unit 6 Flashcards
causes of rising cost
- high prices charged
- high administrative costs (maintaining buildings and personal salaries)
- defensive medicine
- cost of technological advances
- specialist overuse
- waste and fraud
- high price of drugs comparatively
future causes of rising healthcare cost
- growth of aging population
-declined health in youth
-decrease in healthy lifestyles
non-profit healthcare institutions
- healthcare for all
- operate as charities
- exempt from most tax
- pays SS and Medicare taxes
proprietary (for profit) healthcare institutions
- same manner as for profit businesses
-pay local, state, and federal taxes
ex: community health systems, community Corp of America, tenet healthcare
governmental healthcare institutions
-same manner as for profit businesses
-pays local, state and federal taxes
ex: Austin state hospital, Texas health resources
Baylor medical system
historically paid for healthcare with
cash, vegetables, meat, firewood
fee for service plan
-patient pays premiums
-physician determines actions taken
-insurance pays for services
**not cost effective
direct pay payment methods
-pt. pays for costs out of pocket
-may use services more carefully
-catastrophic when costs exceed pt. ability to pay
private insurance payment method
-individual/employer purchases insurance
-employee usually pays some costs
-many plans have varying coverage
government plans payment methods
funded by govt. agency
ex:
-healthcare for military personnel and their families
-veterans administration hospital system
-medicaid
-medicare
medicaid
-20% of US healthcare spending
-reg and partly govt funded
-coverage by private managed care plans in contract with state
-large portion of nursing home expenses
medicaid eligibility
-low income
-children and their parents
-pregnant women
-disabled people
-elderly people needing things not covered by medicare
income included in Medicaid for one
$16,970-$25,520
income included in Medicaid for two
$22,929-$34,480
income included in Medicaid for three
$28,887-$43,440
income included in Medicaid for four
$34,846-$52,400
medicare
-established 1965
-part of social security administration
-health insurance for people 65+
-charged monthly premium, deductible, and coinsurance
Medicare coverage, A, B, C & D
Part A: hospitalization
Part B: Outpatient services
Part C: Medicare advantage plans
Part D: prescription drugs
veterans health administration
-largest integrated U.S. healthcare system
-all vets meeting criteria (including service-related disability) entitled to VA healthcare
what is managed care?
organizations negotiate with providers to form networks
goals of managed care
-affordable healthcare
-high quality healthcare
-discourage unnecessary costs
-eliminate procedure duplication
-earn profit
HMO
-must stay in network
-must have PCP
-must have referral to see specialist
-out of pocket expenses set (low copay)
-must submit requests for special care
PPO
-not required to stay in network
-PCP not required
-no referral necessary
-more expensive
-more provider choice
-can visit providers outside of preferred list (more expensive)
EPO
-exclusive provider network
-HMO/PPO hybrid
-only in network services/ hospitals covered EXCEPT in emergency
-no referral needed to see specialist
-employers can tailor to employee needs
POS
-point of service plan
-HMO/PPO hybrid
-PCP required
-referral required for specialist
-Out of network allowed for increased cost
-10% of Americans have this coverage
employer provided health insurance requirements
-continuous emplyment
-at least 20 hrs per week
-waiting period before eligibiity
-pre-existing conditions may be denied
premium
monthly payed for health insurance
copay
set amount payed for services/perscriptions
deductible
minimum out of pocket cost for healthcare before insurance starts paying for it
higher the deductible, cheaper the _______
premiums
coinsurance
percentage of healthcare payed out of pocket after coinsurance is met
medicare patient coinsurance
20%
reimbursement
what Medicare/insurance pays healthcare provider
managed care cost containment methods
PCP and review of services
primary care provider
-control mechanism
-adds time and expense to receiving care
-consistent care
review of services
-sees which costs will be covered
-requires preauthorization
year and nicknames for affordable care act
2010, ACA or obamacare
purpose of ACA
easier access to healthcare, more affordable for everyone
ACA benefits
-can’t deny preexisting conditions
-businesses with less than 50 employees receive 50% tax credits to provide insurance
-everyone must buy health insurance
-insurer can’t cancel coverage when someone gets ill
-better senior and disabled drug coverage
-can stay on parents healthcare until 27
-websites made accessing ACA coverage easier
since 2010, at least ________ more Americans have health insurance
20 million
numbers assigned to diseases and conditions
international classification of diseases (ICD-10 codes)
used to document and report all kinds of service
current procedural terminology (CPT code)
