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SAR HP 353 > Test 1 > Flashcards

Test 1 Flashcards

1
Q

How does the World Health Organization (WHO) define health?

A

Health is defined as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.

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2
Q

What are the top five causes of preventable premature death for individuals under 80?

A

Unintentional injury
Chronic lower respiratory disease
Heart disease
Stroke
Cancer

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3
Q

What is the primary goal of the U.S. healthcare system?

A

The primary goal is to provide cost-effective healthcare access for individuals.

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4
Q

What are the strengths of the U.S. healthcare system?

A

Advanced technology
Strong research
High-quality medical training

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5
Q

What are the key weaknesses of the U.S. healthcare system?

A

Financing
Administrative costs
Access for low socioeconomic groups
Lack of long term care
Illness prevention
High per capita cost but low health outcome rankings

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6
Q

How does the U.S. healthcare system work for different groups of people?

A

Under 65: Employer-paid insurance.
Native Americans, military, veterans: Government-run hospitals.
Over 65: Medicare (government-funded).

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7
Q

What impact would Medicare for all have on healthcare providers?

A

It would reduce reimbursement amounts for healthcare providers.

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8
Q

What are the key components of the Affordable Care Act (ACA)?

A

Expands coverage
Controls healthcare costs
Improves healthcare delivery.

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9
Q

Who are the key stakeholders in the U.S. healthcare system?

A

Lobbyists
Hospitals
Companies
Insurance companies
Medicare
The public

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10
Q

How has the U.S. healthcare system evolved over time (1900, 1950, 2000)?

A

1900: Healthcare provided at home, with bartering as the primary payment method.

1950: Hospitals became central, with employer-provided insurance plans and more power to insurance companies.

2000: Care expanded to hospitals, clinics, and private practices, with more government involvement and a greater role for employers and insurers.

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11
Q

What are the four main modes of payment in U.S. healthcare?

A

Out of pocket
Private insurance
Employment-based insurance
Government financing

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12
Q

What are the key characteristics of out-of-pocket payment?

A

Unpredictable costs
Frequency of need
Reliance on doctor recommendations,
The most common form of payment in the early 20th century.

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13
Q

What led to the development of private hospital insurance (Blue Cross)?

A

The Great Depression in the 1930s led to low hospital occupancy rates, which pushed the development of hospital-specific insurance plans like Blue Cross.

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14
Q

What are the components of Medicare, and how is each part funded?

A

Part A: Hospital insurance for those over 65 or with certain disabilities, funded by Social Security taxes.

Part B: Outpatient services insurance, funded by federal revenues and monthly premiums.

Part C (Medicare Advantage): Private insurance alternative to Medicare A and B.

Part D: Prescription drug coverage, funded by premiums, deductibles, and copayments.

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15
Q

What are some challenges of Medicare Part D?

A

Gaps in coverage
Lack of negotiation for lower prices until 2026
Confusion due to multiple insurance administrators.

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16
Q

What is Medicaid and who is eligible?

A

Medicaid is a jointly funded federal and state program providing coverage for low-income individuals, children, pregnant women, disabled individuals, and seniors.
Eligibility is determined by income and other factors

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17
Q

What is CHIP (Children’s Health Insurance Program)?

A

A Medicaid companion program aimed at increasing healthcare coverage for low-income children, funded through 2026.

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18
Q

How did the Affordable Care Act (ACA) impact Medicaid?

A

The ACA expanded Medicaid eligibility to citizens and legal residents with family income below 138% of the federal poverty line starting in 2014.

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19
Q

Why is healthcare not considered a normal economic market?

A

Information asymmetry

Insurance as insulation: cost-sharing by insurance hides the real cost from consumers

Conflicting interests

Tax subsidies: market is distorted by subsidies provided by employers and employees

Failure of competition: individual nature of insurance
plans and hospitals keep them from competing as market goods

Suppliers

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20
Q

What are the benefits of having health insurance?

A

Increases access to care.
Improves health outcomes.

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21
Q

What are the financial barriers to healthcare?

A

Lack of insurance.
Underinsurance.
Coverage limits.
Deductibles.
Copayments and coinsurance.
Lack of long-term care coverage.

22
Q

Who are the uninsured in the U.S.?

A

Employed, uninsured: Low pay, part-time jobs, or jobs with no health insurance.
Unemployed, uninsured: Low income but ineligible for Medicaid.
Higher percentages among people of color and those with lower annual household income.

23
Q

Which groups experience the highest rates of lack of access to healthcare?

A

Latinos
People with incomes below $25k
Part-time workers
Unemployed workers
Employees at small firms (less than 25 people).

23
Q

Why do people lack insurance?

A

High costs
Not living in a Medicaid-expanded state
Being undocumented immigrants
Increased premiums

24
Q

What are the different types of health insurance coverage plans?

A
  1. Indemnity Plans
  2. Managed Care Organizations
    - Health Maintenance Organizations (HMO)
    - Preferred Provider Organizations (PPO)
    - Point of Service Plans (POS)
  3. Consumer-Driven Health Plans
    - Health Savings Account (HSA)
    - Flexible Spending Account (FSA)
    - Health Reimbursement Accounts (HRA)
25
Q

What are the pros and cons of Health Maintenance Organizations (HMO)?

A

Pros: No paperwork, inexpensive, focuses on preventive care.

Cons: Limited physicians, specialized care is harder to get, out-of-network care is not covered.

26
Q

What are the benefits of Preferred Provider Organizations (PPO)?

A

Most expensive but offers the most freedom, network, and non-network providers.

