test review Flashcards
12 hours
how many people were uninsured in 2010?2016?
almost 50 million people were uninsured in 2010, and then in 2016 after the passage of the ACA the number decreased to 28.1 million people
what has happened to the cost of healthcare in this country? GDP?
Health spending in the US is increasing: 2010: 17.4% and 2016: 17.9%…Total amounted to $2.6 trillion in 2010 – $3.3 trillion in 2016.
what is the per capital basis?
in 2010: $8,412 in 2016: $10,348
how many people does the healthcare system kill every year?
250,000 people
where is the health care dollar being spent?
physicians and hospitals (52%), important in healthcare policy development
why does health care cost so much?
because we have an increase in elderly people with multiple chronic medical conditions and so this drives healthcare costs, 15 of most expensive conditions account for 44% of spending
who pays the bill?
Private insurers & medicare/medicaid (mostly),tricare, employers, individuals
describe the uninsured and the impact of not being insured?
whites account for the highest uninsured individuals with hispanics and blacks more likely to be uninsured, more likely to be single/unmarried, lack of an education (no high school diploma), adults ages 19-64 of working age
Less likely to get preventative care
More likely to postpone care
Will go to the ER for care- high volumes of patients, long waits, expensive
Less likely to fill RX or get follow up/recommended care
Avoidable mortality
Generally they are in poorer health than the general population
what is medicare part A?
also known as the Hospital Insurance (HI) program, covers inpatient hospital, skilled nursing facility, some home health visits, and hospice care. Part A is funded by a tax of 2.9 percent of earnings paid by employers and workers (1.45 percent each), along with an additional 0.9 percent paid by higher-income taxpayers (wages above $200,000/individual and $250,000/couple). An estimated 55 million people are enrolled in Part A in 2015.
what is medicare part B?
the Supplementary Medical Insurance (SMI) program, helps pay for physician, outpatient, some home health, and preventive services. Part B is funded by general revenues and beneficiary premiums. Beneficiaries who have higher annual incomes (more than $85,000/single person, $170,000/married couple) pay a higher, income-related monthly Part B premium; the Affordable Care Act (ACA) froze the income thresholds at 2010 levels from 2011 through 2019. An estimated 51 million people are enrolled in Part B in 2015.
what is medicare part C?
also known as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), as an alternative to traditional Medicare. These plans receive payments from Medicare to provide all Medicare-covered benefits, including hospital and physician services, and in most cases, prescription drug benefits. In 2014, 15.7 million beneficiaries were enrolled in Medicare Advantage plans.
what is medicare part D?
Provides drug coverage if the beneficiary joins a Medicare Prescription Drug Plan that are available through private companies.
what are services not covered by Part A and Part B?
Most dental care; Eye exams related to prescribing glasses; Dentures; Cosmetic surgery; Acupuncture; Hearing aids and exams for fitting them
what are the ways managed care manages care?
Selection of providers based on quality, cost, location and services; Focus on population health; Use of care management tools; Quality assessment; Cost controls
what are the types of MCO’s?
Health Maintenance Organizations (HMO);
Exclusive Provider Organizations (EPO);
Point-of-Service Plans (POS);
Preferred Provider Organizations (PPO)
what are the major payment methodologies?
capitation, global payment, fee-for service, and episodic payments
define patient-centered medical homes (PMCH)?
refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care” -IOM
what are the seven core components of PCMH?
1) personal physician
2) physician directed medical practice
3) whole person orientation
4) coordinated/integrated care
5) focus on quality and safety
6) increased access
7) payment reform
how the seven core components of PCMH address the six domains of healthcare quality?
