National Health Systems Flashcards
National Health Systems
What are the three main factors to keep in mind when comparing health systems?
Financing (public; private; out-of-pocket)
Delivery (public; private non-profit; private for-profit)
Access (universal; not universal)
National Health Systems
Give illustrating examples of the four major forms of healthcare delivery systems as found in the hodgepodge of the U.S. system.
Beveridge Model - ________________________
National Health Insurance - ________________________
Bismarck Model - ________________________
Out-of-pocket - ________________________
Beveridge Model - VA system
National Health Insurance - Medicaid and Medicare
Bismarck Model - those getting insurance from their employers (private )
Out-of-pocket - whoever pays direct costs without insurance
National Health Systems
For each example below from the hodgepodge of the U.S. healthcare system, identify which healthcare delivery system each represents.
VA system - ______________________
Medicaid and Medicare - ______________________
Private insurance - ______________________
Those without insurance - ______________________
VA system - Beveridge Model
Medicaid and Medicare - National health insurance
Private insurance - Bismarck Model
Those without insurance - Out-of-pocket
National Health Systems
Describe the financing of the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Public financing via general taxes
National Health Systems
Describe the delivery mechanism of the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Publicly owned and some private providers
National Health Systems
Describe access to care in the Beveridge model (UK, New Zealand, Spain, Scandinavia).
Universal care
National Health Systems
Describe financing in the Bismarck model (Germany, France, the Netherlands, Japan).
Private financing via joint efforts of employers and employees
National Health Systems
Describe the delivery mechanism in the Bismarck model (Germany, France, the Netherlands, Japan).
Care mostly via private providers
National Health Systems
Describe access to care in the Bismarck model (Germany, France, the Netherlands, Japan).
Universal coverage
National Health Systems
Describe financing in the National Health Insurance model (Canada, Taiwan, South Korea).
Public financing via special taxes
National Health Systems
Describe the delivery mechanism in the National Health Insurance model (Canada, Taiwan, South Korea).
Care mostly via private providers
National Health Systems
Describe access to care in the National Health Insurance model (Canada, Taiwan, South Korea).
Universal coverage
National Health Systems
Describe financing in the out-of-pocket model (rural Africa, Southeast Asia).
Most countries are too poor or disorganized to provide financing
National Health Systems
Describe the delivery mechanism in the out-of-pocket model (rural Africa, Southeast Asia).
Care via private providers
National Health Systems
Describe access to care in the out-of-pocket model (rural Africa, Southeast Asia).
Only those who can pay or access charity care will receive service
National Health Systems
Is the U.S. system most like the Beveridge, Bismarck, NHI, or out-of-pocket health system models?
It is a blend of each.
Beveridge - VA system
National Health Insurance - Medicaid and Medicare
Bismarck - those getting insurance from their employers (private )
Out-of-pocket - whoever pays direct costs without insurance
National Health Systems
Summarize the main health system models (Beveridge, Bismarck, national health insurance, and out-of-pocket) according to:
financing (public or private),
delivery (public or private),
and access (universal or not).
National Health Systems
How do we know the U.S. healthcare system needs reform?
Financing, delivery, and access needs are not being met efficiently, then the system needs to change.
Spiraling costs and the lack of universal coverage indicate a broken system.
National Health Systems
What are the requirements for hospice care?
≤ 6 mo. life expectancy if disease runs its normal course
National Health Systems
Contrast preventative care in fee-for-service and capitation payment systems.
Capitation favors preventative medicine more than fee-for-service
(preventative medicine keeps you from seeing the doctor, which would be lucrative to the provider in the capitation system but detrimental in the FFS system)
National Health Systems
Which system maximizes physician risk: fee-for-service, prospective payment, or capitation?
Capitation
National Health Systems
What do fee-for-service systems encourage physicians to do?
Maximize intensity; maximize encounters
National Health Systems
What do capitation systems encourage physicians to do?
Minimize intensity; minimize encounters
National Health Systems
Describe the prospective payment model.
Each service has a predetermined amount for insurance reimbursement
The provider benefits only if he keeps costs below the reimbursement limit
National Health Systems
What does the prospective payment model encourage physicians to do?
Maximize encounters; minimize intensity
National Health Systems
How does a pay-for-performance (value-based payment) model work?
