Week 9 Tues highlights

Question 1

Primary care: first contact providers of care who handle most common problems and are critical to the delivery of clinical ________________ services

Answer 1

preventative

Question 2

1) Who are the foundation of a healthcare system?
2) Explain “medical home”

Answer 2

1) PCPs
2) Primary care is a team effort: patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.

Question 3

What are the core values called that all individuals employed in caring industries are expected to incorporate in the way that they care for their patients?

Answer 3

Six C’s of Care

Question 4

1) How Much Money Does the United States Spend on Health Care?
2) How much do other developed countries spend?

Answer 4

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

Question 5

Who pays the bill for healthcare?

Answer 5

1) Insurance coverage
2) Out-of-pocket expenses
-(Deductible, copays, and coinsurance)

Question 6

What happened to federal govt spending after COVID (2021)?

Answer 6

Went down by 3.5%

Question 7

Important insurance terms:
1) Define cap
2) Define copayment
3) Define coinsurance

Answer 7

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

Question 8

Important insurance terms:
1) Define covered services
2) What do customary, prevailing, and reasonable mean?

Answer 8

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

Question 9

Important insurance terms; define each:
1) Deductible
2) Eligible
3) Out of pocket expenses

Answer 9

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)

Question 10

Important insurance terms:
1) Define medical loss ratio and give an example
2) Define portability
3) Define premium

Answer 10

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

Question 11

Medicare:
1) A ____________ 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
2) Funded by a ________ tax of 1.45% from employees and 1.45% from employers
3) Incl. ______ and older, expanded to include _______ persons eligible for Social Security disability benefits and those with end stage ________ disease

Answer 11

1) federal
2) payroll
3) 65; disabled; renal

Question 12

More recent medicare changes:
1) Drugs ____________ covered by Part D.
2) _____________ services have expanded.
3) Skilled ____________ or ____________ care is covered (NOT nursing home or custodial care).
4) Are hearing aids and eyeglasses covered by Medicare?

Answer 12

1) partially
2) Preventative
3) nursing or rehab
4) No

Question 13

1) How many are enrolled in medicare?
2) Providers paid on a fee-for-service basis with medicare

Answer 13

1) 65.7 million enrolled
2) fee-for-service basis

Question 14

List the four parts of medicare

Answer 14

1) Part A (inpatient)
2) Part B (outpatient)
3) Part C (Medicare Advantage)
4) Part D (Rx)

Question 15

Medicare Part B (outpatient)
1) There’s no __________, but annual __________ required
2) Is it voluntary?
3) ____% funded by a monthly premium

Answer 15

1) premium; deductible
2) Voluntary
3) 25%

Question 16

1) What are offered by private insurance companies to cover all or most of the 20% copayment with outpatient medicare (part b)?
2) Part B of medicare has a $____deductible for 2025 (minimum based on yearly income)

Answer 16

1) Medigap policies
2) $257

Question 17

Part C of Medicare is what?

Answer 17

Medicare advantage

Question 18

1) Describe “donut hole” in the contexts of medicare part D
2) Describe the current state

Answer 18

1) 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
2) Now, $2,000 out of pocket limit for rx drugs

Question 19

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?

Answer 19

1) federal and state
2) largest; 72 million
3) No
4) $584.4 billion (2024)

Question 20

Medicaid Basic Health Program (optional):
States can provide coverage to individuals who:
1) Are _________ and _______ the age of 64.
2) Do not qualify for what?
3) Income up to 185% of the _________________, which for a family of 4 is ~$32,150 (2025)

Answer 20

1) citizens; under
2) Medicaid, Child Health Insurance Program (CHIP), or other min. essential coverage
3) Federal poverty level (FPL)

Question 21

Child Health Insurance Program (CHIP)
1) Provide free health coverage for ______________ and _____________ 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?

Answer 21

1) pregnant women and children
2) CoverKids
3) Qualified non-citizens.

Question 22

1) Medicaid covers ___________ services such as hospital and provider care, labs and X-ray services, home health services, and nursing facility services for adults
2) States are required to provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children until what age?

Answer 22

1) mandatory
2) 21

Question 23

Big issues regarding Medicaid Access include what 2 things?

Answer 23

1) Reimbursement rates to clinicians are often comparatively low
2) Many clinicians will choose not to participate

Question 24

The largest single category of insurance coverage in the US is what?

Answer 24

Employment based health insurance

Question 25

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)

Answer 25

community

Question 26

With employer based healthcare, community rating was replaced by _____________ rating (employers and employees pay based on their groups’ use of services in previous years)

Answer 26

experience

Question 27

Until the 90s, provided payments to clinicians and hospitals based on ______________ payments (charges paid for specific services provided)

Answer 27

fee-for-service

Question 28

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?

