health care systems and culturally changing US climicate - week 6 Flashcards
Patient Protection and -Affordable Care Act (2010)
Increase in type of coverage and mandated everyone have health insurance
-Increase in WHO has coverage
LARGELY Debated legislation
Supreme court upheld all provisions save for one:
Obamacare
No insurance is created- it regulates private insurance to ensure you get more rights and protections (regulates existing plans)
Health Insurance Marketplace
Individual mandate
Employer mandate
The Basics
Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center. Also included in this category are home health services and hospice care (note: some plans may limit coverage to no more than 45 days). –will put limits on it-
Ambulatory patient services (outpatient care)
Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. Typically, this is a trip to the emergency room, and includes transport by ambulance. You cannot be penalized for going out-of-network or for not having prior authorization. –will apply to insurance-
Emergency service (trips to the emergency room)
- Ambulatory patient services
- Emergency services
- Hospitalizations
- Maternity and newborn care
- Mental health services
- Prescriptions drugs
- Rehabilitations services/devices
- Laboratory
- Preventative/wellness
- Pediatric services
10 essential benefits of minimal essential coverage
Pros
-You cannot be dropped for being sick and needing medical care
-Gender equality
-Justified rate hikes
Cons
-Insurance companies need to cover these additional expenses- which means charging higher premiums
-Open enrollment periods only
Preexisting or new conditions
Pros
-More employers are offering health insurance as a benefit
-Small businesses can get tax credits for health insurance premium costs
-80/20 rule: hospitals cannot make more than 80% of their cost- have to spend that on healthcare costs or offer it as rebate
Cons
-Some businesses are laying off employees or reducing hours to comply with federal mandate
employer mandates
Pros -Mandates for breastfeeding moms -Contraception Cons -religion or morals
contraception
Pros -Slowed the growth of hospital spending -Punishing high patient turnover Cons -oversight also costs money -gov involvement in private business/health decisions
hospital oversight
Readmissions
Infections
Huge amounts of training and policy changing to be compliant
Consolidation with other facilities to help meet these needs
The goal is to have more insured patients, but $ cuts came before benefits have. That’s a lot of revenue that has dropped in the meantime.
hospitals - how healthcare is changing
More patients coming in for preventative treatments
Dentists will see children for annual services
REQUIREMENT to move to EMRs
Pediatricians see many more patients
The removal of lifetime caps by insurance agencies means better chronic illness management for children
doctors - how healthcare is changing
85 services or items added to health insurance plans
Leads to higher premiums
Can charge more now for more children
Can adjust based on age, but not gender
Hiring more staff to meet the new demands
Insurers must now provide breast pumps, lactation consultants, shingles vaccines, aortic aneyrysm screenings, dentist checkups for kids, autism screenings, folic acid supplements for preg women, etc.
insurers - how health care is changing
originally withholdings, then rationing them out if you meet the standards
medicare - value based healthcare
1% of Medicare Reimbursement 70% from clinical performance guidelines 30% HCAHPS $963 million dollars per fiscal year 2% by 2017
the cost of patient satisfaction
Patient Satisfaction does not correlate with Quality
- The most satisfied patients spent the most on healthcare and prescription drugs
- 12% more likely to be admitted to the hospital
- 9% more in total healthcare costs
- Higher mortality rates
validity of HCAHPS
