Lecture 1/Chapter 1 & 2 Flashcards
1
Q
Access to healthcare
A
- is access equitable (fair)
- who has access
- if we increase access to healthcare cost goes up
- ways to restrict access to healthcare: referrals and copays
2
Q
cost of healthcare
A
-if we limit cost of healthcare we lower quality and restrict access to healthcare
3
Q
quality of healthcare
A
- how do we maintain quality
- no one wants low quality healthcare
- quality is going to depend on access and cost of healthcare
- if we increase a
- we always want to maintain quality
4
Q
American health care
A
- not everyone is automatically covered by health insurance
- no real health care “system”
- financing, insurance, delivery and payment
- not coherent
- no cooperation
5
Q
organizations and individuals involved in american health care
A
- educational and research institutions
- medical suppliers
- insurers
- payers
- claims processors to health care providers
6
Q
MCO’s
A
managed care organizations
7
Q
government programs
A
- finance and insure health care for select groups of people who meet programs prescribed criteria for eligibility
- sometimes deliver certain health care services directly to certain recipients like veterans and military, native americans, some uninsured
- finances public insurance through medicare, medicaid and childrens health insurance program (CHIP)
- government doesnt oversee the whole “system”
8
Q
employers
A
- purchase health insurance for employees through private sources
- employees receive health care from private sectors
9
Q
public insurance
A
- medicaid
- medicare
- children health insurance program (CHIP)
- provide insurance low income, elderly, disabled, government employees, and pediatrics
- insurance arrangements for many publicly insured people are made through private entities like health maintenance organizations (HMO) -> blends private and public
- tax revenue is used
10
Q
HMOs
A
health maintenance organizations
11
Q
characteristics of US health care “system”
A
as a result of the mix of public and private:
- multiplicity of financial arrangements for health care services
- numerous insurance agencies or MCOs that have various mechanisms for insuring against risk
- multiple payers that make their own determinations regarding how much to pay for each type of service
- diverse setting where medical services are delivered
- numerous consulting firms offering expertise in planning, cost containment, electronic systems, quality and structuring of resources
12
Q
US consumes more health care services than any other country
A
- no one is in control of the “system”
- capitalistic health care
- represents a greater proportion of the countrys total economic output
- not cost efficient service but some of the best
- not everyone has access
13
Q
ideal health care system
A
- two primary objectives:
- enable all citizens to obtain needed care
- ensure that services are cost effective and meet certain established standards of quality
- US doesnt provide to all citizens and does not have cost effective services, but there is quality
14
Q
quad function model
A
- health care delivery system incorporates 4 components
- financing
- insurance
- delivery
- payment
- degree of overlap varies between private and government run systems
15
Q
financing
A
- necessary for obtaining health insurance or to pay for health care services
- employers mostly finance health care for employees (can extend to family)
- government finances in public programs
16
Q
insurance
A
- protects the insured against financial catastrophe by providing expensive health care services when needed
- determines the package of health services that the insured person is entitled to receive
- specifies how and where health care may be received
- MCO or insurance company also functions as a claims processor and manages disbursement of funds to health care providers
17
Q
delivery
A
-provision of health care services by various providers
18
Q
provider
A
- refers to any entity that delivers health care services and either independently bills for those services or is supported through tax revenue
- physicians
- dentists
- optometrists
- therapists
- hospitals
- diagnostics
- imaging clinics
- suppliers of medical equipment
19
Q
payment
A
- deals with reimbursement to providers for services delivered
- insurer determines how much is paid
- funds for actual disbursement come from the premiums paid to the MCO or insurance company
- at time of service pt usually pays copay
- remainder is covered by MCO or insurance company
- in medicare and medicaid tax revenues are used to pay providers
20
Q
medicare
A
- for elderly and certain disabled individuals
- public insurance
- administered by federal government
21
Q
medicaid
A
- for the indigent
- administered by federal and state government
22
Q
Childrens health insurance program (CHIP)
A
- for children from low income families
- administered by state and federal government
23
Q
problems with employee insurance
A
- some small businesses cant get group insurance at affordable rates
- in some places, participation in health insurance programs is voluntary -> some people dont join bc health insurance premiums are too expensive
- employers dont pay 100% of the insurance premiums
- self employed need to find their own insurance -> individual rates are higher
24
Q
premium cost sharing
A
-when the employee offers health insurance premium and requires the employees to pay for a portion of it (its expensive)
25
Q
health care reform
A
-refers to the expansion of health insurance to cover the uninsured
26
Q
uninsured
A
those without public or private insurance coverage
27
Q
patient protection and affordable care act of 2010
A
- affordable care act (ACA)
- reduce # of uninsured
