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NURS322 > Module11 > Flashcards

Module11 Flashcards

1
Q

Questions to consider when thinking about health care financing

A

Is the ability to have good health a right or a privilege?

Is the ability to see a Health Care Provider when you are sick a right or a privilege?

Is the ability to have health insurance a right or a privilege?

Should access to good health be dependent upon one’s ability to pay?

What is the individual’s responsibility for one’s health?

What is the government’s responsibility for its citizen’s health?

What is society’s responsibility for its members health?

What barriers are present that prevent people from attaining good health?

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2
Q

What important factors are influencing the demand for health care?

A

Demographics:

  • Baby boomer life expectancy increased w/ more chronic disease as a result
  • Foreign born population is growing
  • US Household of 2 parent families decreasing, single parent families increasing
  • Increased income inequality - urban population has limited incomes
  • Limited health workforce
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3
Q

When discussing important resources for insurance, what are the two most importnat?

A

People

Money

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4
Q

What important factors are influencing resource allocation for insurance?

A

Public Insurance (Medicare and Medicaid)

Private Insurance (For Profit Health Plans Raise Premiums to increase profit margin)

Consumer Demands for access to health care

New medical technology

Overuse and Misuse of medical services

High administrative costs

Escalating prescription drug costs and utilization

Medical needs and demands of 77 million baby boomers

Uninsured

Populations living in poverty

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5
Q

What important factors are contributing to increasing health care costs?

A

Increase in chronic illness

People are living longer

Advances in treatments and therapies

Prescription Drugs: Including Direct to Customer marketing

Physician Salaries: Physician as an employee v Physician as self employed

Insurance company mergers: less competition existing

Moral Hazard

Being Uninsured (Ult. taxpayers have to pay through medicare/aid to offset)

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6
Q

Moral Hazard

A

When people have insurance they tend to use the health care system more frequently

they may engage in higher risk behavior because they have better access to the health care system

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7
Q

The majority of the uninsured are …

A

people in low-income WORKING families

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8
Q

Who is more insured, adults or children?

A

Adults are more likely to be uninsured than children, r/t limited availability of public coverage

0-18 get free insurances

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9
Q

Who has a higher risk of being uninsured than non-Hispanic whites?

A

POC

Hispanic People (insanely high uninsured rate)

Non-white races

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10
Q

Adults making under 21,000 a year have a high chance of being …

A

uninsured

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11
Q

75% of uninsured people are…

A

actually WORKING FULL TIME

because of this employment, they cannot get public assistance insurance

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12
Q

What are some reasons why people remain uninsured?

A

Expensive premiums

No insurance offered through their job

They may be in a state that did not expand medicaid

Undocumented immigrants are ineligible

A shift from supportive manufacturing jobs to non supportive service sector jobs

Shift from full time to part time employment

Decreasing unionization trends

Decline in real wages

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13
Q

What are some important trends in regard to the uninsured/insurance?

A
  1. Trend in uninsured relates to the economy. Number of uninsured people increased during recessions when people lose their jobs
  2. Public programs fill in some loss of coverage (decrease uninsured), but many adults are currently ineligible for them
  3. As the economy has stabilized recently, coverage losses have slowed
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14
Q

Reasons people state they are uninsured?

A

Cost is too high

lost job or changed employers

lost medicaid

employer does no offer or ineligible for coverage

family’s status change

no need for it

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15
Q

How does being uninsured affect people?

A
  1. 1 in 5 adults go without needed med care
  2. Deaths among uninsured adults (25-64) is 22,000 a year, while diabetics only have 17,500 in the same age group
  3. less preventive care –> diagnosed at more advanced disease stages –> tend to get less therapeutic care –> High mortality
  4. Controlling for age, race, sex, income: uninsured cancer patients are 1.6x more likely to die within 5 years than insured
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16
Q

What are age trends related to uninsured status?