Answer 28

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

Question 29

In the 90s 1) Fee-for-service systems turned into what? Explain how it works. 2) What did Staff model HMOs turn into? Explain

Answer 29

1) Preferred Provider Organizations (PPOs) -Work only w "preferred providers" -Providers join and agree -If patients use out of network provider, have to pay additional costs out of pocket 2) Point of Service Plans (POSs); pts in an HMO may choose to receive their care outside the system but expect to pay more out of pocket

Question 30

Health Insurance Exchanges: What is the goal of creating a competitive marketplace?

Answer 30

Help increase access and control the cost of health insurance

Question 31

1) Until 2010, ____% of all Americans were uninsured and ____% considered underinsured 2) In 2023, uninsured: ___%

Answer 31

1) 15%; 7.5% 2) 9.5%

Question 32

The uninsured include: 1) _________, ___________ individuals who choose not to purchase insurance 2) Low-income or near low-income individuals who ___________ qualify for Medicaid

Answer 32

1) Healthy, young 2) do not

Question 33

__________ attempted to address the needs of the uninsured: 1) Young individuals can stay on their parent’s insurance plan until age _____. 2) States provided with option to expand eligibility for ____________. 3) Health __________ exchanges

Answer 33

ACA 1) 26 2) Medicaid 3) insurance

Question 34

Under the ACA, all individuals are required to do one of what two things?

Answer 34

Either: 1) Purchase health insurance or 2) Pay a substantial state-determined fine

Question 35

List a 3 important Consequences of Lack of Adequate Health Insurance

Answer 35

1) More likely to use the ED [for preventative care] 2) Increased mortality rate 3) Large debts

Question 36

Define underinsured

Answer 36

Out-of-pocket healthcare costs eat up 10% or more of your household income or your deductible equals 5% or more of your income.

Question 37

What are essential health benefits?

Answer 37

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

Question 38

Federal and state programs for those who are injured on the job or have a disabling condition:

Answer 38

Worker’s Compensation Federal Programs for Workers

Question 39

What are 2 Programs Available for Those Who are Disabled or Injured on the Job?

Answer 39

1) Social Security Disability Insurance (SSDI) and 2) Social Security Income (SSI)

Question 40

US healthcare Cost approximately _____% of GDP ______________- mix of federal, state, employer, and self-pay

Answer 40

17.6%; complicated

Question 41

Insurance Admin costs are __________ : 25%–30% of total costs, including administrative costs of health insurance, clinicians, and institutions, but this does not include _________________ spent by patients and their families

Answer 41

high; administrative time

Question 42

Reimbursement is a Mix of ___________, ______________, and ___________ with incentives are the most commonly used methods

Answer 42

fee-for-service, capitation, and salary

Question 43

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. 3) Primary care increasingly based upon who? 4) Who increasingly coordinate inpatient care?

Answer 43

1) private practice dominant 2) 1/3 primary care, 2/3 specialists 3) NPs + PAs 4) Hospitalists Need for better continuity of care between institutions and between clinicians.

Question 44

Comprehensiveness of insurance: 1) ____________ with ______________ offered through employment-based insurance and through health insurance exchanges, as well as Medicaid/Medicare 2) Under the ACA, what happened? -Generally, insurance plans require coverage of __________

Answer 44

1) Health insurance with cost sharing 2) Preventive services increased, insurance required coverage of approved preventive services and no copayments. -Essential Health Benefits.

Question 45

Patient choice in the US: 1) Considerable choice of _____ care and often direct access to _________ care. 2) There's greatly increased access for those with what?

Answer 45

1) primary; specialty 2) Comprehensive insurance with high levels of provider reimbursement

Question 46

Cost and cost containment in the US: Emphasis on ____________ as means of controlling costs, and there's cost-sharing by ___________

Answer 46

competition; patients

Question 47

**Canada:** Financing: 1) National policy to keep expenditures close to _____% of GDP 2) Combination of ____________ and federal. 3) 70% ______________ payment through taxes; 30% ______________ insurance payments by individuals 4) Admin costs are ______; approximately ____% or less of total cost

Answer 47

Financing: National policy to keep expenditures close to 10% of GDP 2) provincial 3) government; private 4) low; 15%

Question 48

In Canada, there's _____________ insurance as well as negotiated _______________ reimbursement for basic health services

Answer 48

government; fee-for-service

Question 49

Canada: 1) What's the ratio of PCPs to specialists? 2) Do PCPs admit to hospitals? 3) What is the catch with their access here?

