Healthcare Access and Payment Systems/Care Coordination Flashcards
Sick care
o Hospital
o Clinic
o Federally Qualified Health Centers
o Free Clinics
o Pharmacy
o Help people get better
Well care
o Public Health Programs
o Community Events
o Help maintain the health of society
3 dimensions of the American HC system
Quality: The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine).
Access: The timely use of health services to achieve the best health outcomes. This includes: insurance coverage, geographic availability, and personal relationships (Institute of Medicine). Ability to gain health services to achieve health outcomes
Cost: the actual cost of providing services related to the delivery of healthcare, including the cost of procedures, therapies and medications. This does NOT include expenditure costs such as money paid for services or fees (National Institute of Health). Thea actual cost of the services of the delivery of HC. Not just the cost of what the patient would pay, but the actual cost of the HC
How do we pay for HC?
Insurance
Cash
Charity Care
Insurance - 3 types
Private/Commercial
Affordable Care Act
Employer Provided Insurance employer offers health insurance as a benefit. If that is not the case, you are able to go to the marketplace and find a HC plan (made possible by the ACA)
Government
Medicare (Federal)
* Funded and regulated by federal gov.
* People >65
Medicaid (State)
* Funded 50% federal and 50% states
* Carried out at state level (regulated)
* For poor people. Definition of ‘poor’ varies from state to state
Self-contained insurer/provider
VA
Indian Health Services
* Own all facilities. Provider AND payer of care
Cash for payment
o People can go BUY healthcare
o Plastic/cosmetic surgery
o Out-of-pocket
o Lots of providers may not see patients if they do not have providers
Charity Care for payment
o Free care for people that can get at places. Free clinics
- Premium
the monthly or annual amount you pay in order to have health insurance coverage
what you pay to JUST HAVE health insurance
- Deductible
the amount of money you must pay out of pocket, before insurance coverage kicks in
premium + any interaction with HC system and you get a bill, you WILL pay a certain amount of money before the insurance kicks in and pays
- Co-pay
flat fee you pay toward cost of medical care. May start before or after the deductible phase. May or may not apply to the deductible amount.
Dependent on insurance plan. EX: If you go to the dr., you have $20 copay regardless of if you have hit your deductible yet
- Co-insurance
your shared responsibility for medical costs with the insurance company. Applies after the deductible has been met.
Pay month premiums, interaction if HC system that costs 500$. I have a 200$ deductible. I pay the first 200$, the co-insurance will be an 80/20 split between what the insurance pays and what I pay with the remaining 300$. Insurance will pay 80% and I will be responsible for the last 20%
- Out of Pocket Max
The maximum amount you will pay annually for medical care. 1000, 5000, or a few hundred based on variation of these terms and how they apply to different plans
Network
o group of providers, hospital systems, physicians/doctors/provider offices that have a specific contract with insurance company and they are ‘in-network’. Providers that do NOT have a contract are ‘out of network’
Basic Provisions of the ACA
Guaranteed Coverage
Essential Health Benefits
Individual Mandate to Purchase Insurance
Creation of “Health Exchanges”
Premium Subsidies
Medicaid Expansion
Medicare Reform
Lifetime Spending Limits Erased
Guaranteed Coverage
Cannot be denied for pre-existing conditions, children can remain on parent’s insurance until age 26 used to be could stay on parents insurance as long as you were a full-time student, but now ; used to have a gap between graduation and starting a job with your new insurance
o KEY!
Essential Health Benefits
Those benefits that MUST be provided under law (preventative care without co-pay, contraceptive management, etc..)
