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