Pay-for-performance (e.g. if you keep all your diabetic patients at a healthy A1c level, you get a bonus; if you don’t, then you lose some of your reimbursement)
National Health Systems
How does a bundled payment (value-based payment) model work?
A single pre-negotiated payment is given for all services related to a certain procedure. The physician makes a profit by minimizing services and keeping costs below that payment
National Health Systems
How does a shared savings payment model (value-based payment) work?
Accountable care organizations: physicians band together, and if they succeed in improving health outcomes and lowering costs for the insurance company, then they share in the savings
National Health Systems
What are the three main forms of reimbursement?
Government, private, and out-of-pocket
National Health Systems
Describe Medicaid/Medicare reimbursement.
The government decides on prices via diagnostic-related groupings. (This is the smallest reimbursement category.)
National Health Systems
Describe private insurance reimbursement.
Insurers negotiate with providers on behalf of their clients to keep prices as low as possible (more lucrative for providers than Medicare/Medicaid reimbursements)
National Health Systems
Describe out-of-pocket reimbursement.
Individuals without insurance must pay full price (most lucrative for providers as there is no negotiation of prices)
National Health Systems
What is ‘cost-shifting?’
Physicians often receive the least reimbursement for Medicare and Medicaid patients and suffer a loss by seeing these patients (in terms of the cost of treatment vs. reimbursement).
In order to offset this loss, physicians often raise prices on their private insurance patients, thus raising premiums for employers. In a way, this means the general population pays doubly for Medicare/Medicaid, once in taxes and once in raised premiums.
National Health Systems
What is coinsurance?
The percentage of costs a patient is expected to pay after their deductible and before their out-of-pocket maximum.
National Health Systems
Do copays contribute to deductibles or out-of-pocket maximums?
No
National Health Systems
What is an insurance premium?
The regular monthly amount paid to keep insurance (if employed, this comes straight out of every paycheck)
National Health Systems
What is the list of drugs a particular insurance plan will pay for?
The formulary
National Health Systems
What is a provider network?
The list of approved providers the insurance plan will reimburse for services
National Health Systems
Will HMOs reimburse costs for visits to out-of-network providers? Will PPOs?
No; sometimes
National Health Systems
How do the fee-for-service, prospective payment, and capitation systems differ in regards to provider risk, intensity of care, and frequency of care?
National Health Systems
What are the two types of private insurance payment?
Indemnity (the insurer pays the patient who then pays the provider);
direct (the insurer pays the provider directly)
National Health Systems
What percentage of all U.S. health expenditures (17% of the GDP) go toward public health?
2% (0.34% of the GDP)
National Health Systems
What is the ACA Medicaid expansion?
An expansion of Medicaid to cover all individuals under 65 years of age and below 138% of the FPL.
Originally, the law only covered pregnant women, women, children, and some disabled individuals (impoverished men are now included).
National Health Systems
Have all states implemented the Medicaid expansion?
No, the SC ruled that it is not mandatory.
National Health Systems
What is the percentage breakdown of types of insurance Americans hold?
National Health Systems
If all states had implemented the Medicaid expansion, what estimated percentage of Americans would be covered by some sort of insurance (Medicaid or not)?
95%
National Health Systems
Are only the poorest of the poor uninsured in the U.S.?
No, ironically, it is the medium-poor
National Health Systems
How is the Medicaid expansion financed?
The vast majority of funds come from the federal government.
Savings come through the associated reduction in costs of uninsured patients, which are more expensive than insured patients
National Health Systems
What was a vital part of the ACA that has now been neutered?
The individual mandate
National Health Systems
What are methods of cost reduction in the U.S. healthcare system?
EHRs incentives and penalties (HITECH Act of 2009) → Both Medicare and Medicaid provide incentive payments and also payment penalties for failure to use
Value-based purchasing program → hospitals are rewarded based off their level of improvement over threshold of benchmark hospitals and also against the baseline set for each hospital as an individual entity (i.e. hospitals scored against each other and in their own improvement against their own baseline)
Payment reductions and penalties → excess patient readmission ratios leads to payment reductions
National Health Systems
What is the benefit of the ACA online healthcare exchanges?