PPOs attract people who want to avoid referrals for specialists and prefer out-of-network care options.

27
Q

What is a Point of Service (POS) Plan, and how does it work?

A

A hybrid between HMO and PPO, combining prepaid insurance with fee-for-service.

Requires a PCP, more flexible than HMO but less than PPO.

Pros: Free to use non-network providers.

Cons: High copayments for non-network providers, referrals needed, and paperwork required for out-of-network reimbursement.

28
Q

What are Consumer-Driven Health Plans?

A

High-deductible, low-premium plans with tax-free bank accounts used only for medical expenses (e.g., HSAs and FSAs).

29
Q

What is the difference between Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA)?

A

HSA: Tied to high-deductible health plans, tax-free, accrues interest, carries over year to year, and funds are portable but taxed if withdrawn for non-medical use.

FSA: Not tied to high-deductible plans, up to $3650 can be contributed, but funds must be used by the end of the year or are forfeited.

30
Q

What programs increase access to healthcare?

A

COBRA: Provides group-rate insurance for 18 months after losing coverage, but premiums are unaffordable for many.

Medicare: Covers individuals over 65 and those with certain disabilities.

Medicaid: Provides care for individuals at or below 138% of the federal poverty level.

31
Q

What is cost-sharing in health insurance, and what are its effects?

A

Cost-sharing involves patients paying part of healthcare costs through deductibles, copayments, or coinsurance. According to the RAND study, patients with cost-sharing plans used fewer inappropriate services but also fewer appropriate services, leading to poorer health outcomes.

31
Q

What are non-financial barriers to healthcare access?

A

Primary care physician shortage
Finding physicians who accept insurance
Scheduling appointments
Physical distance (especially in rural areas), Transportation
Language and cultural barriers
Gender
Ethnic background.

32
Q

What are the key influences on health status?

A

Public health interventions, medical care, socioeconomic status, and age.

33
Q

What was the Whitehall Study, and what were its findings?

A

The study examined British male civil servants and found a strong association between lower employment grade and higher mortality rates. Men in lower-grade jobs had a mortality rate three times higher than those in higher-grade jobs.

34
Q

What are access-to-care issues faced by women?

A

Dissatisfaction with physician care
Lower quality of preventive care
Inappropriate care
Difficulty affording prescriptions
Reduced access to abortion services
Minority women, in particular, face higher rates of HIV/AIDS and barriers to healthcare access due to poverty and lack of education.

34
Q

What policy changes could improve access to healthcare?

A

Increased payment to PCPs, restructured payment systems, reduced documentation requirements, and building stronger teams with non-clinical staff to support healthcare delivery.

35
Q

How does Medicare set reimbursement rates? (Key points from Chapter 3)

A

Medicare uses Relative Value Units (RVUs) to set clinicians’ reimbursement fees.

36
Q

What are the common methods of payment for healthcare services?

A

Fee-for-service (FFS)

Per diem (daily rates)

Episode of illness payments (bundled fees)

Capitation (payment per patient)

Global budgets (aggregated payments)

37
Q

What is the Resource-Based Relative Value Scale (RBRVS)?

A

Calculates fee-for-service payments based on time, effort, and geographic factor (Set by Medicare)

38
Q

Historically, how were physicians paid for fee-for-service?

A

Usual, Customary, and Reasonable (UCR) fees

39
Q

What is Episode of Illness payment for physicians?

A

single, bundled payment for all services related to a specific illness or procedure (e.g., surgery or obstetrics)

40
Q

What is Capitation, and how does it apply to physician payments?

A

Physicians are paid a set amount per patient for a specific time period

Financial risk on the provider

Adjustments are made for financial risk, such as carve-outs for specific services and risk-adjusted capitation for patients with higher medical needs.

40
Q

How are physicians paid through salaries?

A

Physicians in public sector facilities (e.g., VA, military) and staff-model HMOs often receive salary-based payments.

In group-model HMOs, physicians may be salaried through capitation contracts.

41
Q

What are the Two-Tiered and Three-Tiered payment models in healthcare?

A

Two-Tiered: Involves a health plan and a primary care physician (PCP).

Three-Tiered: Adds an intermediary group (Independent Practice Association - IPA), which bears financial risk for specialist services.

41
Q

What are the merits of capitation payments?

A

Better ability to plan and control costs.

Nurses and assistants can provide “virtual visits.”

Improved care delivery, as each patient has a primary care provider (PCP).

Providers can negotiate better rates for specialty and ancillary services.

42
Q

What is the Diagnosis-Related Groups (DRG) payment system in hospitals?

A

Lump-sum payments based on the patient’s diagnosis

Hospitals bear the financial risk of length of stay

43
Q

How does Medicare Advantage (MA) work?

A

Private companies contract with CMS to manage Medicare spending for a group of patients.

The CMS pays a capitated rate to the MA plan, which then contracts with providers.

While it typically uses FFS reimbursement, Medicare Advantage costs Medicare more than traditional plans.

44
Q

What strategies were used in the 1990s for cost containment in healthcare?

A

Pressure was placed on providers to limit the number and costs of services.

Bundling services into one payment and shifting risk to providers was a common approach.

Traditional FFS was replaced by fee schedules and rate negotiations to contain costs.

45
Q

How are British healthcare providers reimbursed under the National Health Service?

A

Global budgets for overhead costs.

Capitation payments for general services (per member, per month).

Fee-for-service payments for specific prevention services.

This system shifts risk away from payers and toward physicians.

SAR HP 353 (2 decks)

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