Healthcare Overview Flashcards
Out of Pocket Maximum
Limit you pay per year on Medical expenses - all payments except premium count towards this number
Premium
Amount you pay to health insurance company to maintain health care coverage - you either pay entire cost or share with employer
Deductible
Amount you pay each calendar year before insurance kicks in for non preventable expenses
Higher premium = lower deductible while Lower premium = higher deductible
Copay
Fixed amount you pay for health care service when you receive a service
Coinsurance
Once deductible is met, you pay a coinsurance and the insurance pays the rest (usually a % number)
Formulary
List of drugs (generic and name brand) that health plan prefers - of your medication is not on that list you will have to pay more
HMO
You chose PCP from a network of health care providers and all care is coordinated trhough them
You need a referral for in nerwork specialist and hospitals - Out of network is only covered at hospital in event of true emergancy
- Premiums are lower but out of pocket costs are lesser
- Good option if you don’t need a specialist a lot
PPO
Offers a nerwork of health care providers and you can see and get care from both in and out of network people
- You do NOT need to choose a PCP
- NO refferals needed to see a specialist
- Premiums, deductibles, and copays are higher
Point of Service plan
Combination of HMO and PPO
- You need a PCP and referrals for specialist care
- You can get both in and out of network care but you have to pay more for out of network (although it will be even more if you go without a referral)
Risk
Potential to lose money, earn less, or spend more time without addition payment
Who is at Risk with Fee for Service
Person Paying bill
Who is at Risk with Payment by illness
Provider for length of stay and post op visits at insurer for number of illnesses
Who is at Risk with Per Diem
Provider for number of tests and insurer for LOS
Who is at Risk with Capitation
Provider because insurance pays one time even if the person keeps getting sick
Accountable Care Organizations
System has group of provider s and other providers to coordinate patient care
- Breaks down hoops to ensure care for patients
- Idea is to coordinate providers and provide high quality care at a low cost
- Idea is to reduce duplication and unnecessary interventions, keep people healthy, and decrease # of ER visits
Health Care History: Pre 1980
- For poor
- No real treatment (mostly moral/religious instead of medical)
- Funded by leading society
- Mainly for education
- Unsafe and Unhygienic Surgery
Health Care History: 1890-1930
- Use of Anesthesia
- Anteseptic procesures
- Diagnostic testing
- Expansion of Care (acute care, surgery for middle-upper class)
- Hospitals instituting pay for service
- Social Changes (WW I)
- AMA Established
- Veteran Benefits created
- HMO created by Baylor Hospital (private insurance)
- Depression
Health Care History: 1930-1970
1939: Blue Cross Plans (free choice of hospital, and community rating)
1940: 20 Million individuals with Insurance
1942: Health Insurance offered by employers was negotiable through three rulings (1- Wage freezes, 2- Legit for labor-management negotiations, 3- health insurance via employers was tax exempt)
- Tech Advances
- Hill Burton Act
- Medicare and Medicaid established
What is the Hill Burton Act
Joint federal and state funding for health care
Health Care History: 1970-1980
- More high tech (increased costs
1980: Rise of HMO’s and support for managed care as a cost control device
1983: Medicare prospective payment system, DRGs
1989: Medicare physician payments under tighter control
Health Care History: 1990-2000
-Hospital infections rise (MRSA)
- Increased conditions MDs can treat –> increase in errors
- Hospitals and physician network grows (increased costs and less charity)
- For profit institutions increased in importance (private health insuranve)
- Costs keep rising
Health Care History: 21st Century
- Hospitals consolidate into hospital system (Insurance companies must pay more)
- Specialists for single specialty group (more profitable procedures out of hospital, negotiations for higher reimbursement possible)
- Crisis in primary care (less graduating MDs want to be family doctors
- Pharma under fire for higher costs