A growing body of scientific evidence shows that PCMHs are saving money by reducing hospital and emergency department visits, mitigating health disparities, and improving patient outcomes. The evidence we present here outlines how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities; in addition the five year cohort study in terms of quality measures indicated PCMH showed modest improvements in two areas compared to control group
define personal physician of the seven core components of PCMH
Patients value relationships, continuous care= better outcomes +lower cost
define physician directed medical practice of the seven core components of PCMH
Physicians organizes and clarifies each team members role
define whole person orientation of the seven core components of PCMH
Care for all stages of life. Body, mind, spirit cultural approach
define coordinated/integrated care of the seven core components of PCMH
coordinated care across all healthcare settings and efficient transfer of info= better outcomes
define the focus on quality and safety of the seven core components of PCMH
evidence based medicine, performance measuring tools
define increased access of the seven core components of PCMH?
expanded hours, patient access to electronic records
define payment reform of the seven core components of PCMH
PCMH more primary care visits and fewer specialists visits
Fewer diagnostic tests
what is value based insurance design (VBID)?
the lowering or elimination of financial barriers to the purchase of high value drugs or services in the hope of raising compliance and avoiding more expensive future medical cost, such as hospitalization
what are the goals of VBID?
achieve cost savings, maximize clinical benefits
what is the potential impact on providers?
high value services provided by high cost providers will likely be considered low value, so a physician charging $5,000 colonoscopy vs $1,500. Likewise, physicians providing low value services will struggle and so there is a need to keep up to date
what are the six dimensions of health care quality?
safe effective patient-centered timely efficient equitable
define safe
avoiding harm to patients from the care that is intended to help them
define effective
providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively)
define patient-centered
providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
define timely
reducing waits and sometimes harmful delays for both those who receive and those who give care
define efficient
avoiding waste, including waste of equipment, supplies, ideas and energy
define equitable
providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status
describe the strategies to expand coverage, of them which one was not fully implemented and the one that has been modified? what were these the expansion strategies of?
- insurance coverage must be provided to certain classes of individuals often not able to afford coverage (2 parts)
- individuals must have coverage (individual mandate or pay a fine)
- employers with more than 50 employees must provide affordable coverage (full-time)
- health benefit exchanges/marketplaces
- medicaid expansion
of these:
the individual mandate was modified
medicaid expansion was not fully implemented
; the first phase of the ACA
what is policy?
- can be formal or informal
- can be separated from the law
- intended and unintended consequences
- value-driven
- not always separated from one another
or
Whatever governments choose to do or not to do
Regulate behavior Distribute benefits Extract taxes Engage in conflicts Reward members of society
(Dye, 2017)
what are the key characteristics for successful policy development?
- Accessibility (for all)
- Cost (lower the better)
- Quality (higher the better)
- Desired Outcome = Improved health status
- Looking to provide value, cost matched quality of care
*stemmed from Magee and Lombergd
what are the primary objectives of a health system?
- improve health of a population
- respond to expectations like providing adequate care and information systems
- provide financial protection against costs of ill health
Describe the first phase of reform and why it is important?
the “Coverage Agenda” and important because it provided coverage to the people who want and need it
briefly describe each of the strategies that the ACA covered, remember the 5 strategies, the first having two
1) Insurance coverage must be provided to certain classes of individuals
a) Adult dependant Coverage until
b) Pre-existing conditions can’t affect if you receive coverage.
2) individual mandate - effective January 1, 2014 that required individuals not covered by a government or employer to obtain acceptable health coverage or pay a fine, but this was modified in 2019 removing the penalty fee
3) employer mandate - employers with 50 or more full time employees must offer insurance, who must work at 30 hours/week, and must provide minimum coverage (60% actuarial value)
4)exchange/marketplace - like the expedia/kayak for healthcare and look at different plans and the difference being the percent of costs covered by the plan: Bronze (60%) Silver (70%) Gold (80%) Platinum (90%)
5)medicaid expansion - All newly eligible adults, up to 138% of poverty level guaranteed a benchmark benefit package that meets the essential health benefits available through the exchanges. It became a problem because this was seen as coercion of the federal government on the states
how does health insurance work?
