Health Systems Policy & Management (II) Health System Models Flashcards
What are the three main factors to keep in mind when comparing health systems?
Financing (public; private; out-of-pocket)
Delivery (public; private non-profit; private for-profit)
Access (universal; not universal)
Describe the financing of the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Public financing via general taxes
Describe the delivery mechanism of the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Publicly owned and some private providers
Describe access to care in the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Universal care
Describe financing in the Bismarck model (Germany, France, the Netherlands, Japan).
Private financing via joint efforts of employers and employees
Describe the delivery mechanism in the Bismarck model (Germany, France, the Netherlands, Japan).
Care mostly via private providers
Describe access to care in the Bismarck model (Germany, France, the Netherlands, Japan).
Universal coverage
Describe financing in the National Health Insurance model (Canada, Taiwan, South Korea).
Public financing via special taxes
Describe the delivery mechanism in the National Health Insurance model (Canada, Taiwan, South Korea).
Care mostly via private providers
Describe access to care in the National Health Insurance model (Canada, Taiwan, South Korea).
Universal coverage
Describe financing in the out-of-pocket model (rural Africa, Southeast Asia).
Most countries are too poor or disorganized to provide financing
Describe the delivery mechanism in the out-of-pocket model (rural Africa, Southeast Asia).
Care via private providers
Describe access to care in the out-of-pocket model (rural Africa, Southeast Asia).
Only those who can pay or access charity care will receive service
Is the U.S. system most like the Beveridge, Bismarck, NHI, or out-of-pocket health system models?
It is a blend of each.
Beveridge - VA system
National Health Insurance - Medicaid and Medicare
Bismarck - those getting insurance from their employers (private )
Out-of-pocket - whoever pays direct costs without insurance
Summarize the main health system models (Beveridge, Bismarck, national health insurance, and out-of-pocket) according to:
financing (public or private),
delivery (public or private),
and access (universal or not).
Does the U.S. system need reform?
Yes, if financing, delivery, and access needs are not being met efficiently, then the system needs to change.
Spiraling costs and the lack of universal coverage indicate a broken system.
What is acute inpatient care?
Hospital care with an average length of patient stay of ≤ 25 days
(⅓ of healthcare expenses and ½ of all healthcare personnel)
What is another name for outpatient care?
Ambulatory care
How are most ambulatory services used (in descending order)?
Primary care offices > Surgical and medical specialty care offices > hospital EDs > hospital outpatient departments
What is a long-term care facility?
An inpatient care location with an average length of stay of > 25 days
E.g. nursing home, rehabilitation center, etc.
What percentage of elderly individuals receive care from family members?
80%
What are the requirements for hospice care?
≤ 6 mo. life expectancy if disease runs its normal course
What is provided in hospice care?
Palliative care; end-of-life counseling for patient and family
Contrast preventative care in fee-for-service and capitation payment systems.
Capitation favors preventative medicine more than fee-for-service
(preventative medicine keeps you from seeing the doctor, which would be lucrative to the provider in the capitation system but detrimental in the FFS system)
Which system maximizes physician risk: fee-for-service, prospective payment, or capitation?
Capitation
What do fee-for-service systems encourage physicians to do?
Maximize intensity; maximize encounters
What do capitation systems encourage physicians to do?
Minimize intensity; minimize encounters
Describe the prospective payment model.
Each service has a predetermined amount for insurance reimbursement
The provider benefits only if he keeps costs below the reimbursement limit
What does the prospective payment model encourage physicians to do?
Maximize encounters; minimize intensity
How does a pay-for-performance (value-based payment) model work?
Pay-for-performance (e.g. if you keep all your diabetic patients at a healthy A1c level, you get a bonus; if you don’t, then you lose some of your reimbursement)
How does a bundled payment (value-based payment) model work?
A single pre-negotiated payment is given for all services related to a certain procedure. The physician makes a profit by minimizing services and keeping costs below that payment
How does a shared savings payment model (value-based payment) work?
Accountable care organizations: physicians band together, and if they succeed in improving health outcomes and lowering costs for the insurance company, then they share in the savings
What are the three main forms of reimbursement?
Government, private, and out-of-pocket
Describe Medicaid/Medicare reimbursement.
The government decides on prices via diagnostic-related groupings. (This is the smallest reimbursement category.)
Describe private insurance reimbursement.
Insurers negotiate with providers on behalf of their clients to keep prices as low as possible (more lucrative for providers than Medicare/Medicaid reimbursements)
Describe out-of-pocket reimbursement.
Individuals without insurance must pay full price (most lucrative for providers as there is no negotiation of prices)
What is ‘cost-shifting?’
Physicians often receive the least reimbursement for Medicare and Medicaid patients and suffer a loss by seeing these patients (in terms of the cost of treatment vs. reimbursement).
In order to offset this loss, physicians often raise prices on their private insurance patients, thus raising premiums for employers. In a way, this means the general population pays doubly for Medicare/Medicaid, once in taxes and once in raised premiums.
What is coinsurance?
The percentage of costs a patient is expected to pay after their deductible and before their out-of-pocket maximum.
Do copays contribute to deductibles or out-of-pocket maximums?
No
What is an insurance premium?
The regular monthly amount paid to keep insurance (if employed, this comes straight out of every paycheck)
What is the list of drugs a particular insurance plan will pay for?
The formulary
What is a provider network?
The list of approved providers the insurance plan will reimburse for services
Will HMOs reimburse costs for visits to out-of-network providers? Will PPOs?
No; sometimes
What are the two types of private insurance payment?
Indemnity (the insurer pays the patient who then pays the provider);
direct (the insurer pays the provider directly)
How do the fee-for-service, prospective payment, and capitation systems differ in regards to provider risk, intensity of care, and frequency of care?
