Health Systems Policy & Management (II) Health System Models

Question 1

What are the three main factors to keep in mind when comparing health systems?

Answer 1

Financing (public; private; out-of-pocket)

Delivery (public; private non-profit; private for-profit)

Access (universal; not universal)

Question 2

Describe the financing of the Beveridge model (UK, New Zealand, Spain, Scandinavia).

Answer 2

Public financing via general taxes

Question 3

Describe the delivery mechanism of the Beveridge model (UK, New Zealand, Spain, Scandinavia).

Answer 3

Publicly owned and some private providers

Question 4

Describe access to care in the Beveridge model (UK, New Zealand, Spain, Scandinavia).

Answer 4

Universal care

Question 5

Describe financing in the Bismarck model (Germany, France, the Netherlands, Japan).

Answer 5

Private financing via joint efforts of employers and employees

Question 6

Describe the delivery mechanism in the Bismarck model (Germany, France, the Netherlands, Japan).

Answer 6

Care mostly via private providers

Question 7

Describe access to care in the Bismarck model (Germany, France, the Netherlands, Japan).

Answer 7

Universal coverage

Question 8

Describe financing in the National Health Insurance model (Canada, Taiwan, South Korea).

Answer 8

Public financing via special taxes

Question 9

Describe the delivery mechanism in the National Health Insurance model (Canada, Taiwan, South Korea).

Answer 9

Care mostly via private providers

Question 10

Describe access to care in the National Health Insurance model (Canada, Taiwan, South Korea).

Answer 10

Universal coverage

Question 11

Describe financing in the out-of-pocket model (rural Africa, Southeast Asia).

Answer 11

Most countries are too poor or disorganized to provide financing

Question 12

Describe the delivery mechanism in the out-of-pocket model (rural Africa, Southeast Asia).

Answer 12

Care via private providers

Question 13

Describe access to care in the out-of-pocket model (rural Africa, Southeast Asia).

Answer 13

Only those who can pay or access charity care will receive service

Question 14

Is the U.S. system most like the Beveridge, Bismarck, NHI, or out-of-pocket health system models?

Answer 14

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

Question 15

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).

Answer 15

Question 16

Does the U.S. system need reform?

Answer 16

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.

Question 17

What is acute inpatient care?

Answer 17

Hospital care with an average length of patient stay of ≤ 25 days

(⅓ of healthcare expenses and ½ of all healthcare personnel)

Question 18

What is another name for outpatient care?

Answer 18

Ambulatory care

Question 19

How are most ambulatory services used (in descending order)?

Answer 19

Primary care offices > Surgical and medical specialty care offices > hospital EDs > hospital outpatient departments

Question 20

What is a long-term care facility?

Answer 20

An inpatient care location with an average length of stay of > 25 days

E.g. nursing home, rehabilitation center, etc.

Question 21

What percentage of elderly individuals receive care from family members?

Answer 21

80%

Question 22

What are the requirements for hospice care?

Answer 22

≤ 6 mo. life expectancy if disease runs its normal course

Question 23

What is provided in hospice care?

Answer 23

Palliative care; end-of-life counseling for patient and family

Question 24

Contrast preventative care in fee-for-service and capitation payment systems.

Answer 24

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)

Question 25

Which system maximizes physician risk: fee-for-service, prospective payment, or capitation?

Answer 25

Capitation

Question 26

What do fee-for-service systems encourage physicians to do?

Answer 26

Maximize intensity; maximize encounters

Question 27

What do capitation systems encourage physicians to do?

Answer 27

Minimize intensity; minimize encounters

Question 28

Describe the prospective payment model.

Answer 28

Each service has a predetermined amount for insurance reimbursement

The provider benefits only if he keeps costs below the reimbursement limit

Question 29

What does the prospective payment model encourage physicians to do?

Answer 29

Maximize encounters; minimize intensity

Question 30

How does a pay-for-performance (value-based payment) model work?

Answer 30

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)

Question 31

How does a bundled payment (value-based payment) model work?

Answer 31

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

Question 32

How does a shared savings payment model (value-based payment) work?

Answer 32

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

Question 33

What are the three main forms of reimbursement?

Answer 33

Government, private, and out-of-pocket

Question 34

Describe Medicaid/Medicare reimbursement.

Answer 34

The government decides on prices via diagnostic-related groupings. (This is the smallest reimbursement category.)

Question 35

Describe private insurance reimbursement.

Answer 35

Insurers negotiate with providers on behalf of their clients to keep prices as low as possible (more lucrative for providers than Medicare/Medicaid reimbursements)

Question 36

Describe out-of-pocket reimbursement.

Answer 36

Individuals without insurance must pay full price (most lucrative for providers as there is no negotiation of prices)

Question 37

What is ‘cost-shifting?’

Answer 37

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.

Question 38

What is coinsurance?

Answer 38

The percentage of costs a patient is expected to pay after their deductible and before their out-of-pocket maximum.

Question 39

Do copays contribute to deductibles or out-of-pocket maximums?

Answer 39

No

Question 40

What is an insurance premium?

Answer 40

The regular monthly amount paid to keep insurance (if employed, this comes straight out of every paycheck)

Question 41

What is the list of drugs a particular insurance plan will pay for?

Answer 41

The formulary

Question 42

What is a provider network?

Answer 42

The list of approved providers the insurance plan will reimburse for services

Question 43

Will HMOs reimburse costs for visits to out-of-network providers? Will PPOs?

Answer 43

No; sometimes

Question 44

What are the two types of private insurance payment?

Answer 44

Indemnity (the insurer pays the patient who then pays the provider);

direct (the insurer pays the provider directly)

Question 45

How do the fee-for-service, prospective payment, and capitation systems differ in regards to provider risk, intensity of care, and frequency of care?

Answer 45