Module 5 lecture, part 1 Flashcards
What is the broad definition of a HC system?
Major components of the system and processes that enable ppl to receive healthcare
What is the restricted definition of a HC system?
The act of providing healthcare to pts (i.e., in a hospital or physician’s clinic)
What are the primary objectives of a HC system?
To deliver services that are cost-effective and meet established standards of quality
What are the four components of the quad-function model?
Financing
Insurance
Delivery
Payment (to provider)
What is the purpose of financing?
To obtain health insurance or to pay for HC services
Who finances HC as a fringe benefit?
Employers
Who is the financier in public programs?
The gov’t
What does insurance do?
Protects the insured against catastrophic risks
Determines the package
What is delivery?
The provision of HC services by various providers
In the US, where does most HC delivery come from?
Private providers
The amount to pay is determined by who?
The insurer
From what sources do providers get paid?
Co-pay by the pt and the remainder paid by the insurance company
The revenues used to pay providers in gov’t plans
Where do the funds come from?
From premiums paid to the MCO or insurance company
Who can function as a claims processor and mange the distribution of funds to the HC providers?
MCO or insurance company
Definition of provider
Any entity that delivers HC services and receives insurance payment directly for those services
Is the US healthcare system really a system? if no, why not?
No
Little or no networking, interrelated components, standardization, coordination, cost containment as a whole, planning, or direction
What are some negative aspects of the US HC system?
Duplication
Overlap
Inadequacy
Waste
Complexity
Inefficiency
Financial manipulation
Fragmentation
What is the result in the US HC system?
Multiple financial arrangements
Many insurance companies with different risk mechanisms
Many payers with different determinations
A large array of settings where medical services are delivered
Many consulting firms
What are the 10 main characteristics of the US HC system?
No central agency
Partial access
Imperfect market
Third-party insurers and payers
Multiple payers
Power balancing
Litigation risks
High technology
Continuum of services
Quest for quality
Describe why there is no central agency in the US HC system?
No global budget to determine total HC expenses
No governmental controls of the frequency of HC services
Mostly private financing and delivery
Aspects of partial access in the US HC system
Access restricted to those with insurance coverage or money to pay for services
Those without insurance or money wait until a health problem arises then receive HC at an emergency room
Lack of access to primary care leads to a lag in pop health
What type of financing accounts for 53% of total healthcare expenditures
Private financing, primary through employers
Who determines the public health sector expenses and reimbursement rates for Medicare and Medicaid?
The gov’t
Who sets standards of participation through policy and regulations?
The gov’t
What must providers do in order to be certified to provide for Medicare and Medicaid pts?
They must comply with standards. These certification standards are regarded as minimum standards of quality.
Define access
The ability to obtain HC when needed
Who finances the remaining 47%?
The gov’t
Who finances 53% of insurance?
Individuals
