Healthcare, Social and Employee Benefit Systems Flashcards
What are the different multi-national models used to describe benefit provision?
Define primary healthcare
Healthcare services which serve as a first point of consultation for all patients, such as general practitioners, family physicians, physiotherapists, respiratory therapists, occupational therapists, speech therapists, dieticians, as well as a non-physician primary care provider (or mid-level provider) such as a physician assistant or nurse practitioner. Facilities are usually available at local community level.
Who are the key supply-side providers of healthcare?
Define seconday healthcare
Healthcare services provided by medical specialists and other health professionals (for example, cardiologists, urologists, and dermatologists), including acute care and skilled attendance during childbirth, intensive care, and medical imaging services. Secondary care may be provided in or out of hospital. Facilities are usually found in more urban areas.
Define tertiary healthcare
Specialised consultative healthcare, usually for in-patients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital or academic hospital. Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative, and other complex medical and surgical interventions. Facilities are usually only found in major metropolitan areas, possibly attached to a medical school.
What are the arguments for an against broad eligibility criteria?
for:
- could tap into market that is untouched by competitors (opportunity for increase in market share)
- larger business volumes could spread fixed costs amongst members (economies of scale)
- less tests need to be done, which could save on costs
- ultimately, more customers’ needs are being met
- cannot be accused for discriminating, but rather inclusive
against:
- more individuals to go through underwriting process (costly and time consuming)
- could allow for adverse selection if competitors don’t have same approach
- more costly to provide benefits to more members
- people may not stay at employer very long, so cost vs. benefit ratio may not be viable.
- difficult to tailor benefits to suit a very large and diverse group of people
Solidarity
When contributions are not related to risk, but rather shared equally or paid according to ability, and benefits are paid either in accordance with need (for example, a health benefit scheme or means-tested retirement benefit scheme) or in accordance with an agreed schedule of benefits. Social solidarity requires mandatory participation in a risk pool. Contrast with mutuality.
Mutuality (or mutual insurance)
When contributions are paid according to risk and benefits are paid either in accordance with need (for example, a health benefit scheme or means-tested retirement benefit scheme) or in accordance with an agreed schedule of benefits. In this case, participation may be voluntary, and at least some effort may be made to ensure that premiums or contributions reflect risk, to ensure that members share the risks in a way that is not too unfair. Contrast with solidarity.
Equity
Equity refers to fairness and justice. It does not necessarily mean that every person is treated equally. For example, intentional cross-subsidies from higher-income earners to lower-income earners may be considered more equitable in the broader context of society even though the two groups are not treated equally. Alternatively, equity refers to the ownership of shares of a company. These may be listed or unlisted.
Managed care organisations (MCOs)
For-profit entities, typically owned by shareholders, offering managed care services. These entities combine clinical and financial techniques to manage risk, reduce cost, and improve quality by encouraging the delivery of cost-effective high-quality healthcare. Like HMOs, these organisations often contract with PMI providers via capitation arrangements.
Administrator
(In a South African benefit arrangements context) an entity appointed by a medical scheme or retirement fund to run the operations such as collect premiums or contributions, pay claims or benefits, and enforce regulatory compliance. In retirement funds, administrators may also fulfil such functions as managing cashflows and communicating with members.
Quaternary care
Quaternary facilities deal with very rare cases and experimental treatments. Facilities are centres of excellence and usually specialise in a particular condition.
Social assistance
State benefits that are non-contributory and funded from general taxation. These benefits generally provide a minimal level of benefit, with the aim of reducing poverty.
Social insurance
A contributory, mandatory pillar of a benefit model operated by the state. Benefits are funded from contributions and everyone in a specified group (mostly working adults) is required to contribute. Every individual’s social insurance benefits will to some extent be related to the individual’s lifetime contribution.
