Paying for healthcare Flashcards
1
Q
When was health insurance first created?
A
- ancient Greeks and Roman
- modern is in early 20th century
2
Q
What was employer-sponsored healthcare + when was it first created?
A
- first created in 1923
- only covered memebers expsnesed at single hospital- Baylor Hospital
- Provided H for teachers at pre-paid monthly rate
- creation of blue cross/ blue shield
- forerunner of today’s HMOS
3
Q
Why was health insurance offered in WWII?
A
- as an incentive to recruit to workers because they were prohibited from raising wages
4
Q
What is fee-for-service?
A
- became very popular in 1960s
- payment method in which doctors, hospital, and medical practice charge seperately for each service they perform
- pt or insurance company is responsible for the amt the healthcare provider chargers for the service
- not cost effective for most
5
Q
What are the types of hospital?
A
- non-profit: provide healthcare for all, aualify as charities, exempt from most taxes, do pay SS and medicare taxes
- proprietary-for profit: community health systems, community corporiation of America, Tenet Healthcare
- Governmental - VA, Austin State Hospital, Texas Health resources, Baylor Medical System
6
Q
What is direct pay (capitation) ?
A
- type of system where provider don’t participate in any insurance reimbursement
- they fix prices and charge a set monthly fees to pt regardless of the number of visits
7
Q
What is private insurance?
A
- managed care is a type of private insurance
- purchased by paitents
- primarily provided by your employer as part of your benefit package
- purchased in “bulk” by employers to provide to their employees
8
Q
What are government plans?
A
- services paid by government agency
- Medicare and Medicaid
9
Q
What are the challenges of rising costs of healthcare?
A
- US spends more per capita than other countires but does not have the highest success or satisfaction rates
10
Q
What are the causes for the rising costs?
A
- high prices for healthcare services and goods
- significant adminsitrative costs (costs of maintaining buildings and personnel salaries)
- defensive medicince
- cost of technological advances
- overuse of specialists
- waste and fraud
- high price of drugs relative to other products
- high costs to develop
11
Q
What aer future causes for risign costs?
A
- growth of aging population
- decline health in young
- decrease in healthy lifestyle
12
Q
How to lower costs?
A
- bill and code correctly (International Classification of Disease (ICD-10), numbers assigned to diseases and conditions, used to determine and justify charges by providers), Current procedural termin ology (CPT code, used to document and report all types of services)
- DRGs - efforts impsoed by government and managed care to lower healthcare costs
13
Q
What is Veterans Health Administration?
A
- largest integrated health care system in US
- serves veterans who meet certain qualifications
14
Q
What is Medicare?
A
- Federal INSURANCE program
- health insurance for ppl 65 and older and disabled persons
- charges monthly premium
- covers 80% of approved charges
- paid by a trust fund, funded with payroll taxes
- same program nationwide
- pt pay deductibles and for part of coverage
- types:
Part A: Hospitalization
Part B: Outpatient services
Part C: Medicare advantage plans
Part D: Prescription drugs
15
Q
What is medicaid?
A
- Federal and State ASSISTANCE program
- public health insurance program for low-income and disabled persons
- partly funded by federal governments
- administered and differs by states
- funding differs slightly from state to state
- covers large percentage of nursing home costs
- provides medical coverage to needy individuals
- based on income level
- pt pays very little or no part of coverage
- participants receive regular dental and vision exams
16
Q
similarites between medicare and medicaid>
A
- benefits ppl with disabilities
- prescription drug coverage
- outpatient hospital care
- inpatient hospital care
17
Q
What is worker’s compensation?
A
- Serves as a benefit that pays for medical care for employees who are injured or become ill because of their jobs
17
Q
What is worker’s compensation?
A
- Serves as a benefit that pays for medical care for employees who are injured or become ill because of their jobs
18
Q
What is managed care + goals ?
A
- designed to decrease out of pocket expenses for healthcare services
- organizations negotiate with providers to form networks
- aims to: provide affordable healthcare, ensure high-quality care, discourage unnecessary costs, eliminate duplication of procedures, earn a profit
19
Q
What are the requirement for employer provided helath insurance (managed care)
A
- eligibilty depends upon continous employment
- employees must work at least 20 hours or more per week
- most companeis ahve awaiting peroids before insurance beeifts r available
- pre-existing conditions may be ineligible
20
Q
What is HMO?