It is a ‘single door’ to health coverage - the system also tells individuals if they qualify for Medicaid, tax credits, or unsubsidized exchange coverage in real time and allows for selection of these programs
National Health Systems
Individuals up to what percentage of the FPL can receive some federal subsidies on the healthcare exchanges?
400% FPL
National Health Systems
What are some required covered benefits the ACA mandates that insurers provide?
Preventive services, ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health services, prescription drugs, rehabilitative services, laboratory services, and pediatric services
(every insurance plan in the country now covers these items)
National Health Systems
What are some benefits of the ACA?
- More covered benefits
- Remain on parents’ insurance until age 26
- No more denials or insurance policy cancelations based on health status or pre-existing conditions
- More community health centers
National Health Systems
Are insurance premiums increasing or decreasing (overall)?
Increasing
National Health Systems
Are the ACA healthcare exchanges becoming more or less competitive (are there more or less insurance options)?
Less competitive (less options available)
National Health Systems
Describe the U.S. medical system in general terms.
A loose, non-centralized system
Varying sponsors (private and public), providers (institutions and physicians), and access (by age, health, and economic status)
The third-party system isolates patients and physicians from the true costs of procedures so that it is difficult for anyone to make informed decisions based on actual costs
National Health Systems
Should the U.S. healthcare system adopt a model such as the Beveridge, Bismarck, out-of-pocket, or national health insurance models?
Not necessarily;
other countries’ successes and failures do not directly predict the success of a health system here. There are too many external factors that make countries different from one another (e.g. geography, size, demographics, morbidity, mortality, culture, political climate, wealth, etc.)
National Health Systems
What national healthcare model does Canada utilize in providing universal healthcare coverage?
The National Health Insurance model
National Health Systems
What national healthcare model does France utilize in providing universal healthcare coverage?
The Bismarck model
National Health Systems
What national healthcare model does Japan utilize in providing universal healthcare coverage?
The Bismarck model
National Health Systems
What national healthcare model does Spain utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model does Italy utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model does New Zealand utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model does the Netherlands utilize in providing universal healthcare coverage?
The Bismarck model
National Health Systems
What national healthcare model does South Korea utilize in providing universal healthcare coverage?
The National Health Insurance model
National Health Systems
What national healthcare model does Germany utilize in providing universal healthcare coverage?
The Bismarck model
National Health Systems
What national healthcare model does Scandinavia (Denmark, Norway, and Sweden) utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model does the UK utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model does Taiwan utilize in providing universal healthcare coverage?
The National Health Insurance model
National Health Systems
What national healthcare model do both Sweden, Denmark, and Norway all utilize in providing universal healthcare coverage?
The Beveridge model
National Health Systems
What national healthcare model do Austria, Switzerland, and the Czech Republic all utilize in providing universal healthcare coverage?
The Bismarck model
National Health Systems
Name some of the large countries who the WHO rated best in overall performance in the year 2000.
- France
- Italy
(San Marino)
(Andorra)
(Malta)
- Singapore
- Spain
- Oman
- Austria
- Japan
- Norway
National Health Systems
What country has the best 5-year survival rate for colorectal cancer?
South Korea
(US is 5th)
National Health Systems
What country has the best 5-year survival rate for breast cancer?
The United States
National Health Systems
What country has the best 5-year survival rate for cervical cancer?
South Korea
(US is 19th)
National Health Systems
What country has the lowest rate of in-hospital 30-day mortality following a heart attack?
Denmark
(US is 7th)
National Health Systems
What country has the lowest rate of in-hospital 30-day mortality following a stroke (ischemic or hemorrhagic)?
Japan
(US is 16th for hemorrhagic and 4th for ischemic)
National Health Systems
How do most countries that follow the multi-payer Bismarck health insurance model manage to avoid the cost inflation and other issues associated with the U.S. employer-based system?
Tight government regulation of payers
Name potential solution(s) to the following issues in the U.S. healthcare system:
Price gouging / inflation
Price differences by location
Lack of universal coverage
Overtreatment
Price transparency (via government regulation)
Price transparency (via government regulation)
Mandated coverage (e.g. Medicare for all) that maintains our private system (a la Bismarck or NHI)
Accountable care organizations (more incentives in this direction)
