Week 10; Systems and Finance Flashcards
Health Care Funding From:
Private Insurance, government Insurance, people pay themselves – out of pocket
Private Insurance
Purchased from for profit and not-for-profit insurance companies; examples include: Blue Cross, Blue shield, HMO’s such as Kaiser. Most private insurance is purchased by employers for their
employees, costs shared by employer and employee
What is an HMO?
Health maintenance organization; a type of health insurance plan that limits coverage to care from doctors who work for or contract with the HMO. Generally won’t cover out-of-network care except in an emergency. May require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
What is a PPO?
Preferred provide organization, most popular type of insurance. Allows you to visit whatever in-network provider without requiring a referral from pcp, freedom to choose
What is a CCO?
Coordinated Care Organization, a network of all types of health care providers (physical health care, addictions and mental health care and dental care providers) who work together in their local communities to serve
people who receive health care coverage under the Oregon Health Plan (Medicaid). CCOs focus on prevention and helping people manage chronic conditions, like diabetes. This helps reduce unnecessary
emergency room visits and gives people support to be healthy.
Patient protection and Affordable Care act (2010)
Also known as Obamacare. Health care reform to increase availability, affordability, and use of health
insurance.
Medicare –
Funds for elderly, the disabled, and people receiving
long-term dialysis from government
Medicaid –
funds health care for people living below poverty
level and/or have disabilities through government
CHIP –
Children’s Health insurance plan – coverage through
Medicaid and separate Federal chip program. Low to modest incomes. Provides no-cost or low-cost health coverage for eligible children in Oregon. These programs provide health coverage for children
so that they can get routine check-ups, immunizations and dental care to keep them healthy, even if a child has been turned down in the past or parents don’t know if they qualify, a child may be able to get health coverage.
Tricare
Covers approximately 9 million active duty and retired military personnel and their families. TRICARE is the worldwide health care program for uniformed service
members and their eligible family members
Medicare Part A –
hospital insurance
Medicare Part B –
medical insurance
Medicare Part C–
now called medicare advantage plan, cover A and B and most offer drug plan AND vision and/or dental
Medicare Part D –
prescription drug plan; Medicare Supplemental or Medigap plan – extra health insurance to pay some or all of the 20% of bills that medicare doesn’t cover
Supplemental security income (SSI)
Federal income supplement program funded by general tax revenues not social security taxes. Designed to help aged, blind, disabled people who have little or
no income. Provides cash to meet basic needs for ford, clothing, and shelter.
Social Security Disability (SSDI)
Federal funds to help people with disabilities. Available to workers who have accumulated a sufficient number
of work credits. Differs from SSI is available to low-income individuals or those who have never worked.
Veterans Health Administration
Government operated health care system comprehensive health care to eligible veterans
According to many, there are two primary causes for such high healthcare costs:
US health Care model, changes spur demand and raised
costs.
Chronic diseases: diabetes and heart disease – responsible for 85% of costs
Limiting Access
Insurance companies have refused to cover people with pre-existing conditions. Stopped coverage for high end users. Denied certain procedures, medications. Limited number of visits that are reimbursed. Increased deductibles and copays. Insurance only covers partial payment for procedures or large copay for inpatient or surgery.
Negative Effects
People will avoid getting healthcare including preventative care, i.e. flu vaccines. Women may avoid screening tests. Then if cancer develops, it may be advanced by the time they go to a physician. Complex or complicate procedures such as referrals and prior authorizations limiting access to care.
Eliminating Unnecessary Care
Defined as care that does not improve health. Difficult to recognize and to eliminate. Various organizations develop guidelines. Different organizations have different guidelines. Estimated that 1/3 of health care costs occurred in the last year of life. Palliative and hospice may not be covered.
Improving Health
Increasing use of inexpensive services that help prevent
disease may reduce need for more expensive services. For example, early mammography may identify early breast CA and avoid need for more expensive procedure such as a radical mastectomy. Other areas often identified are colon cancer, obesity and/or diabetic management, smoking campaigns, BP management, Increase number of PCPs who can provide screening, eliminate co-payments for preventive services, financial incentives to providers for following preventive care
guidelines, use of RN Care managers or RN Case Managers, use of Health Coaches, reimbursing GYM memberships.
Decreasing reimbursement for Care used
Lower fees, insurance companies and the government may negotiate lower fees with hospitals or they simply dictate set fees. In the US, medicare and Medicaid determine reimbursement rates. These tend to influence other plans. Providers may be reimbursed less.
Increased use of primary care
Decreased use of inpatient by increasing use of primary care. More procedures done on outpatient basis. Encouraging med students to choose primary care. Government may provide more funding for primary care training than specialty training. Primary care made more “attractive” – unclear how this will be done. Use of Patient-Centered medical home.