A

People tend to be insured between 0-18

There is a spike in un-insurance at age 19 to age 30 and may not feel they need insurance

The amount of uninsured decreases slowly to age 64

Medicare kicks in at 65 and people are insured again

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17
Q

What are the financial implications of having high uninsured populations?

A
  1. Uninsured face bills they cannot afford
  2. Medical bills quickly translate into debt, since they have low/mod income with little to no savings
  3. Hospitals charge the uninsured higher rates than those paid by public programs or private health insurers due to the latter’s negotiations
  4. Hospitals and other providers raise rates to offset the costs of those that do not pay their bills
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18
Q

What is medical bankruptcy

A

bankruptcies from unpaid medical bills which effected 2 million people in 2013

This makes health care the #1 cause of such filings, and outpacing bankruptcies due to credit card bills or unpaid mortgages

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19
Q

How much of the population age 19-64 will struggle with health care related bills this year?

A

more than 20% (56 million)

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20
Q

How many adults with year round health insurance coverage will accumulate medical bills that they cannot pay off this year?

A

almost 10 million

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21
Q

Ways to pay for health care

A
  1. Self Pay
  2. Private Insurance companies
  3. Public or Government insurance programs
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22
Q

What kinds of private insurance companies are there?

A
  1. Managed Care Organizations (3: HMO, PPO, POS)

2. Indemnity Plans (ex: Blue Cross/Blue Shield)

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23
Q

What are important examples of public/government insurance programs?

A
  1. medicare
  2. medicaid
  3. child health plus
  4. veterans administration (VA)
  5. indian health service
  6. workers comp
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24
Q

Almost half of health insurance of the insured in the US is from …

A

employer sponsored health insurance

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25
Q

62% of adults with dependent children pay their insurance premium out of …

A

employer sponsored insurance

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26
Q

Half of children insured (0-18) in the US are covered by…

A

their parents employer sponsored insurance

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27
Q

Self-Pay

A

Person is responsible to pay the entire bill for services

Typically you end up paying more than with insurance *

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28
Q

Why may you pay more with self pay?

A

Providers (hospitals and physician groups) contract with insurance companies normally and agree to charge an insurance companys pre determined and set amount for that particular service that is lower than the standard fee

So you do not get that lower rate

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29
Q

Why can self pay sometimes be less expensive than other insurances?

A

Providers sometimes have a policy where you get a discount if you pay up front with cash

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30
Q

Private Insurance / Employer Sponsored Insurance

A

Employers decide which health insurance to offer employees from a private company

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31
Q

What things does employer sponsored insurance affect?

A
  1. The cost of health care to the employee

2. Choice of providers and methods for accessing care

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32
Q

What things are causing a decline in employer sponsored insurance?

A
  1. Increasing health care costs
  2. Shift from manufacturing jobs to service sector jobs
  3. Increase in the number of low income families
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33
Q

Managed Care Organizations

A

type of private insurance developed because of the escalation of health care costs

It makes the insurance company an intermediary for financing health care, and accountability for cost was removed from provider and patient

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34
Q

How does managed care organization insurance differ from conventional health insurance?

A

It either provides services directly or contracts with providers

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35
Q

Goal of Managed Care Organizations?

A

Provide the highest quality of care to a population, efficiently and affordably, within the limits of available funding

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36
Q

What is the impact Managed Care Organizations have on providers?

A

Providers assume responsibility and accountability for the health of a given population, sharing the financial risk inherent in that responsibility.

If the provider does well, they are given financial incentives for care

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37
Q

Managed Care Organizations emphasize…

A

Coordinated and comprehensive services

Appropriate use of health care services

evidence based decision making

cost effective diagnosis and treatment

population based planning

health promotion and disease prevention

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38
Q

Managed Care Organization Cost Containment Strategies via the consumer?