A
Health Maintenance Organization
- Must stay in network
- Must select a PCP
- Must have referral to see specialist
- Out of pocket expenses are set
- copay is often low
- Specialty care must be submitted to HMO for approval – may be denied
21
Q
What is EPO?
A
Exclusive Provider Organization
- Must stay in network
-PCP not required - No referral necessary
22
Q
What is PPO?
A
Preferred provider organization
- Not required to stay in network
- PCP not required
- No referral necessary
- More expensive
- Wider range of providers
- May visit doctors outside the list of preferred providers(out of network)
- more expensive
23
Q
What is POS?
A
- Point of Service
- Similar to PPO
- PCP IS required
- Referral IS needed to see specialist
- Lower Cost than PPO but more expensive than HMO
- Wider network of providers to choose from
- Out of network care is allowed
24
Q
What is premium?
A
monthly amount paid for health insurance
25
Q
What is copay?
A
- set amount of money you pay at the time service is rendered for office visitis, prescriptions, ER visits, hospitalizations
26
Q
What is deductible?
A
- portion of cost of all healthcare a person receives before insruance starts paying for it (Higher deductible = cheaper premium)
27
Q
What is coinsurance?
A
- after deductible is met, this is specified percentage of cost of treatment that the patient is still required to pay for medical services (medicare pt pay 20%)
28
Q
What is a pre-existing condition?
A
- illness, disease, injury that a person already had at time of enrolling in ew healthcaer plan
29
Q
What is claim?
A
- request to insurance company to cover helathcare services
30
Q
What is reimbursement?
A
- amount medicare or your insurance company pays to provider
31
Q
What is primary care providers in managed care?
A
- control mechanism - also called a gatekeeper
- requires pt to first see this provider who recommends and approves services
32
Q
What is review of services in managed care?
A
0- proceudre used by companies to determine which costs will be covered
- preauthorization required
33
Q
What is cancer insruance?
A
- specific insurance for treatment of cancers
- additional cost to basic healthcare insurance
34
Q
What is disability income insurance?
A
- if you becom unable t owork due ot injury or illness, you will continue to receive your paycheck
- it varies in amt but usually covers around 60% of your monthly income
- there can be waiting period before benefits begin
- can be long-term or short-term
35
Q
What is vision insurance?
A
may pay a portion of an eye exam and part of a pair of glasses or contact lenses.
36
Q
What is dental insurance?
A
covers a portion of teeth cleaning, fillings, x-rays, orthodontics and oral surgery
37
Q
What is life insurance?
A
- Provides financial payment to a beneficiary in the event of death
- Benefit can vary, depending on the needs of the family and individual
- Employers often offer life insurance to their employees in the amount of the employee’s annual salary
- Individual policies can be purchased
38
Q
What is the affordable care act?
A
- signed into law by President Obama in 2010 with goal to improve accessiblity and quality of US healthcare system
39
Q
What are the benefits of affordabel care act?
A
- insurance cant deny indv with preexisting conidtions
- small businesses receive tax credits for providing health insurance to employees ( anyone who employs 50 or more has to provide insurance)
- everyone must buy healthcare - most controversial aspect of ACA, repealed by Presidnet Donal Trump in2017
- Insurers cant cancel coverage when person becomes ill
- medicare expanions (greater coverage, expand medicaid to indv up to 64, addressed historically low insured rates among low income adults)
40
Q
10 essential health benefits of ACA?
A
- hospital stays
- prescription drugs
- emergency services
- prevention and wellness services and chronic disease management
- rehabilitative and habiltative services and devices
- mental health services and counseling about quitting smoking and reducing alch use
- pediatric services, including oral and vision
- lab services
- ambulance rides
- maternity and newborn
41
Q
How is ACA funded/
A
- cuts in gov spending + increase on taxes of indv, businesses and manufacturers
- excise taxes on health insurers, pharma companies, manufactureres of medical devices
- expand medicare payroll taxes (higher wage earners pay higher tax on earned income)
- raise income tax deduction for medical expenses
- helath insurance tax 9annual fee on insurers that = increase in premium of ppl with managed care)
- excise tax = charges at the moment of manugacture rather than at sale