- required all US citizens and legal residents must be covered by either public or private insurance
- relaxed standards to qualify additional numbers of people for medicaid
- uninsured received insurance through webbased government run exchanges -> if they didnt they paid a tax
- failed to achieve universal coverage
28
Q
health insurance marketplaces
A
- determine whether an applicant qualified for medicaid or CHIP programs
- if they dont then the exchange would enable the person to purchase government approved health plan offered by private insurers through the exchange
29
Q
utilization of health services
A
-quantity of health care consumed
30
Q
managed care
A
- system of health care delivery that:
- seeks to achieve efficiency by integrating the 4 components of health care
- employs mechanisms to control utilization of medical services
- determines the price of services and how much providers are paid
- cost control
- greater integration of health care delivery
- ensuring access to health services, emphasizing preventive care, maintaining broad provider network -> cost control
31
Q
enrollee
A
-individual covered by the insurance plan
32
Q
health plan
A
- arrangement between the MCO and enrollee -> whats covered health services that the enrollee is entitled to
- selected providers
33
Q
10 major characteristics that set the US apart from other health care delivery systems
A
- no central agency governs the system
- access to health care services is selectively based on insurance coverage
- health care is delivered under imperfect market conditions
- insurers from a third party act as intermediaries between the financing and delivery functions
- existence of multiple payers makes the system difficult
- balance of power among various players prevents any single entity from dominating the system
- legal risks influence the practice behavior of physicians
- development of new technology creates and automatic demand for its use
- new service settings have evolved along a continuum
- quality is no longer accepted as unachievable goal
34
Q
no central agency
A
- US is not administratively controlled by department or agency
- private agencies decide their own financial state
35
Q
global budgets
A
- used to control costs
- determine the total health care expenditures on a national scale and allocate resources within budgetary limits
- not in US
- controls technology, resources, specialized services
36
Q
standards of participations
A
- federal government formulates through health policy and regulation
- providers must comply with the standards established by the government to be certified to provide services to medicare, medicaid, and CHIP
- minimum standards of quality
37
Q
access
A
- ability of a person to obtain health care services when needed
- american can access health care if they:
- have health insurance through their employers
- are covered under a government health care program
- can afford to buy insurance with their own private funds
- are able to pay for services privately
- can obtain charity or subsidized care
- even uninsured people are observed by emergency departments (not continual)
38
Q
primary care
A
-continual basic and routine care
39
Q
universal access
A
- ability of all citizens to obtain health care when needed remains mostly theoretical
- even universal coverage doesnt mean you can always be seen when needed
40
Q
imperfect market
A
- US health care is only partially governed by free market
- considered a quasi-market or imperfect market
- power isnt in hands of pt but in the health administrators of health plans
- health plans are the real buyers (not pts)
- prices are determined by payers (MCOs, medicare, medicaid)
- limited choice of providers (not open choice)
- regulations involved (licensed)
- different providers different prices
41
Q
free market
A
- patients and providers act independently
- pts can choose services from any provider
- prices are governed by free and unencumbered interaction of forces of supply and demand
- quantity demanded increases as price is lowered
- quantity demanded will decrease as the price increases
42
Q
demand
A
-quantity of health care purchased
43
Q
moral hazard
A
-once enrollees have purchased health insurance, they may use more health care services than if they were to pay for these services on an out of pocket basis
44
Q
need
A
-amount of medical care that medical experts believe a person should have to remain or become healthy
45
Q
limits to ability of pts to make decisions in health care system
A
- need (do they NEED the treatment)
- delivery of health care can result in demand creation (artificial demand)
46
Q
provider induced demand
A
- suppliers induced demand
- practitioners who have a financial interest in additional treatments also create artificial demand
- physicians prescribe medical care beyond what is clinically necessary
- scheduling too many follow up that arnt necessary, prescribing unnecessary medical tests, unnecessary surgery
47
Q
phantom providers
A
- anesthesiologist, nurse anesthetists, pathologist
- function in an adjunct capacity and bill for their services separately
- makes it difficult to know the price of something before hand
48
Q
package pricing
A
- a bundled fee for a package of related services
- one all inclusive price for ex. -> the surgeons fee, hospital facilities, supplies, diagnostics, pathology, anesthesia, postsurgical follow up
- lets you gauge a better idea of the final price
49
Q
single payer system
A
- national health care system
- one primary payer -> the government
- providers send bill to government agency -> subsequently sends payments to each provider
50
Q
national health insurance
A
- canada
- Financed by government taxes
- Deliver of health care is done by private providers
