- covered benefits

60
Q

Medicare Part D

A

is the voluntary, subsidized outpatient prescription drug benefit, with additional subsidies for beneficiaries with low incomes and modest assets

benefit is offered through private plans that contract with Medicare, both stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug plans (MA-PDPs)

Plan pays 75%

61
Q

What does the medicare perspective include?

A

Ongoing need to improve physician counseling of individual on end of life options.

30% of medicare dollars use in the last 60 days of life (futile care)

62
Q

What is argest insurer of health care provided during the last year of life?

A

Medicare

63
Q

What is advanced care planning? (covered by medicare)

A

discussions that physicians and other health professionals have with their patients regarding end-of-life care and patient preferences

Separate and billable service

64
Q

What are the basic benefits covered with Medicaid?

A

in-patient and out patient hospital services,; physician, midwife and nurse practitioner services; laboratory & x-ray services; nursing home & home health care for individuals age 21+; EPSDT for children under age 21 and long term care support & services. Children make up about half of all Medicaid enrollees, nonelderly adults make up one-quarter, and seniors and people with disabilities make up one-quarter

65
Q

Who/what does Medicaid cover currently?

A
  • 39% of children (Early and periodic screening, diagnostic and treatment - EPSDT)
  • Nearly half of all births
  • 60% of nursing home and other long term care expenses
  • more than 1/4 of all spending on mental health service and over a 1/5th of all spending on substance of all spending on substance abuse treatment
  • 40% of poor nonelderly adults. Medicaid covers 60% of children with disabilities and 30% of nonelderly adults with disabilities, including individuals with severe physical disabilities, developmental disabilities such as autism and traumatic brain injury, serious mental illness, Alzheimer’s disease, and other chronic conditions.
66
Q

What is CHIP?

A

Children’s Health Insurance Program

provides coverage to children in families who earn too much to qualify for Medicaid but not enough to afford private insurance. Some states it covers pregnant women.

Works closely with Medicaid program

67
Q

Slide 47-49

A

Medicaid Under Threat

Medicine & Society 1 (10 decks)

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