Textbook Chapter 16 - Private Insurance Flashcards
the last half of the ___ century witnesses dramatic changes in the way healthcare is financed
20th
health insurance has provided financial security and improved ACCESS to care for millions of americans, but what else has it done?
ensured payment for healthcare providers and fueled the growth of hospitals and the development of new health services
______ are a major cause of personal bankruptcies in the US
catastrophic medical bills
what groups mostly compromise the uninsured in america?
NOT the traditionally considered uninsured (poor, disabled, elderly – they’re cov under medicare/caid)
-largest group = the working poor (working low paying jobs that do not offer health insurance or the premiums are unaffordable)
-foreign born US residents
are there other barriers to health insurance besides cost and insurance?
yes – health education, transportation, organizational barriers, long wait times, home environments, employment conflicts, etc
health insurance ensures payment for healthcare providers, yet it….
restricts provider reimbursement
health insurance creates patient access to healthcare services by reducing financial barriers, yet it…
restricts utilization of the services
at the begininngs of health insurance, most insurance plans were really ___ insurance
disability
explain what “disability insurance” was when it first started
they did not cover health expenses – protected individuals from the loss of income resulting from illness
in 1929, _______ offered hospital care to a group of dallas teachers on a prepaid basis (premiums of $6 per year). restricted care to a particular hospital
baylor university hospital
who built on the idea of baylor university hospital but allowed FREE CHOICE of hospitals
blue cross hospital insurance plans
explain how reimbursement worked in the beginnings of blue cross hospital insurance
free choice of hospitals
pt would pay full bill and then the insurance would reimburse them for 80% of the bill (up to 21 days of hospital expenses)
at the same time blue cross was being created _____ was being created.
explain
blue shield in LA, california
this plan created insurance for physician services as well as orgnazing physicians into a grouop practice (became a model for HMOs in the future)
what is an indemnity plan
this was what health insurance started as
insurances reimbursed the BENEFICIARY rather than the physician
what were the problems with indemnity plans
patients found it inconvenient to collect receipts and complete claim forms — these thousands of claims were also expensive for the insurance to process
early health care programs such as Blue Cross and Blue Shield were controlled by whom?
what can you infer about this
hospitals and physicians
thus, their primary interest was to protect PROVIDERS and not patients from financial loss
previously, most health insurance plans paid on a ____ basis.
what is the problem with this
fee for service
issue is that it offered little to no financial incentive to control utilization, reduce costs, or to enhance the quality of care
as health care costs increased rapidly in the 70s, what did employer groups that paid for health insurance demand?
that the health insurance programs control costs and change their governing bodies to REDUCE THE EXTENT OF PROVIDER CONTROL
What was the 1st program to focus primarily on payment of prescription drug expenses?
Green Shield (in canada)
____ ____ became the major catalyst during the growth of prepaid prescription plans
labor unions
explain how cost sharing can be extremelely effective
should be high enough so as to discourage patients from using unnecessary services and driving up the costs, but should not be so high that pts are discouraged from using actual needed services
“underwriting”
the process of insuring someones
actuarial analysis
estimating the amount of risk assumed by an insurance company
an actuary estimates what 3 expenses
-cost for each type of service
-projected number of services that the group will receive as a whole
-the administrative expenses