A

Barriers made to reduce use of health care by levying forms of co insurance: deductibles, copays, etc

  • Copays lead to a decline in consumer utilization of health services, but poor and sick were disadvantaged by copayments even though co insurance payments are adjusted based on incomes one study showed
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39
Q

Managed Care Organization Cost Containment Strategies via the Provider

A

Addresses the price that insurance pays for services through PPS and DRGs

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40
Q

PPS

A

Medicares Prospective Payment System

Medicare no longer reimbursed hospitals for actual costs incurred, but instead reimbursed them for a PRE SET amount per admission (or discharge) based on the type of illness or procedure performed

So they had a limit of cost during treatment

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41
Q

DRGs

A

Diagnostic Related Groups

470 payment categories of illnesses and procedures that were created from available data that used diagnoses, patient age, and presence of complications as the basis for estimating hospital costs

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42
Q

What data determines DRG?

A

Diagnoses

Patient Age

Presence of Complications

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43
Q

Health Maintenance Organizations (HMOs)

A

Type of Managed Care Organization

Provides financing for healthcare and hires providers to deliver the health care

HMO members (patients) pay a fixed monthly fee regardless of how much care they need, BUT the members must use HMO providers and facilities

No lifetime maximum use

44
Q

Advantages of HMOs

A

Low out of pocket costs (little to no copay / deductibles)

focus on wellness and prevention

usually no lifetime maximum

45
Q

Disadvantages of HMOs

A

tight controls limit access to specialty services

Care from non HMO providers generally not covered

46
Q

Preferred Provider Organizations (PPOs)

A

Type of managed care organization

Group of doctors/hospitals that provide medical service only to a specific group or association at a negotiated and discounted rate

The PPO is sponsored by a particular insurance company, by one or more employers, or by some other type of organization (union or association)

Sponsor then has incentives or policyholders to use the physicians and facilities WITHIN the PPO network

47
Q

How does payment/reimbursement work with a PPO?

A

PPO members pay for services when they occur and the PPO sponsor (employer or insurance company) reimburse member for treatment, minus any out of pocket costs like copays

In some cases, provider can submit the bill directly to the insurance company for them to pay the provider directly and just have the patient pay a copay

48
Q

Advantages of PPOs

A

Free choice of health care provider (more available choices usually)

Out of pocket costs are capped

49
Q

Disadvantages of PPOs

A

less coverage for care received out of the PPO network (will cost much more)

More paperwork and more copays than HMO

50
Q

Point of Service (POS)

A

Type of Managed care organization

Has characteristics of HMO and PPO:

Like HMO, no deductible and usually only a minimal copay when you used a provider within the network

You get to choose a primary care physician responsible for all referrals in the POS network

51
Q

Advantages of POS

A

Free choice of health care provider; no gatekeeper for non network care

minimal copay, no deductible in network

52
Q

Disadvantages of POS

A

high copay for non network

deductible for non network

referrals are needed from primary care provider to see other providers or specialists in network

53
Q

Pitfalls of Managed Care Organizations

A
  1. Loss of customary provider or preferred hospital
  2. Restricted access to specialty care and tests
  3. Restricted access to medications
  4. Managed care has incentive for under service
54
Q

How does managed care restrict access to specialty care and tests?

A

It may require patients to see specialists only on the referral of their primary care physician. PCP may be judged on their use of lab testing as well and there will be pressure to avoid them in marginal situations

many managed care programs use clinical protocols to establish norms for ordering tests. Practitioners often complain that they are too restrictive

55
Q

How does managed care restrict access to medications?

A

some expensive medications not included on the plans formulary.

less expensive drugs with more known side effects may need to be prescribed before offering drugs with better results

56
Q

How does managed care have an incentive for under-service?

A

without clear evidence that a given course of action is indicated, decisions for coverage tend to go to less intensive care under capitation

57
Q

Indemnity Plans

A

Type of private health insurance

Allows the GREATEST flexibility and freedom to choose physician, healthcare professional , hospital or service provider

58
Q

What are Indemnity plans known as and why?

