Nurs exam 3 Flashcards
Health Care Cost
Varies greatly across health care organizations and locations
Challenges in Containing Costs
- Consumer using only healthcare resources needed
- Providers/organizations diagnosing and prescribing only what is needed (Pay for Performance versus fee for service)
- Complexity of health insurance reimbursement can leave consumers vulnerable to high costs
- Chronic disease epidemic
- Focus on disease treatment rather than prevention
Health Insurance
Mechanism to support a group of people to pay for health care services by spreading the cost of health care services among a large number of people, the majority of whom do not need costly health care.
Deductible
the $ amount to be paid before insurance kicks in
Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you’ve paid your deductible.
Copayment
The $ amount you pay per visit after deductible is met
State Health Insurance Exchanges
-Part of the Affordable Care Act
-Helps pool large numbers of individuals to spread risk for insurance and therefore make insurance available
-Subsidies given to people with low income & not qualified for Medicare
Medicare Part A
Hospitalization
Medicare Part B
Outpatient
Medicare Part C
Advantage Plans
Medicare Part D
Prescription Drugs
Managed Care
a health care delivery system organized to manage utilization, quality, and cost.
Managed care provides…
primary, secondary and tertiary care
HMO’s (Health Management Organizations)
members must see PCP to be referred to specialist
PPO (Preferred Provider Organization)
No gatekeeper, no need for referral, no copay but do have deductible
EPO (Exclusive Provider Organization)
Similar to PPO but restrict members to a select list of providers
POS (Point of Service)
MHO/PPO hybrid, not required to have PCP but will have lower rate if they see PCP and are referred to specialist
PHO
required to use their physicians, their hospital, their surgical centers
PSO
owned by providers (not a great choice)
Challenges for Managed Care
-Value based payment
-data-driven decision making
-consumers have more info available to them allowing them to pick the best plan
-increasing drug costs
Electronic Health Record (EHR)
electronic version of a patient medical record (shared over multiple organizations)
