M4L1 Flashcards
what is health care delivery?
- refers to major components of the health care system.
- it is the processes that enable people to receive health care.
- it includes the act of providing health care services to patients.
what are the primary objectives of any health care system?
- to enable all citizens to receive health care services.
- to deliver services that are cost-effective and meet specific pre-established standards of quality.
T or F: the United States have universal access to health care
False. The US does not have universal access to HC
what are the characteristics of universal access?
- HC is financed through taxes.
- HC is run by the government.
- all citizens are entitled to receive HC services.
- it includes routine and basic health care.
US health care system:
- is a fragmented system, meaning that its components are loosely connected.
- has PARTIAL rather than universal access.
- US HCS financing is voluntary, multiplayer system.
- all citizens are NOT ‘entitled’ to routing and basic services.
US HCS is amidst tremendous change and some of these issues are being addressed by?
PPACA = Patient Protection and Affordable Health Care Act (‘Affordable Care Act’ or ‘Obama Care’)
what are the subsystems in the US health care system?
- managed care
- military
- vulnerable populations
- integrated delivery
- long-term care
- public health
these subsystems interact together, some more tightly than others.
what does the “managed care” subsystem do?
-it seeks to achieve efficiency by integrating basic functions of health care delivery.
-they integrate HC services.
-they manage utilization (how HC services are used).
-they determine price (how much can be charged for HC services), so they determine how much HCPs get paid.
-they employ mechanisms to control/manage utilization of medical services.
-
what is the most dominant health care system in the united states?
managed care (MCO=managed care organization)
- it is available to most americans.
- it is financed by employers and government.
how is a managed care organization like an insurance company?
- employers hire MCOs to offer selected health plan to employees.
- government contracts MCO to manage health plans for medicare and medicaid
what are the two ways of financing in MCOs?
capitation and discounted fees
what is capitation
-MCO is paid a set free member per month (PMPM) once you pay, you’ll have access to the agreed upon health care services.
what is discounted fees
(IDP)
- Insurance: MCO assumes risk and acts as insurance carrier.
- Delivery: MCO arranges to provide HC services.
- Payments: MCO disburses payments to providers based on capitation or discounted fee arrangements.
what is an enrollee?
- a member (patient) of the MCO.
- an individual covered by the MCO health plan.
what is a health plan?
- it’s a contractual arrangement between enrollee & MCO.
- it includes list of covered health services that may be utilized by enrollee.
- it uses selected providers.
- it uses primary care providers as ‘gatekeepers’ to specialty providers.
