unit 6

Question 1

causes of rising cost

Answer 1

1. high prices charged
2. high administrative costs (maintaining buildings and personal salaries)
3. defensive medicine
4. cost of technological advances
5. specialist overuse
6. waste and fraud
7. high price of drugs comparatively

Question 2

future causes of rising healthcare cost

Answer 2

• growth of aging population
  -declined health in youth
  -decrease in healthy lifestyles

Question 3

non-profit healthcare institutions

Answer 3

• healthcare for all
• operate as charities
• exempt from most tax
• pays SS and Medicare taxes

Question 4

proprietary (for profit) healthcare institutions

Answer 4

• same manner as for profit businesses
  -pay local, state, and federal taxes
  ex: community health systems, community Corp of America, tenet healthcare

Question 5

governmental healthcare institutions

Answer 5

-same manner as for profit businesses
-pays local, state and federal taxes
ex: Austin state hospital, Texas health resources
Baylor medical system

Question 6

historically paid for healthcare with

Answer 6

cash, vegetables, meat, firewood

Question 7

fee for service plan

Answer 7

-patient pays premiums
-physician determines actions taken
-insurance pays for services
**not cost effective

Question 8

direct pay payment methods

Answer 8

-pt. pays for costs out of pocket
-may use services more carefully
-catastrophic when costs exceed pt. ability to pay

Question 9

private insurance payment method

Answer 9

-individual/employer purchases insurance
-employee usually pays some costs
-many plans have varying coverage

Question 10

government plans payment methods

Answer 10

funded by govt. agency
ex:
-healthcare for military personnel and their families
-veterans administration hospital system
-medicaid
-medicare

Question 11

medicaid

Answer 11

-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

Question 12

medicaid eligibility

Answer 12

-low income
-children and their parents
-pregnant women
-disabled people
-elderly people needing things not covered by medicare

Question 13

income included in Medicaid for one

Answer 13

$16,970-$25,520

Question 14

income included in Medicaid for two

Answer 14

$22,929-$34,480

Question 15

income included in Medicaid for three

Answer 15

$28,887-$43,440

Question 16

income included in Medicaid for four

Answer 16

$34,846-$52,400

Question 17

medicare

Answer 17

-established 1965
-part of social security administration
-health insurance for people 65+
-charged monthly premium, deductible, and coinsurance

Question 18

Medicare coverage, A, B, C & D

Answer 18

Part A: hospitalization
Part B: Outpatient services
Part C: Medicare advantage plans
Part D: prescription drugs

Question 19

veterans health administration

Answer 19

-largest integrated U.S. healthcare system
-all vets meeting criteria (including service-related disability) entitled to VA healthcare

Question 20

what is managed care?

Answer 20

organizations negotiate with providers to form networks

Question 21

goals of managed care

Answer 21

-affordable healthcare
-high quality healthcare
-discourage unnecessary costs
-eliminate procedure duplication
-earn profit

Question 22

HMO

Answer 22

-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

Question 23

PPO

Answer 23

-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)

Question 24

EPO

Answer 24

-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

Question 25

POS

Answer 25

-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

Question 26

employer provided health insurance requirements

Answer 26

-continuous emplyment
-at least 20 hrs per week
-waiting period before eligibiity
-pre-existing conditions may be denied

Question 27

premium

Answer 27

monthly payed for health insurance

Question 28

copay

Answer 28

set amount payed for services/perscriptions

Question 29

deductible

Answer 29

minimum out of pocket cost for healthcare before insurance starts paying for it

Question 30

higher the deductible, cheaper the _______

Answer 30

premiums

Question 31

coinsurance

Answer 31

percentage of healthcare payed out of pocket after coinsurance is met

Question 32

medicare patient coinsurance

Answer 32

20%

Question 33

reimbursement

Answer 33

what Medicare/insurance pays healthcare provider

Question 34

managed care cost containment methods

Answer 34

PCP and review of services

Question 35

primary care provider

Answer 35

-control mechanism
-adds time and expense to receiving care
-consistent care

Question 36

review of services

Answer 36

-sees which costs will be covered
-requires preauthorization

Question 37

year and nicknames for affordable care act

Answer 37

2010, ACA or obamacare

Question 38

purpose of ACA

Answer 38

easier access to healthcare, more affordable for everyone

Question 39

ACA benefits

Answer 39

-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

Question 40

since 2010, at least ________ more Americans have health insurance

Answer 40

20 million

Question 41

numbers assigned to diseases and conditions

Answer 41

international classification of diseases (ICD-10 codes)

Question 42

used to document and report all kinds of service

Answer 42

current procedural terminology (CPT code)