Week 9 highlights Flashcards
Primary care: first contact providers of care who handle most common problems and are critical to the delivery of clinical ________________ services
preventative
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They are the foundation of a healthcare system
“medical home” = primary care is a team effort
patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
What are the core values that all individuals employed in caring industries are expected to incorporate in the way that they care for their patients?
Six C’s of Care
How Much Money Does the United States Spend on Health Care?
2) How much do other developed countries spend?
1) $4.9 trillion yearly, 17.6% GDP which = $14,570/person/yr (2023)
2) half as much per person and 10-11% of GDP yearly
Who pays the bill for healthcare?
1) Insurance coverage
2) Out-of-pocket expenses
-(Deductible, copays, and coinsurance)
What happened to federal govt spending after COVID (2021)?
Went down by 3.5%
Important insurance terms:
1) Define cap
2) Define copayment
3) Define coinsurance
1) A limit on the total amount that the insurance will pay for a service per year/benefit period/lifetime
2) An amount that the insured is responsible for paying even when the service is covered by insurance
3) The percentage of the charges that the insured is responsible for paying after hitting their deductible
Important insurance terms:
1) Define covered services
2) What do customary, prevailing, and reasonable mean?
1) Covered services: a service for which health insurance will provide payment or coverage if the individual is eligible
2) Standards used in the past by many insurance plans to determine the amount that would be paid to the provider of services
Important insurance terms; define each:
1) Deductible
2) Eligible
3) Out of pocket expenses
1) The amount that an individual or family is responsible for paying before being eligible for insurance coverage
2) An individual may need to meet certain criteria to be able to enroll in a health insurance plan
3) Cost of healthcare not covered by insurance; the responsibility of the insured (includes deductibles, copayments/coinsurance)
Important insurance terms:
1) Define medical loss ratio and give an example
2) Define portability
3) Define premium
1) The ratio of benefit payments paid to premiums collected indicating the proportion of the premiums spent on health services by insurers
-Ex: A ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses
2) The ability to continue employer-based health insurance after leaving a job- usually by paying the full cost of the insurance (COBRA ensures 18mos)
3) The price paid by the purchaser of the insurance policy on a monthly or yearly basis
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Federal government program started in 1965
Funded by a payroll tax of 1.45% from employees and 1.45% from employers
65 and older, expanded to include disabled persons eligible for Social Security disability benefits and those with end stage renal disease
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More recent changes…
Drugs partially covered by Part D.
Preventative services have expanded.
Skilled nursing or rehab care is covered (NOT nursing home or custodial care).
Hearing aids and eyeglasses are not covered by Medicare
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65.7 million enrolled
Providers paid on a fee-for-service basis
List the four parts of medicare
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1) No premium but annual deductible required
2) Voluntary supplemental insurance that covers a wide range of diagnostic and therapeutic services
25% funded by a monthly premium
20% copayments for most services
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Medigap policies- offered by private insurance companies to cover all or most of the 20% copayment
$257 deductible for 2025 (minimum based on yearly income)
Part C of Medicare is what?
Medicare advantage
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“Donut hole” – most Medicare drug plans have a coverage gap which is a temporary limit on what the drug plan will cover for drugs – eliminated 1/1/25
Now, $2,000 out of pocket limit for rx drugs
Medicaid:
1) It’s a ________ and ________ level program designed to pay for health services for specific categories or low-income people and other designated categories of individuals.
2) It is the _______ federal health insurance system (*As of Oct 2024, _____ million enrolled)
3) Does it directly provide healthcare?
1) federal and state
2) largest; 72 million
3) No
4) $584.4 billion (2024)
Medicaid Basic Health Program (optional):
States can provide coverage to individuals who:
1) Are _________ and _______ the age of 64.
1) citizens; under
Do not qualify for Medicaid, Child Health Insurance Program (CHIP), or other min. essential coverage
Income up to 185% of the FPL
Federal poverty level (FPL) for a family of 4 is ~$32,150 (2025)
Child Health Insurance Program (CHIP)
1)Provide free health coverage for pregnant women and children who do not have insurance and do not qualify for TennCare (TN’s Medicaid program)
2) What is this called in TN?
3) Kids can get coverage if they are US citizens or what?
1)
2) CoverKids
3) Qualified non-citizens.
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Big issues regarding Medicaid Access:
Reimbursement rates to clinicians are often comparatively low
Many clinicians will choose not to participate
The largest single category of insurance coverage in the US is what?
Employment based health insurance
Employment based healthcare grew in the 50s and 60s based on _____________ rating (cost of insurance was the same regardless of the health status of a particular group of employees)
community
Community rating was replaced by experience rating (employers and employees pay based on their groups’ use of services in previous years)
Until the 90s, provided payments to clinicians and hospitals based on ______________ payments (charges paid for specific services provided)
fee-for-service
1) Are Health Maintenance Organizations (HMOs) free? Explain
2) What are they based on? Define this term
3) What is there the potential for to save costs here?
1) Monthly fee to cover a comprehensive package of services
2) Capacitation: fixed number of dollars per month to provide services to an enrolled member regardless of the number of services provided
3) Underuse of services
slide 23In the 90s
Health Insurance Exchanges: What is the goal of creating a competitive marketplace?