A

“traditional” fee for service insurance

patient pays first portion of medical costs, until the limit of the patients portion
(the deductible) is reached

a copay or co insurance may also apply

59
Q

Advantages of Indemnity Plans

A

Patient has ability to self refer

No geographic or network limitations

60
Q

Disadvantages of Indemnity Plans

A

may cost more

usual, customary, and reasonable (UCR) rates usually apply based on region

61
Q

Medicare

A

Federal program for people over 65, or are disabled with end stage renal disease or Lou Gehrigs disease

62
Q

Medicaid

A

state program for the poor

63
Q

Child health plus (CHIP) / Family Health Plus

A

state program for children

64
Q

Veterans Administration

A

The VA

federal program for veterans

run under the military budget

65
Q

Indian Health Services

A

Federal program for Native Americans

66
Q

Workers’ Compensation

A

state program for job related injuries

67
Q

When was Medicare established?

A

in 1965 as an amendment to the Social Security Act

68
Q

Most people age 65 or older who are citizens or permanent US residents are eligible for …

A

free Medicare hospital insurance (Part A)

69
Q

What are some sub-requirements for free Medicare post age 65?

A

You receive or are eligible to receive social security benefits

You receive or are eligible to receive railroad retirement benefits

You or your spouse (living or deceased, including divorced spouses) worked long enough in a government job where Medicare taxes were paid

70
Q

Over the years, medicare enrollment has …

A

increased greatly for both elderly and slightly for non elderly disabled under 65

71
Q

What pays for the majority of Medicare Part A?

A

payroll taxes

72
Q

Medicare Enrollment Dashboard

A

centers for medicare and medicaid interactive site that displays trends in enrollment in the nation, and by state and county for:

Traditional medicare
Other medicare programs
Prescription drug programs

73
Q

Medicare Part A

A

(Hospital Insurance)

Inpatient hospital stays, care in skilled nursing facility, hospice care, and some home health care that is free for everyone 65+, ESRD, and ALS

74
Q

What does Medicare Part A cover exactly?

A

Hospital Stay: 90 days w/ lifetime reserve of 60 days

Skilled Nursing Facility: If w/in 30 days of hospitalization of 3+ days. Covers up to 100 days

Home Health Services: Covers 80% of the cost for equipment needs

Inpatient Psychiatric Care: 190 days lifetime limit

Medicare Certified hospice: must have recertification every 6 months

75
Q

How does Medicare A interact with Home Healthcare Agencies (CHHA)?

A

The agency must be a certified CHHA in order to bill medicare for services

76
Q

Eligible clients for Medicare A home health care?

A

Must be homebound

show decreasing acuity

care must be intermittent

77
Q

Homebound

A

patient has a taxing effort to leave the home: managing stairs, using assistive devices to ambulate, use of O2

78
Q

Homebound Allowances

A

Visiting Health care provider

One day family event (wedding or funeral)

getting hair done

attending church

79
Q

Homebound Non-Allowances

A

Grocery shopping

senior center activity

eating out at restaurants

80
Q

What does Medicare A decreasing acuity mean?

A

you have a condition where you ARE getting better (Being at best with a chronic issue does not count for medicare)

81
Q

What does Medicare A intermittent care mean?

A

not around the care clock (not a live in nurse - family must help out because nurses aren’t there all the time)

82
Q

Medicare Part B

A

Medical Insurance

Voluntary coverage

Can only get Part B if eligible for part A. Supported by general tax revenues and a required additional income based premium

83
Q

What does Part A not cover that Part B can ?

A

Outpatient services (non hospital; like to the doctors)

84
Q

What things does Part B Medicare cover?

