Midterm 1 Flashcards
HMO
integrated delivery systems, tightly managed network of providers, typically with a primary care gatekeeper
PPO (What is it)
Preferred Provider Networks; insurers create special networks of hospitals and physicians
Tax exclusion
Workers think it’s more valuable that they pay rather than having to of into the market
Who benefits the most from the tax exclusions?
People in higher tax brackets
Who is medicare for?
people over 65 and select disabilities/conditions (about 67.2 million enrolled as of July 2024)
Who is medicaid and CHIP for?
low-income individuals (about 82.7 million in March 2024 went down over 10 million from 2023)
Why did medicaid and CHIP go down?
people were re evaluated after the pandemic and found to not qualify
Who qualified for the “Old Medicaid”?
the deserving poor (had certain determinations)
Who qualifies for the “New Medicaid” (passed as part of ACA)?
all of the poor
Who’s the big majority of the uninsured?
the working poor
Hill-Burton Act (1946)
federal funds given to private community hospitals to expand; in return no discrimination, minimum requirement of uncompensated care for poor, emergency care open to all
About how many hospitals (non profit, for profit, state municipals) do we have?
5000
How many hospitals are non for profit?
about 3000
How many hospitals are for profit?
1200
Why are about half of all hospitals nonprofit and defined as charitable with a tax exemption?
they’re supposed to give back to the community
Which year had the highest hospital admissions?
1981 (peaked at 40 million); people don’t stay overnight as much
Payment Structure of Hospitals (1970s and 1980s)
Diagnosis-related groups (DRG); depended on a product not what the hospital said; anything that went from the hospital standpoint was given a flat free; specific to ICD diagnoses
Payment Structure of Hospitals (1950s and 1960s)
Cost based reimbursement; depended on what the hospital said
What does a DRG incentivize?
getting people out quickly and more efficiently
What was a consequence of DRGs?
hospital admissions became shorter; LOS (length of stay)
Where did DRGs come from?
developed in the 1970s at Yale
What are the 6 different payment rated for hospitals?
1) Chargemaster Rate (retail price)
2) Usual, Customary, and Reasonable Rate (UCR)
3) Commercial Insurer and Blues Rate
4) Medicare Rate
5) Medicaid Rate
6) Actual Cost
Which of the 6 rates does the insurance company pay?
commercial insurer and blues rate; they negotiate the rest (commercial insurer rate is what a private plan will negotiate)
Where do physicians earn the most?
South Dakota because few physicians work in rural areas
Physicians are more likely to:
be employed by health systems
Name 3 Payment Structures for Doctors
Fragmented, Fee for Service, Bias to Procedures
How do they determine the price for physicians that get paid FFS?
1) Medical Coding
2) Medical Billing
3) RVU System
Why will there be a big nursing gap?
because the population is getting older
How have previous staffing patterns contributed to the current nursing shortage?
Contractors are expensive and they have no loyalty
What is path dependence and how does it affect health care?
decisions made before shape circumstances and possibilities of decisions today
What are the 3 streams of policy change?
1) Problems (wide recognition of a problem; has to be affirmed)
2) Policies (have to be solution proposed to solve those problems; have to be vetted)
3) Politics (something that will push that problem and solution over the finish line; ex. an election)
Earliest American Coverage Legislation (First Congress)
(1790) Required shipowners with 150 tons or crew of 10 to have onboard medicine or provide care without deduction from seamen’s wages
Why did they pass the Earliest American Coverage Legislation (1790)?
They don’t want the seamen to spread any infections; they lose money if they go into hospitals
What is the revised version of the Earliest American Coverage Legislation (1798)
Required every shipowner coming into port to pay 20 cent per seamen for every month each worker had been employed
Originalism
Go back to the constitution and find what they meant (looking backwards)
What did Otto von Bismarck do?
Instituted comprehensive set of welfare programs, including health coverage (funded through payroll deductions from employers and employees)
Why does a conservative politician want health care coverage (Otto von Bismarck, 1883)?
Communism, Marxism; Industrial Revolution is causing workers to rebel (did it to appease the workers)
Who was the first president to attempt to enact comprehensive health reform (1912)?
Theodore Roosevelt (didn’t actually propose it while president)
Why was Teddy Roosevelt’s health reform killed?
WW1 and opposition from organized labor
Why was labor against Teddy Roosevelt’s health reform
worried it will undercut their position
Health Care Reform during FDR presidency (1933-1936)
Debated whether to include health insurance in the New Deal programs; didn’t include it because they feared they wouldn’t pass social security
Who introduced the first bill for comprehensive health insurance through social security?
Sen Wagner, Murray and Rep Dingell
Why did they exclude dental care and other things in the first bill for comprehensive health insurance through social security?
Because medicine was cheap at the time
In 1947, who sponsored a plan to create a government subsidized, non-profit insurance system with premiums scaled to subscribers incomes?
Nixon
