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The Economics And Financing Of Healthcare Delivery (HCMG 2020) > Insurance > Flashcards

Insurance Flashcards

1
Q

What is a network?

A

A panel of providers

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2
Q

What do Medicare and Medicaid do to offer managed care for some beneficiaries?

A

Contract w/ private insureres

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3
Q

What are some methods of cost containment?

A
  • networks
  • prior authorization
  • referral requirements
  • value-based payments
  • negotiated rates w/ hospitals & outpatient providers through selective contracting
  • addressing social determinants of health
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4
Q

What is the main source of coverage in the US?

A

Employer sponsored coverage, followed by Medicaid and medicare

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5
Q

what is “job lock”?

A

Staying in a job to keep insurance

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6
Q

What are some problems with employer sponsored coverage?

A

Increases inequality because healthy people are more likely to work -> have good insurance

Inefficiency from job lock

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7
Q

What is a self-funded plan?

A

Firms pay for some or all of the health care of their employees with their own funds rather than buying them health insurance “manage their own risk pool”

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8
Q

What are fully-insured plans?

A

Plans purchased from an insurance company at a set rate (risk taken on by insurer)

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9
Q

What is a health maintenance organization?

A

PCP referrals are usually required; out-of-network care hella expensive

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10
Q

What is a preferred provider organization?

A

PCP and referrals are not typically required; out-of-network care is still more expensive

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11
Q

What is a point of service plan?

A

Not sure, PCP and referrals may be required; sometimes referred to as “HMO without the walls” or a combination of HMO and PPO

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12
Q

What is an exclusive provider organization?

A

PCP is not typically required; a referral may be required; out-of-network is not covered

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13
Q

What is an indemnity plan?

A

No network, just see anyone

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14
Q

What is an HRA or HSA?

A

Health reimbursement arrangement
Health savings account

can be appended to high deductible health plan and are tax exempt

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15
Q

What is a high deductible health plan?

A

Deductible greater than $1,600/individual (usually has low premiums)

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16
Q

What is a consumer driven health plan?

A

HDHP + HRA/HSA

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17
Q

What is the hierarchy of plan generosity?

A

Platinum: 10%
Gold: 20%
Silver: 30%
Bronze: 40%

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18
Q

What is the most common plan?

A

PPO (preferred provider organization) followed by HDHP/SO

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19
Q

What is a marketplace plan?

A

Health insurance exchanges can be found on a website for individuals without access to affordable insurance where they can buy plans

The ACA also has subsidies for individuals between 100 and 400% of the federal poverty level

20
Q

Who is Medicare for?

A

65 year olds, some individuals w/ disabilities, and anyone w/ end stage renal disease

21
Q

Which is operated at the federal level: Medicare or Medicaid?

A

Medicare

22
Q

What are the four parts of Medicare

A

Part A: inpatient insurance
Part B: outpatient insurance
Part C: Medicare advantage
Part D: drugs

23
Q

How popular is Medicare Advantage?

A

More than half of Medicare beneficiaries

24
Q

What is capitation?

A

Per person per capita

25
Q

Is Medicare solvent? Why?

A

Nope
- Aging population increases pool
- Healthcare costs are increasing more than inflation
- Funding is mainly from payroll taxes and premiums which cant keep up w/ growing demand

26
Q

What are ways to target solvency in Medicare?

A
  • introduce other payroll taxes
  • increase age of eligibility
  • increase premiums more for higher-income beneficiaries
  • increase deductibles
  • implement more cost sharing
  • restructure Medigap and other supplemental coverage
27
Q

What is Medicaid?

A

Health insurance for low income and disabled people

28
Q

What do 1115 waivers do?

A

Focus on specific groups and extend benefits to them

29
Q

How much did the Federal government pay for Medicaid spending?

A

100% which slowly decreased with years

30
Q

How is the federal medical assistance percentage determined?

A

State per capita incomes (between 50-83%)

31
Q

How is Medicaid reimbursement?

A

Crazy low

32
Q

How is Medicaid reimbursement?

A

Crazy low

33
Q

Medicaid is the primary payer of __ ___ ___

A

Long term care

34
Q

What are Medicaid managed care organizations?

A

Contract managed companies that take the financial risk for services in their contracts, accounts for 2/3s of Medicaid beneficiaries

35
Q

What does capitation incentivize insurers to do regarding utilization?

A

Keep it low

36
Q

What are social determinants of health? What do they have to do with Medicaid?

A

Societal and environmental conditions, Medicaid and their MCOs target SDoH

37
Q

How many dual-eligible of Medicare and Medicaid are there?

A

1 in 7 Medicaid enrollees and 1 in 5 Medicare enrollees

38
Q

What is defined as being underinsured?

A

Out of pocket healthcare costs being equal to greater than 10% of household income

39
Q

Did the ACA eliminate being uninsured?

A

Helped it, didnt save it

40
Q

What determines premiums?

A

85% is claims experience and 15% is loading charge

41
Q

What are 5 levels of reimbursement? What do they rank by?

A

1-5, by complexity

42
Q

What is community rating and how does it affect premiums?

A

All patients in given area must pay similar premiums, this can lead to too high of premiums which drives individuals out of the market

43
Q

What is guaranteed issue?

A

A ban against insurers denying patients w/ pre-existing conditions

44
Q

What is experience rating?

A

Charge different things based on a patients experiences such as smoking, age, location, individual v family enrollment, plan category

45
Q

Based on the Rand Health Insurance Experiment, how does cost sharing impact risky behaviors?

A

It doesnt

46
Q

What are the three threats to internal validity pointed out by Aron-Dine et al regarding Rand Experiment?

A
  • no random assignment
  • differential participation across plans (more free care group participated)
  • differential reporting across plans (med spending reported more by free care group)
47
Q

What did Finkelstein find using The Oregon Lottery regarding the efficiency of Health Insurance?

A

No improvement in physical health outcomes was detected, use of health care services and diabetes detection and management increased, depression and financial strain decreased

The Economics And Financing Of Healthcare Delivery (HCMG 2020) (6 decks)

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