A

MD Services: annual physicals, prevention and screening services

Outpatient Hospital Services (outpatient surgery, diagnostic tests, radiology and pathology)

ER visits

Ambulance Fees

Outpatient rehab Services

radiation Therapies

Renal dialysis

Tissue transplants

Prosthetics

Medical equipment and supplies

85
Q

Medicare Part C

A

Medicare Advantage Plans

Similar to HMO (Home Maintenance Organizations)

Auth by the Balanced Budget Act of 1997 “Medicare + Choice program” and renamed to Medicare Advantage with passage of Medicare Prescription Drug, Improvement, and Modernization act of 2003

86
Q

Benefits and Offerings of Part C

A

Similar to HMO

VOLUNTARY

Most offer some prescription (drug) coverage

Lower out of pocket expenses

87
Q

Medicare Part D

A

Prescription Drug

Voluntary Prescription Drug Program

Must have part A or B and requires a monthly premium and deductible

Fully implemented in 2006 but added to MMA of 2003

88
Q

2 Options for Medicare Part D

A
  1. standalone for those who want to remain in original medicare (A or B)
  2. for those who have part C
89
Q

Medicare Part D adds prescription drug coverage to …

A

Traditional Medicare

Some Medicare cost plans

Some medicare private-fee-for-service plans

Medicare medical savings account plans

90
Q

Coverage Gap and Medicare Part D?

A

The drugs obtained must be under a manufacturer discount agreement while in a coverage gap to be phased out in 2020

the coverage gap is the amount of money the insurance company will pay per year for drugs before you have to do it yourself for a while until it reaches an excessive amount and returns again

50% brand drugs; 70% generic drugs

91
Q

What other medicare part may offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans?

A

C

92
Q

Medicaid

A

insurance for the poor

93
Q

Vital Roles of Medicaid?

A

Health Insurance Coverage - for the 31 mil children, 16 mil adults in low income families

Assistance to Medicare Beneficiaries - 20% of all medicare beneficiaries

Long Term Care Assistance - 1.6 million institutional residents, and 2.8 million community based residents

Support for Health Care System and Safety net - 16% of national health spending and 40% of long care services

State capacity for Health Coverage - federal share can range from 50-83%

94
Q

People on medicaid tend to be more what than those on private insurance?

A

Disabled

Poor or Near Poor

Poor Health

Unable to work or limited in working

have a physical and mental chronic condition

95
Q

Premium

A

when you pay a company to have a policy (insurance)

could be deducted from pay or paid directly

96
Q

Deductible

A

set amount determined in your policy that will need to be paid first for healthcare services before the insurance company pays any bills

97
Q

Co-payment

A

Set amount determined in policy that you need to pay the provider each visit

98
Q

Co-insurance

A

similar to copay, but not a set amount

It is a percentage determined by the insurance company you have to pay the provider (ex: 20% of total bill), but the insurance company sets the allowable amount for this bill (So if they only allow 500 dollar bills but yours is 800, they will pay 80% of 500 and you have to pay 20% of 500 plus another 300).

99
Q

Capitation

A

The limit on the amount the provider and insurance company have negotiated and agree to charge and pay for services that are provided regardless of the # of office visits

ex: NP works with a heart patient, regardless of amount of visits that provider will get the same payment - so they are pressured to do a good job

100
Q

Formulary

A

List of medications that the insurance company will cover, usually at a lower cost

Each company has their own formulary

101
Q

Benefits

A

Services that the insurance company covers - may not provide everything but there is a list they will cover

102
Q

Fee-For-Service

A

The payment that the insurance company has given to the health care provider for services the health care provider determines is needed and bills for (Paying for what you get)

103
Q

Retrospective Payment

A

payment determined after services are provided - similar to fee for service

ex: I did this, and this is the cost of it

104
Q

Diagnostic Related Groups

A

Payments predetermined by the insurance company for care that is provided by healthcare organizations based on the diagnosis at the time of admission

105
Q

Prospective Payment

A

Predetermined / Pre agreed amount the insurance company will reimburse to the healthcare provider for specific types of services provided

(Similar to DRG- many agencies have switched to this)

(Schedule has to be well managed or you will lose money)

106
Q

Incrementalism

A

Term that says you are rolling out a policy or new change incrementally (slowly) - applying changes in policy more slowly (certain groups first and then expand)

Can be grandfathered in

107
Q

Moral Hazard

A

when people have insurance they tend to use the healthcare system more frequently, and they engage in higher risk behavior because of access to the healthcare system

NURS322 (13 decks)

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