Hours 7 and 8 Flashcards
How health insurance works/managed care
what has been the trend in U.S. health care spending? How much and amount per capita?
steadily increasing; in 2010, 17.4% GDP, $2.598 trillion/$8,412 per capita; in 2016, 17.9% GDP, $3.337 trillion/$10,348 per capita which is an increase of +8.4%
how fast has health care expenditures increased compared to the general inflation rate?
8 times
how do US health care costs compare to other countries?
we rank number 1 in health care costs spending $19.4 trillion, $5 trillion more than the next leading country, Japan
where is the health care dollar being spent?
leading is hospital care (31.7%), next physician and clinical services (19.8%), other personal health care (15.2%)
what demographic is the US spending a lot of money on?
older patients
what health issues have the highest cost?
most expensive being heart disease, cancer, trauma, mental disorders; the 15 most expensive conditions accounting for 44% of spending and those with chronic conditions cost more
why are these increases in health care costs important to address?
health status is impacted if patients cannot pay bills; it puts pressure on businesses making them less competitive affecting employment, money spent on health care cannot be spent elsewhere, this impacts national debt
what is the national debt as of June 30, 2018?
$21.195 trillion or $64,373 per capita
why do we need health insurance?
risks- the world is a dangerous place in addition to uncertainty- a bad event happens
what are some risks of certain events, use examples from 2014?
Drug/medication overdose, MVA, fire, falls, lightning, flood
what were the leading causes of death in 2015?
heart disease, malignant neoplasms, chronic lower respiratory diseases and unintentional accidents
why health insurance?
according to Teitelbaum and Wilensky - “Individuals purchase health insurance to protect themselves against the risk of unforeseen and costly events”; insurance spreads the risks of costly events over a larger population
what is a beneficiary or insured?
the health insurance consumer and if you have health insurance you are a beneficiary or insured
what is a premium?
the annual amount paid by or on behalf of a beneficiary to purchase covered medical services
what are covered medical services?
medical goods and services defined in the insurance contract or policy
deductibles? define this term
an annual, or plan year amount, that must be paid before the insurance company pays anything
co-payment
A fee paid every time a beneficiary receives certain services form a provider like a $50 payment every time you go to the ER
Do co-payments count toward meeting the deductible?
Usually not, depends on the plan
what is Co-insurance?
a percent, usually 20%, that the beneficiary must pay after the deductible has been met.
what is maximum Out of pocket?
Maximum amount that will be paid by the beneficiary during the plan year
what does In-Network mean?
refers to providers that are contracted with the insurance company. Insurance company pays more of the bill
what does Out-of-Network mean?
providers not contracted with the insurance company. Patient pays more of the bill
what is a formulary?
list of prescription drugs covered by insurances, they are often placed in tiers and copayments differ by tier level in that you can have generic versus name brand, pharmacy versus mail order
what is a high deductible plan?
the employer pays 100% of the premium, higher annual deductible, and higher maximum out of pocket
what are some issues with traditional insurance?
fee for service reimbursement, where providers are paid for the volume of services provided, which does not place limits on access to services; healthy people do not want to buy insurance because people have different levels of risk tolerance; co-payments, co-insurance, and deductibles are regressive meaning that they can limit access to care for those at lower income levels; there is no relationship between payments and clinical effectiveness; 50% of individuals are covered by the employer and the insurance does not follow the individual so changes in employment status can create gaps in coverage
what are some examples of Payors?
governmental health insurance programs; private health insurance programs; out of pocket; all paid by individuals who are patients or will likely be patients at some point in time
when was medicare signed into law?
so along with medicaid, on July 30, 1965 signed by Lyndon B Johnson
after we medicare was signed into law, what was the next most significant legislative change?
Dec 8, 2003 when George W. Bush signed the Medicare Modernization Act - Part D
what, as quoted by Lyndon B Johnson, were the intended consequences of Medicare?
“No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings they have so carefully put away over a lifetime . . . No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents . . .
how has the medicare beneficiaries and the number of workers per beneficiary changed and expected to change over time say from 2000 to 2030?
so it is expected to decrease from 4 workers per beneficiary to 2.4 with a gradual increase in number of beneficiaries
What is medicare?
it covers individuals age 65 or older, under age 65 with certain disabilities and any age with permanent kidney failure.
How much of the population does medicare cover?
15.5% of the US population
