PUSHES EXAM I Flashcards
How much is the total U.S health care expenditures in year 2017?
$3.5 trillion
How much of the total U.S health care expenditures in 2017 of GDP?
17.9%
What are the major factors contributing to high costs of healthcare?
Social factors, chronic disease and aging, prescription drugs and other advances in medical tech, fragmented healthcare delivery, current payment and reimbursement, administrative costs for providers and payers
What is the universal goal of the health care system?
Adequate access to quality care at a reasonable cost (aqc)
What is the triple aims of healthcare system target?
- Better individual care and experiences
- Better population health
- Lower cost
What is access?
The ability to obtain health services when needed
What are the major components of access? (contributing factors)
- Ability to pay
- Availability of health care personnel and facilities
- Ease of use and barriers (transportation, language or cultural issues )
How many people are currently uninsured in the U.S?
27.4 million
What are the reasons for being uninsured among uninsured non elderly adult?
- Cost is too high
- lost job
- lost medicaid
- status change
- employer does not offer or ineligible for coverage
- No need for health coverage
How many adult are underinsured in the U.S?
41 million
What is the definition of underinsured?
when your out of pocket cost adds up to 10 percent more than your household income. Or deductible is five percent of your income.
very low income
What is primary care?
first contact care
basic or general health care
Which physicians are PCPs?
- Nurse practitioners
- Physician assistants
- Chiropractors
What is secondary care?
Provided by specialist treating problems that require more specialized clinical expertise. Usually more specific type of diseases, more complicated procedures
What is tertiary care?
management of the most complex disorders. Highly specialized, highly technological, typically institution based.
How can yo get tertiary care?
Referral from primary or secondary care provider.
What are some examples of tertiary care?
burn treatments, high risk pregnancy
What is preventive care?
- Attempts to prevent disease or injury
2. Actions to reduce exposures to health problems
What are examples of preventive care?
Vaccinations and screening test
What is chronic care?
Care for chronic conditions. These conditions persist over time
What is respite care?
service for dependent patients that provides temp. care relief to their informal caregivers
What is long term care?
Extended assistance for chronically ill, mentally ill, or disabled people. They have limitations in performing activities of daily living (ADL) or IADL.
What are ADLs?
Activities of daily living: basic self-care tasks, eating, bathing, dressing, bathroom, transferring or walk around
What are IADLs?
shopping, cooking, managing meds, handling money
What are the services that LTC often?
- Skilled nursing care
- Assisted living programs
- Rehab
- home health
- Outreach programs
What is acute care?
Short-term, intense medical care. Inpatient hospitalization
What is subacute care?
inpatient service for pts that no longer need hospital care but require more intensive skilled nursing than what is available at nursing homes.
How long are pts at subacute care for?
until condition is stabilized or the treatment course is completed
Is subacute care nursing more intensive than acute?
No but its more than traditional nursing.
How long is the usual length of stay?
4.5 days
How can hospitals be classified?
- Size: number of beds
- Location: urban or rural
- Type of service
- Ownership: Pubic, private nonprofit or proprietary
- Multiunit affiliation: chain or independent
- teaching or church affiliated
What is ambulatory care?
outpatient care that does not require inpatient hospitalization. Walk in pt
What does ambulatory care include?
disease prevention, health promotion, and medical care
What is the ACO?
Accountable Care Organization that is a model of care affordable care act that decreased healthcare cost by encouraging networks to coordinate care and receive bonuses for efficient care delivery.
What is eligible expense, negotiated rare , payment allowed and approved charge?
Allowed amount
Before the Affordable Care Act (ACA), what was the determining factors in eligibility and rates for Individual Health Insurance Plans?
Age and Health
What did the ACA do in terms of factors for eligibility?
BANNED the denial of insurance coverage based on pre-existing health conditions.
How do employers group premium setting based on?
Experience rating and community rating
What is a experience rating?
insurance premiums based on the health history or the medical claims of group of insured individuals.
Under employee insurance, how do employee’s pay different amount of premiums?
- demographic characteristics
- Past healthcare utilization
- Medical status
- Other factors
Is community rating or experiencing rating used more by employers?
Community rating
What is a community rating?
premiums based on specific geographic area. Everyone in a community pays the same premium.
