Topic 8 - Health Care in the U.S

Question 1

Explain HMOs

Answer 1

• paid doctors on salary rather than fee for service insurance system
• “gatekeeper” doctors to prevent unnecessary use of specialists
• emphasis on prevention
• affordable health care

Question 2

Explain the difference between medicare and medicaid

Answer 2

Medicare: for people > 65 and disabled
Medicaid: disadvantaged individuals and funded by both the state and the federal government

Question 3

Name the crises in health care

Answer 3

1. Rising cost
2. Access to care
3. Quality of care
4. Errors

Question 4

Describe the Flexner Report.

Answer 4

• highlights inadequate requirements and poor facilities in medical schools
  -subsequent legislation resulted in closing many medical schools

Question 5

Explain the fee-for-service model.

Answer 5

prior to 1930, people used to be able to pay out of pocket for care - costs were as not prohibitive as they are today

Question 6

What was the Social Security Act of 1965?

Answer 6

• Medicare and Medicaid was created
• federal program-funded from social security taxes

Question 7

How were Diagnostic Related Groups established?

Answer 7

• increasing costsled the federal gov. to implement this managed care system and because of over-treatments

Question 8

What is Managed Care?

Answer 8

• refers to any system that controls costs through closely monitoring and controlling the decisions of health care providers

Question 9

Explain the 1983 Diagnostic Related Groups (DRG).

Answer 9

• limits the amount of reimbursement funds for Medicare and Medicaid patients
• logic changed now physicians and hospitals are rewarded for under treatment - increase revenues by restricting care
• shift from inpatient to outpatient surgery

Question 10

What are some key aspects of the Affordable Care Act?

Answer 10

• goal to provide health insurance for 32 mil. uninsured Americans
• individual madate
• employer madate
• limits on deductibles and copayments

Question 11

What was Blue Cross Blue Shield designed for?

Answer 11

• protect doctors and hospitals
• fee-for-service insurance
• community rating: each person charged based on average risk of entire community

Question 12

Explain actuarial risk rating

Answer 12

• insurers maximize their profits by ding whatever they can to avoid signing up individuals who are at high risk
• individual premimum bsed on individual risk

Question 13

Explain the state children’s health insurance program

Answer 13

• extended converage for children under 18 through Medicaid