Week 1 Flashcards
Triple Aim
optimize health system performance by 1. improve pt experience of care 2. improve health of populations 3. reduce cost of health care Simplified as: Cost, Access, Quality
Two different arrangements for birth of modern American insurance
baylor hospital partnership-blue cross
kaiser permanente
employer sponsored insurance- fully insured:
employer buys ins from private company, ins company assumes financial risk. profit goes to ins company
employer sponsored insurance- self insured
employer contracts w/ private company and acts as payer and assumes risk. profit goes to employer
COBRA
allows ppl to retain employer ins for up to 18-36 months following loss of coverage
types of public insurance
medicare medicaid state children's health insurance program (S-CHIP & CHIP) indian health services veterans health administration tricare
non-hospital inpatient facilities
skilled nursing facilities (nursing homes)
long term acute care hospitals (LTACHS)
inpatient rehab facilities
what are nursing homes used for
pts who need 24 hour care
what are LTACHS used for
pts who need intensive, hospital-level care for weeks or months
what are inpatient rehab facilities used for
pts who require rehabilitation, but may not be medically complex
define certificate of need (CON)
requires that new facilities need to show there is a need for services before approval
three major accreditation agencies in US
- national committee for quality assurance (NCQA)
- the joint commission for the accreditation of healthcare organizations (Joint Commission)
- Utilization review accreditation commission (URAC)
what year did medicare and medicaid pass?
1965
what was the health maintenance organization act?
req employers with over 25 employees and offering health insurance to include at least one HMO-type plan
what did the mental health parity act do?
expanded psychiatric benefits
what was the Health Insurance Portability and Accountability Act
protection of health info
what was the Medicare Prescription Drug, Improvement, and Modernization Act
created prescription drug coverage through Medicare Part D
what was the State Children’s Health Insurance Program
Expansion of Medicaid to low-income children
what year was the affordable care act implemented?
2010
define a policy
specifies what risks are covered
define coverage
risks covered and money paid for losses
what is the term used to describe the person who purchases the insurance policy?
subscriber
term for other individuals on insurance policy?
dependents
what are the two ways that premiums are set?
community rating: all subscribers pay the same monthly premium
underwriting: subscribers charged differently depending on medical care required and personal factors
what is cost sharing?
remaining amount the member pays after insurance pays health care provider/facility
what factors make-up cost sharing?
the sum of these factors determines what?
deductible
copayment
coinsurance
out of pocket max
which source of insurance is the most common type?
employer sponsored insurance
COBRA allows someone to stay on insurance for up to 18 months if:
coverage lost due to termination or reduced hours
COBRA allows someone to stay on insurance for up to 36 months if:
spouses or dependents who lose coverage due to separation or employee’s death