Help increase access and control the cost of health insurance
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Until 2010, 15% of all Americans were uninsured and 7.5% considered underinsured
Uninsured: 9.5% (2023)
The uninsured include:
1) _________, ___________ individuals who choose not to purchase insurance
2) Low-income or near low-income individuals who ___________ qualify for Medicaid
1) Healthy, young
2) do not
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ACA attempted to address the needs of the uninsured
Young individuals can stay on their parent’s insurance plan until age 26
States provided with option to expand eligibility for Medicaid
Health insurance exchanges
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Under the ACA, all individuals are required to purchase health insurance or pay a substantial state-determined fine
List a 3 important Consequences of Lack of Adequate Health Insurance
1) More likely to use the ED [for preventative care]
2) Increased mortality rate
3) Large debts
Define underinsured
out-of-pocket healthcare costs eat up 10% or more of your household income or your deductible equals 5% or more of your income.
What are essential health benefits?
Examples:
Ambulatory patient services (outpt)
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance use disorder services including behavioral health treatment
Prescription drugs
Rehab and habilitative services and devices
Lab services
Preventative and wellness services and chronic disease management
Pediatric services, including oral and vision care
Federal and state programs for those who are injured on the job or have a disabling condition:
Worker’s Compensation
Federal Programs for Workers
Title of slide 31
US healthcare Cost approximately _____% of GDP
______________- mix of federal, state, employer, and self-pay
17.6%; complicated
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Insurance Admin costs:
High: 25%–30% of total costs, including administrative costs of health insurance, clinicians, and institutions, but this does not include administrative time spent by patients and their families
Reimbursement is a Mix of ___________, ______________, and ___________ with incentives are the most commonly used methods
fee-for-service, capitation, and salary
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Delivery of care:
1) There is a mix of practice types, but _______________ is dominant
2) Physicians (MDs/DOs) make up ______ of primary care and __________ of specialists
Mix of practice types with private practice dominant
2) 1/3 primary care, 2/3 specialists
Primary care increasingly based upon nurse practitioners and Physician Assistants
Hospitalists increasingly coordinate inpatient care
Need for better continuity of care between institutions and between clinicians.
Comprehensiveness of insurance:
1) ____________ with ______________ offered through employment-based insurance and through health insurance exchanges, as well as Medicaid/Medicare
1) Health insurance with cost sharing
2) Under the ACA, preventive services increased, insurance required coverage of approved preventive services and no copayments.
Generally, insurance plans require coverage of Essential Health Benefits.
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Patient choice:
1) Considerable choice of _____ care and often direct access to _________ care
1) primary; specialty
Greatly increased access for those with comprehensive insurance with high levels of provider reimbursement
Cost and cost containment:
Emphasis on competition as means of controlling costs
Cost-sharing by patients
Canada
Financing:
National policy to keep expenditures close to 10% of GDP
Combination of provincial and federal
70% government payment through taxes
30% private insurance payments by individuals
Administrative costs:
Low: approximately 15% or less of total costs
39 canada
Government insurance for basic health services
Negotiated fee-for-service reimbursement with single payer for basic
39 canada
: 1/2 primary care, 1/2 specialists
Primary care docs admit to hospitals
May have Limited access to high-tech procedures
Canada 40
canada 40
Canada 41
UK admin costs are ______ than Canada, _________ than United States
more; less
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Comprehensiveness of insurance:
National Health Service comprehensive with little cost sharing, plus may cover transportation costs
Incentives to provide preventive services and home care
Cost and cost containment:
“Global budgeting” – an overall limit on national spending
Negotiated rates of capitation and salary with government as single payer with National Health Service having considerable negotiating power
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National Health Service provides limited choice of general practitioners
Waiting lines for services, especially specialists and high-tech procedures
Referral to specialists generally needed
Greater choice with private insurance
1) What country relies most heavily on market justice?
2) Which places more emphasis on social justice?
3) Which is somewhere in-between?
1) United States
2) UK
3) Canada
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Spends more per person and as a percentage of GDP
Has a higher percentage of uninsured
System is more complex for patients and providers and costs much more to administer
Places greater emphasis on giving patients a wider choice of clinicians
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Places more emphasis on specialized physicians with more nurse practitioners and physician assistants providing primary care
Has a more complex system for ensuring quality and a unique system of malpractice law
Encourages rapid adoption of technology
Give 3 reasons why healthcare costs are increasing
1) The aging of the population
2) Technological innovations
3) Raised the expectations of patients.
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1) The _________ of the US healthcare system creates more issues; because of this, multiple layers of ____________ are required
1) complexity; administration
2) Clinicians bill for each service provided, justify the services provided in their documentation, and occasionally obtain approval for payments prior to treating the individual
List the Six categories identified by the National Academy of Medicine and potential savings…
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Increasing competition between medical and insurance providers
To control costs, US healthcare system needs what 4 characteristics to be in place?
1) Informed purchaser
2) Purchasing power
3) Multiple competing providers
4) Negotiation
