Understanding Healthcare Systems Flashcards
the US has the most ____ health care system in the world: just over ___ of GDP
the US has the most expensive health care system in the world: just over 17% of GDP
explain the pressures that explain the rise in health care costs
- demographic pressures
- technological pressures
- overall rising cost of health care
describe the specific challenges for the US
- malpractice and defensive medicine
- some ineffective and inappropriate care
- higher prices and medical inflation
- administrative waste
- pressures of profit in medical care
describe the asymmetry of information
- consumers (patients) rely on suppliers (physiciand and other health care professionals) for expertise and recommendations
- providers depend on patients for necessary information to assist with diagnosis
give the breakdown of healthcare financing in the US
describe the breakdown of health care coverage
describe how an individual private insurance functions
- a third party payer “insures” health care services
- 2 financial transactions
- individual pays a premium (contribution) to a health insurance plan
- when the individual needs care, the insurer reimburses the provider of care
list the problems of private health insurance?
- large administrative overhead
- cost gets higher for people who become sick
- before 2010: those who apply for insurance and are at risk for illness can be turned down
describe how an employment-based private insurance functions
- employers pay part of the premium (contribution) to purchase health insurance for employees
- subsidized by the federal government through tax exemptions for employers ($260 billion in 2009)
list the positive aspects of employer-based insurance
- cost lower than individual insurance
- administrative cost high, but not as high as individual insurance
- people can obtain insurance as part of their employment benefit package
list the problems with employer-based insurance
- costs can rise steeply from year to year
- employer has no obligation to provide insurance
- the employer can require you to pay a greater % of the premium
define premium
the basic fees collected by the insurer on a monthly or an annual basis
describe a deductible
amount of money to be paid out-of-pocket before the insurer will begin to pay
define experience rating
- insurers differentiate premiums for individuals based on potential risk of getting risk
- insurer sets premiums differently for each group based on the “experience” of each group in using health services
- $200, $400 or $600/month
describe community rating
- insurer sets premiums based on the community of its subscribers
- $400/month for all
- health insurance principle of redistribution enhanced by this
name the 3 primary goals of the Affordable Care Act (ACA)
- 3 primary goals
- make affordable health insurance available to more people
- expand the Medicaid program to cover all adults with income below 138% of the federal poverty level
- support innovative medical care delivery methods designed to lower the costs of health care generally
describe government financing
- almost one-third of the US population is eligible for government health care programs
- federal, state and local employees
- Military and Veterans Administration
- government-financed public health insurance programs
government-financed health programs were developed as a way to ______
government-financed health programs were developed as a way to provide affordable care to those “shut out” of the commercial insurance market
- the elderly (Medicare)
- the disabled (Medicare)
- the poor (Medicaid)
- needy children (Medicaid)
describe Medicare Part A
- contributory social insurance program
- everyone with an income must contribute through social security taxes
- everyone who pays in is covered
- administered through Social Security
- employers and employees contribute 1.45% each of wages and salaries
- self-employed pay 2.9%
describe eligibility for Medicare Part A
- covers Americans 65 and over eligible for Social Security
- whether or not they are retired
- must have paid into SS for a minimum of 10 years
- covers spouse as well, once they turn 65
- covers Americans under 65 with permanent disability
- waiting period: after they have been receiving SS disability for 24 months
- exceptions to waiting period: chronic renal disease, ALS
- waiting period: after they have been receiving SS disability for 24 months
what does Medicare Part A not cover?
unskilled (custodial) nursing home care
describe Medicare B coverage
- all “medically necessary” services
- physician services
- physical, occupational, speech therapy
- medical equipment
- diagnostic testing
describe eligibiltiy for Medicare Part B
- eligibility
- people eligible for Medicare Part A
- plus payment of Medicare Part B premium
- financing
- monthly premiums $105 (with some variation)
- general revenues (federal taxes)
describe Medicare Part C
- since 2003, Medicare beneficiaries can enroll in private health plans through “Medicare Advantage”
- provides benefits under Parts A and B, and often Part D as well under managed care plan
- Medicare then subsidizes the plan premium rather than direct reimbursement to providers
describe Medicare Part D
- added partial prescription drug coverage
- contributions (monthly premiums plus yearly deductible)
- administered by private insurance plans; subsidies to enroll Medicare beneficiaries
describe the donut hole problem seen in Medicare Part D
- Medicare stopped paying for prescriptions once you reach your drug coverage limit
- until 2010, the initial drug coverage limit was $2380; once you reach that, you are in the donut hole and pay the full cost of prescription drugs until your total out-of-pocket cost reaches $4550
- with the ACA, once a patient reaches the donut hole, they are eligible for a 50% discount on the total cost of brand name while in the gap
describe SCHIP
State Children’s Health Program (SCHIP)
- providers coverage for kids in families with incomes at or below 200% of the federal poverty line