What is pure community rating?
prohibits rate variation based on demographic or health factors.
What kind of community rating is more commonly used?
Modified community rating
What is Modified community rating?
rate vary based on demographics (age, family size, location, life style) . BUT cannot vary based on pre existing health conditions
What percent of the health care cost was to medicare?
21%
As of 2018 how many people are enrolled in medicare?
60.4 million
What are the characteristics of the medicare population?
- 3+ chronic conditions
- income below $23,500
- Savings below $61,400
What does Medicare Part A cover?
Hospital Insurance
inpatient care, short term stays in SNFs, hospice care, and post-acute home health care
What amount of premium do Medicare Part A pay?
$0.
How much deductible do pts that have medicare part a pay?
$1,364 for each episode of illness
Under medicare part a, how long do each episode of illness last?
It lasts 2 months
For Medicare Part A, how much do pts pay for the first 60 days of hospital care?
none
For Medicare Part A, how much do pts pay for the first 20 days of SNFs?
none
For Medicare Part A, how much do pts pay for hospice care?
non
For Medicare Part A, how much do pts pay for home health services?
none
How much do pts under Medicare Part A pay for premium?
None unless they don’t meet the 40 threshold
What does Medicare Part B cover?
Supplementary Medical Insurance . Outpatient hospital care, physician visits, ambulance services, laboratory services, durable medical equipment, diagnostic tests (x-rays, mri)
What is the premium for Medicare Part B?
$135.50 per month and higher for incomes > 85,000. Decrease if you have SS benefits
For Medicare Part B, what id the deductible?
$185 per year lower than part A.
What is $0 for Medicare Part B?
home health and clinical laboratory
What does Medigap plans cover?
Part A deductible, SNF coinsurance, and foreign travel emergencies
What does the monthly premium of Medigap depend on?
health, age, location and plan
What percent of medicare benes have Medigap?
25%
What type of Medigap plans cover Medicare Part A and Part B deductible
plan F
What are the requirements for Medigap?
Have to have part A and elected to enroll in part B
What is Medicare Part C?
A managed care program that provide medicare advantage. It gives inclusions to extra benefits and lower cos sharing requirements like Rx drugs, dental care, routine physical exams, vision services, health and wellness programs and other services
What is limited with Medicare Part C?
access to physicians and other providers are limited to those in the network
What are the requirements for Medicare part C?
Must be eligible to enroll in part A and part B.
Is the Medicare Advantage enrollment increasing?
Yes
What are the most medicare advantage enrollees in?
HMOs
What is Medicare Part D?
Outpatient prescription drug benefit
When was the Medicare Modernization Act established and implemented?
2003, 2006
What is required of benes for Medicare Part D?
must enroll in medicare advantage or private stand alone plan
How many Medicare benes are enrolled in Part D plans?
75%
For Medicare Part D, what do benes have to pay from premium?
varies by income and plan
Of Medicare Drug Plans what percentage is enrolled in PDPs vs. MAPDs?
58% vs. 42%
Is Part D participation voluntary?
yes
What is the Readmission Reduction Program?
Hospitals are penalized if high readmissions for select conditions: Pneumonia, hip surgery, acute myocardial
What did the ACA DO?
Close the donut hole
What are the proposals for Medicare in the Future?
- Restructuring benefit design and cost sharing
- Raising eligibility age
- Allowing those < 65 years to buy in
What were the eligibility group under Medicaid before ACA?
- Pregnant women
- Children
- Parents of dependent children
- Individuals with disabilities
- Individuals age 65+
- federal minimum income < or = 133% of the Federal Poverty Level
What are the eligibility under Medicaid after the ACA?
- < or = 138% FPL
2. All adults
What are the impact of Medicaid under the expansion under ACA?
- Large increases in Medicaid enrollment
- Reductions in uninsured rates
- Coverage gains in specific vulnerable populations: Young adults, people with HIV, parents, mothers, children, rural areas
- Improvements in self-reported health
What are the key ACA impact on Medicaid?
- Expansion to non-elderly adults
- Increase outreach and simplify enrollment process
- Increased fees paid to PCP
- Changes in premium amounts and copayment limits
- Changes in health care delivery, increased innovation and demonstration projects
What is CHIP?
Children health insurance program
