Week 9 Tues highlights Flashcards
Primary care: first contact providers of care who handle most common problems and are critical to the delivery of clinical ________________ services
preventative
1) Who are the foundation of a healthcare system?
2) Explain “medical home”
1) PCPs
2) Primary care is a team effort: patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
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?
Six C’s of Care
1) 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
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
1) federal
2) payroll
3) 65; disabled; renal
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?
1) partially
2) Preventative
3) nursing or rehab
4) No
1) How many are enrolled in medicare?
2) Providers paid on a fee-for-service basis with medicare
1) 65.7 million enrolled
2) fee-for-service basis
List the four parts of medicare
1) Part A (inpatient)
2) Part B (outpatient)
3) Part C (Medicare Advantage)
4) Part D (Rx)
Medicare Part B (outpatient)
1) There’s no __________, but annual __________ required
2) Is it voluntary?
3) ____% funded by a monthly premium
1) premium; deductible
2) Voluntary
3) 25%
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)
1) Medigap policies
2) $257
Part C of Medicare is what?
Medicare advantage
1) Describe “donut hole” in the contexts of medicare part D
2) Describe the current state
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
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.
2) Do not qualify for what?
3) Income up to 185% of the _________________, which for a family of 4 is ~$32,150 (2025)
1) citizens; under
2) Medicaid, Child Health Insurance Program (CHIP), or other min. essential coverage
3) Federal poverty level (FPL)
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?
1) pregnant women and children
2) CoverKids
3) Qualified non-citizens.
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?
1) mandatory
2) 21
Big issues regarding Medicaid Access include what 2 things?
1) Reimbursement rates to clinicians are often comparatively low
2) 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
With employer based healthcare, community rating was replaced by _____________ rating (employers and employees pay based on their groups’ use of services in previous years)
experience
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
In the 90s
1) Fee-for-service systems turned into what? Explain how it works.
2) What did Staff model HMOs turn into? Explain
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
Health Insurance Exchanges: What is the goal of creating a competitive marketplace?
Help increase access and control the cost of health insurance
1) Until 2010, ____% of all Americans were uninsured and ____% considered underinsured
2) In 2023, uninsured: ___%
1) 15%; 7.5%
2) 9.5%
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
__________ 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
ACA
1) 26
2) Medicaid
3) insurance
Under the ACA, all individuals are required to do one of what two things?
Either:
1) Purchase health insurance
or
2) 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?
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
What are 2 Programs Available for Those Who are Disabled or Injured on the Job?
1) Social Security Disability Insurance (SSDI) and
2) Social Security Income (SSI)
US healthcare Cost approximately _____% of GDP
______________- mix of federal, state, employer, and self-pay
17.6%; complicated
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
high; administrative time
Reimbursement is a Mix of ___________, ______________, and ___________ with incentives are the most commonly used methods
fee-for-service, capitation, and salary
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?
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.
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 __________
1) Health insurance with cost sharing
2) Preventive services increased, insurance required coverage of approved preventive services and no copayments.
-Essential Health Benefits.
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?
1) primary; specialty
2) Comprehensive insurance with high levels of provider reimbursement
Cost and cost containment in the US: Emphasis on ____________ as means of controlling costs, and there’s cost-sharing by ___________
competition; patients
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
Financing:
National policy to keep expenditures close to 10% of GDP
2) provincial
3) government; private
4) low; 15%
In Canada, there’s _____________ insurance as well as negotiated _______________ reimbursement for basic health services
government; fee-for-service
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?
1) 1/2 primary care, 1/2 specialists
2) Yes
3) May have Limited access to high-tech procedures
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?
1) all
2) No
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?
1) Private and government-subsidized insurance
2) Private insurance or self-pay
Canada:
1) When can you see a specialist?
2) What are regulated/ restricted?
3) What have considerable negotiating power?
1) Referral needed to see specialists
2) Capital purchases
3) Negotiated fees with government as single payer
UK admin costs are ______ than Canada, _________ than United States
more; less
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
1) 12%
2) National Health Service (NHS)
3) 10%
UK type(s) of insurance and reimbursement include what 2 things? Explain
NHS and Private options:
1) Single payer
2) Specialists = salaried in NHS + additional income through private insurance system
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?
1) government; private
2) PAs
3) two-thirds; one-third
4) do not
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
1) little
-preventive
2) Cost and cost containment:
“Global budgeting”
3) capacitation
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
1) limited
2) specialists
3) specialists
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
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
1) more
2) higher
3) more
4) greater
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
1) NPs + PAs
2) malpractice law
3) rapid
Give 3 reasons why healthcare costs are increasing
1) The aging of the population
2) Technological innovations
3) Raised the expectations of patients.
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
1) complexity; administration
2) service; documentation; approval
List the Six categories identified by the National Academy of Medicine and potential savings from largest to smallest
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
What is the total excess healthcare cost in the US?
$750 billion/yr
What is Needed to Enable Competition to Reduce Healthcare Costs?
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