Answer 49

1) 1/2 primary care, 1/2 specialists 2) Yes 3) May have Limited access to high-tech procedures

Question 50

Canada: 1) For medically necessary basic services, there's universal coverage that's government funded and guaranteed to ___________ people. 2) Is there private insurance allowed for medically necessary services?

Answer 50

1) all 2) No

Question 51

Canada: 1) What are the Canadian options for private and government-subsidized insurance for other things like drugs, long-term care, home care, + bulk purchasing of drugs on formulary (decreased costs)? 2) What abt for dental, vision, and many non-physician services?

Answer 51

1) Private and government-subsidized insurance 2) Private insurance or self-pay

Question 52

Canada: 1) When can you see a specialist? 2) What are regulated/ restricted? 3) What have considerable negotiating power?

Answer 52

1) Referral needed to see specialists 2) Capital purchases 3) Negotiated fees with government as single payer

Question 53

UK admin costs are ______ than Canada, _________ than United States

Answer 53

more; less

Question 54

UK: 1) Spends about ____% of GDP, but rising, excluding private insurance costs 2) Tax supported comprehensive and universal coverage through ________________ (NHS). 3) Private insurance system with overlapping coverage purchased as additional coverage by about ___% of the population

Answer 54

1) 12% 2) National Health Service (NHS) 3) 10%

Question 55

UK type(s) of insurance and reimbursement include what 2 things? Explain

Answer 55

**NHS and Private options:** 1) Single payer 2) Specialists = salaried in NHS + additional income through private insurance system

Question 56

UK: 1) Governmental system of healthcare delivery in National Health Services, including ______________ owned and administered hospitals (but greater than 500 _______ hospitals) 2) Emphasis on physicians, but now use ______. 3) Primary care general practitioners about _____-thirds; specialist physicians about ____-thirds. 4) General practitioners generally do or do not admit to hospital?

Answer 56

1) government; private 2) PAs 3) two-thirds; one-third 4) do not

Question 57

UK 1) Comprehensiveness of insurance: National Health Service comprehensive with _______ cost sharing, plus may cover transportation costs -Incentives to provide ________- services and home care 2) An overall limit on national spending is what? 3) Negotiated rates of ____________ and salary with government as single payer

Answer 57

1) little -preventive 2) Cost and cost containment: “Global budgeting” 3) capacitation

Question 58

UK: 1) National Health Service provides _________ choice of general practitioners 2) There are waiting lines for services, especially _____________ and high-tech procedures. 3) Referral to ______________ generally needed; greater choice with private insurance

Answer 58

1) limited 2) specialists 3) specialists

Question 59

1) What country relies most heavily on market justice? 2) Which places more emphasis on social justice? 3) Which is somewhere in-between?

Answer 59

1) United States 2) UK 3) Canada

Question 60

The USA: 1) Spends per person and as a percentage of GDP 2) Has a __________ percentage of uninsured 3) System is _________ complex for patients and providers and costs much more to administer 4) Places _________ emphasis on giving patients a wider choice of clinicians

Answer 60

1) more 2) higher 3) more 4) greater

Question 61

The USA: 1) Places more emphasis on specialized physicians with more of who providing primary care? 2) Has a more complex system for ensuring quality and a unique system of _____________ law. 3) Encourages ____________ adoption of technology

Answer 61

1) NPs + PAs 2) malpractice law 3) rapid

Question 62

Give 3 reasons why healthcare costs are increasing

Answer 62

1) The aging of the population 2) Technological innovations 3) Raised the expectations of patients.

Question 63

1) The _________ of the US healthcare system creates more issues; because of this, multiple layers of ____________ are required. 2) Clinicians bill for each _________ provided, justify the services provided in their ____________, and occasionally obtain ___________ for payments prior to Tx

Answer 63

1) complexity; administration 2) service; documentation; approval

Question 64

List the Six categories identified by the National Academy of Medicine and potential savings from largest to smallest

Answer 64

1) Unnecessary services and overuse 2) Excess Administrative costs 3) Inefficiently delivered services 4) Prices that are too high 5) Missed prevention opportunities 6) Fraud

Question 65

What is the total excess healthcare cost in the US?

Answer 65

$750 billion/yr

Question 66

What is Needed to Enable Competition to Reduce Healthcare Costs?

Answer 66

Increasing competition between medical and insurance providers

Question 67

To control costs, US healthcare system needs what 4 characteristics to be in place?

Answer 67

1) Informed purchaser 2) Purchasing power 3) Multiple competing providers 4) Negotiation