utilization of premiums, deductibles, coinsurance,co-payments, maximum out of pocket costs the patient pays in collaboration with health insurance company.
example annual premium $20,603 (87% paid by VCOM) annual deductible $300/individual and $600 per family maximum out of pocket $1,500/individual and $3,000 per family primary care visit $25 co-pay emergency room $150 co-pay plus 20%
what are the issues with traditional insurance?
fee for service reimbursement
healthy people do not to buy health insurance
Insurance co-payments, co-insurance, and deductibles are regressive meaning that they can limit access to care for those at lower income levels
There is no relationship between payments and clinical effectiveness
50% of individuals covered by employer
Insurance does not follow the individual so changes in employment status can create gaps in coverage
what are the forms of cost sharing?
medicare, medicaid, private health insurance, out-of-pocket
what impacts health?
behaviors 30-50% social circumstances 15-40% environment 5-20% genetics 20-30% medical care 10-20%
economics environment education culture political instability individual lifestyle access to the healthcare system
everything!
what are problems with most cost sharing programs?
They do not discriminate between services based on their clinical value
Cost sharing is regressive – same deductible for people of different incomes
how cost sharing should ideally work?
Cost sharing through higher co-payments would discourage low value care
Absence of co-payments would encourage use of high value care
why is good policy hard to do?
politicians want votes, They do not want to stick their necks out for a good cause that may conflict with their careers; also someone or some group has to suffer large economic losses and our political process cannot force anyone to shoulder this burden
what are the key federal government insurance programs discussed in class?
Centers for Medicare & Medicaid Services (CMS)- operates medicaid and medicare, largely responsible for implementing the ACA
Health Resources and Services Administration (HRSA)- preserving access to essential health services for poor, uninsured, rural, medically isolated and socioeconomically depressed pop
Centers for Disease Control and Prevention (CDC)- to protect public health and safety
all within the United States Department of Health and Human Services (DHHS)
who is credited for the implementation of Health Reform - Two Phases
Donald Berwick
• Identify the insurance options that might be best for a defined individual?
medicare, medicaid, the five coverage expansion strategies
in terms of politics, what is authoritative?
implies that the individuals must obey or should obey and that the authority can compel individuals to obey or be punished
in terms of politics, what is allocation?
limited resources are directed from one use to another use
in terms of politics, what is value?
“distributing goods and services that are held in favor by the public”
define Health Maintenance Organization (HMO)?
1) providers are salaried
2) negotiated rates with purchasers of health care
3) coordinate and control services provided
4) use only their network of providers
5) established quality standards
define exclusive provider organizations (EPO)?
same like HMO except that there is no out of network options, the main difference from the HMO. If you go out of network, no payment will be made for services
define Point of Service Plans (POS)?
1) have a provider network that receives capitated payments or other methodology that puts providers at risk
2) requires patients to have a gatekeeper to control access
3) patients can go out of network but pay more as providers paid fee for service
define Preferred Provider Organization?
1) provide a network of providers
2) does not limit where the patients can go, but covers higher percent of bill for going to in network providers
3) providers accept discounted feed
4) patients pay more for choice
in terms of payment methodologies, define capitation
a fixed fee per member per month
in terms of payment methodologies, define global payment
one payment for all services provided to a defined population
in terms of payment methodologies, define episodic payments
All episodes of care are paid the same regardless of complexity or costs
in terms of payment methodologies, define fee for service
a set fee per unit of service - charges
what are the three big issues in health care? how big are they?
cost, access, quality; with respect to a steady increase in health care costs from 2010 to 2016 (per capita basis, GDP, increasing national debt) we can see how these big issues play an important role in being addressed;
what are the factors that limit access to healthcare?
accessibility
affordability
availability
acceptability
what drives overall healthcare costs?
number of beneficiaries health of beneficiaries services per beneficiary cost per unit of services quality of the service
What are the Health System Building blocks according to WHO?
health services delivery health workforce health information health medicines health financing leadership and governance