o Insurance companies can NOT offer plans that DO NOT cover preventative cares (well child visits, colonoscopies, mammograms, immunizations). In the past, you could get a plan that did not cover this type of health maintenance/preventative care to be cheaper, but the ACA placed law that insurance companies MUST provide this care
Individual mandate to purchase insurance
(No longer applies as of 2019)
o Paid when you file your taxes if you didn’t have insurance, you had to pay a penalty when you filed taxes. Idea is to encourage people to buy and be covered by insurance
o You HAD to have insurance from some source. Supreme court determined that it was not legal to force someone to buy something. Taken out of ACA in 2019
Creation of “Health Exchanges”
o If your employer does not provide insurance, you’re self-employed, you have several part-time jobs, you can go to the Health Exchange and access/purchase a health plan much easier than was done in the past
Premium Subsidies
o For people who cannot afford premiums, money from gov. to assist people in paying premiums if they could not
Medicaid Expansion
o Supreme court reviewed, decided that federal government cannot force states to pay for something. Many states decided they were not going to expand Medicaid because of money, but some states have now decided to expand Medicaid
Medicare Reform
o Largely with preventing fraud and waste in Medicare program
Lifetime Spending Limits Erased
o Kind of goes with Guaranteed Coverage
o In past, there was lifetime spending limits. If you got really sick and needed lots of expensive medical care, eventually they would say there is a lifetime spending maximum so they could cut you off when you got to that point. These have been erased
Commercial/Private Insurance
TONS of plans. Each are required to meet the requirements of the ACA, however each plan is going to have a premium/deductible/copay/coinsurance/out of pocket maximum, and the insurance companies will have a ‘network’ if you go with those providers within vs outside the network the prices will change
Government Sponsored Insurance
Medicare
Medicaid
Indian Health Services
Veteran’s Affairs
Medicare
WHAT TO UNDERSTAND: this is for people who are 65 and older, some disabled people and some with specific illnesses or diagnoses. Largely, think of as geared towards elderly.
***Entirely a federally funded and managed program! Medicare across the entire country will be the same! Providers can vary, but COVERAGE will be the same and payment will be the same
Medicaid
Insurance for low-income populations. Managed/paid for in part by US government, and remainder is paid for by the state
MANAGED at the state level – from state to state, you will see very different levels of Medicare programs
ALWAYS for low income and children up to 18/19 depending on state
Highly variable to eligibility criteria: typically preggo women 100% covered, disabled people, very low income seniors
NE MEDICAID
Annual Income less that 100% FPL federal poverty level
* 12,140 for a single person
Savings/Assets (including home, cars, bank accounts) must be less than $4000
Medicare VS Medicaid
- Two different plans
- Two different applications
- Two different payers
- Two different managers
- Medicare: elderly, Medicaid: poor people
- Medicare: managed and paid for at federal level
- Medicaid: paid for at federal and state level but managed at STATE level. Highly variable of coverage based on state.
- If you are poor enough to qualify for Medicaid, its really good insurance. Typically, 100% coverage of hospital care, SNF, dr. offices, including prescriptions (may have extra cost)
Indian Health Services
- People registered with a tribe can get payment for their care and their care
- Typically on reservations
Veterans Affairs
- National health insurance plan. Services provided at government owned facilities. Insurance coverage is totally paid for
Cash and Charity care: Federally Qualified Health Centers
o Federally qualified health centers: meet requirements through federal government and they can apply for that status. Provide very comprehensive care (dental, vision, pharmacy, mental health, transportation). Charles drew, One World, All Care. These clinics meet federal requirements and operate on a ‘sliding fee’ scale: based on income. When you go, you take pay stubs/income tax forms to provide evidence of income, then they determine how much you have to pay for each service. Some slide down to 0$, some don’t. While they have to meet standards and qualifications, may still look different depending on clinic. May continue to see patients if they cannot pay, and some may not. Theoretically should be very similar, but in practice may look a lot different.
Charity Care
o Care is charged, then ‘written off’ if patient cannot pay. Acknowledged the fact they the will never receive payment
Hospitals are subsidized by federal government to do this because government recognizes that they have required hospitals to see people in emergency situations and also they acknowledge that we NEED hospitals, and if there are too many ‘nonpayers’, the hospitals will not be able to remain open
What do we mean by HC access?
- Financing/paying for HC. Paying for preventative services. Paying for health care, exercise.
What are HC access issues?
- Transportation: far distance to HC, urban where it can be difficult to get to
- Language: inability to speak English should NOT impede available of healthcare. Providing culturally and linguist care. MARTY, interpreting device. Interpreters that should not be used: young children, someone in the hallway who speaks the language. Long wait to get appropriate interpreter
- Rural: what is available and what is quality
- Urban can I get it?
- Populations with specific access issues: migrants, undocumented. Language.
- People with disabilities: yes get Medicaid, but providers may not provide services needed to get care (people with disabilities may need general anesthesia for dental care, but many dentists do not do that service). Or just being a in wheelchair with public transportation
- Poverty: not just paying for HC, but all things that contribute to health healthy life- safe household (no allergens, lead), healthy foods (time and energy to cook healthy foods), education available and its quality
