Week 9: Tuesday Flashcards
1) PCPs are first contact providers of care who handle most common problems and are critical to the delivery of clinical _______________ services; they are the ____________ of a healthcare system.
2) What does “medical home” mean?
1) preventative; foundation
2) Primary care is a team effort: patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.
Six C’s of Care are the core values that all individuals employed in caring industries are expected to incorporate in the way that they care for their patients.
Contact
Comprehensive
Coordinated
Continuity
Caring
Community
6 Cs of primary care:
List the primary care ideals and realities for Contact
1) The point of first contact with the healthcare system; the entry point
2) Patients enter the healthcare system through many disconnected points, including the emergency room, specialists, urgent care centers, nontraditional practitioners, etc
6 Cs of primary care:
List the primary care ideals and realities for Comprehensive
1) Primary care intends to be able to Dx and Tx the majority of issues
2) Rapid ^ in # of Txs and high volume practices increase specialist referrals
6 Cs of primary care:
List the primary care ideals and realities for Coordinated
1) Intends to be the focal point of Dx and Tx, w. coordination w referrals if needed
2) PCPs are being replaced by hospitalists who are full time in the hospital, provide care for inpatients, and direct pt access to specialists
6 Cs of primary care:
List the primary care ideals and realities for Continuity
1) Pt followed over many years; continuous care
2) Pts increasingly req. or encouraged to change providers due to insurance
6 Cs of primary care:
List the primary care ideals and realities for caring
1) Individualized care based on individual relationships
2) Becoming an increasingly administrative entity
6 Cs of primary care:
List the primary care ideals and realities for Community
1) Primary care designed to connect the individual pt with the community
2) Healthcare professionals and public health have a long history of being distant and at times contentious
1) Secondary care refers to what kind of care? Give examples.
2) Tertiary care refers to what kind of care? Give examples
1) Specialty care
-ObGyn, anesthesiology
2) Subspecialty care (often provided in academic or specialized health centers)
–Trauma center, burn center, NICU
Where does the largest % of our healthcare spending go?
Hospitals (30.4%)
1) How Much Money Does the United States Spend on Health Care?
2) How does this compare to other developed countries? (UK, Canada, Germany, France, Japan, Australia)
1) $4.9 trillion yearly, 17.6% GDP which = $14,570/person/yr (2023)
Medicare spending: $848.2 billion (2023)
Medicaid spending: $871.7 billion (2023)
2) Those other countries spend about 1/2 as much per person and 10-11% of GDP yearly
1) Describe government spending on healthcare peak-pandemic in 2020
2) Describe the after COVID effects in 2021
1) COVID effects: 2020 (compared to prior)
Federal government spending (+36%)
U.S. healthcare spending overall (+10.3%)
2) After COVID effects: 2021
Federal government spending (- 3.5%)
U.S. healthcare spending overall (+2.7%)
Medicare:
1) What is it?
2) What funds it? How much from each?
3) Who does it include?
4) When is the enrollment period? How many are enrolled?
5) Providers paid on a __________ basis
1) Federal government program started in 1965
2) Payroll tax of 1.45% from employees and 1.45% from employers
3) 65 and older, expanded to include disabled persons eligible for Social Security disability benefits and those with end stage renal disease
4) Enrollment period: 3mos before turning 65 and 3mos after; 65.7 million enrolled
5) fee-for-service
What are the more recent medicare changes?
1) Drugs partially covered by Part D.
2) Preventative services have expanded.
3) Skilled nursing or rehab care is covered (NOT nursing home or custodial care).
4) Hearing aids and eyeglasses are not covered by Medicare
1) Part A (inpatient) of medicare covers what?
2) Is there a premium?
1) Covers hospital care, skilled nursing care, home health care after hospitalization, hospice care
2) No premium but annual deductible required
Medicare part B:
1) What is it?
2) Who funds it? Are there copays? Is there a deductible?
3) What are Medigap policies?
1) Voluntary supplemental insurance that covers a wide range of diagnostic and therapeutic services
2) 25% funded by a monthly premium
-20% copayments for most services
-$257 deductible for 2025 (minimum based on yearly income)
3) Offered by private insurance companies to cover all or most of the 20% copayment
Part C (Medicare Advantage):
1) What is it?
2) What is the catch here?
1) Provided by private companies approved by Medicare, it’s usually Part A, B and D with extra benefits like vision, dental, hearing
2) Usually need to use medical providers who are in the plan’s network
Part D (Rx):
1) Who is eligible?
2) Is there a premium or deductible?
3) What does donut hole mean?
1) Those who are enrolled in Parts A and B
2) Requires monthly premium and annual deductible
3) 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) What is it?
2) How many are enrolled?
3) Who is eligible?
4) What care can you get with it?
5) Total cost?
1) Federal and state program designed to pay for health services for specific categories or low-income people and other designated categories of individuals
2) Largest federal health insurance system (*As of Oct 2024, 72 million enrolled)
3) All states are members so are required to provide benefits for the disabled, children, and pregnant women based on the federal poverty level
4) Does not provide health care directly.
5) Cost: $584.4 billion (2024)
Medicaid Basic Health Program (optional)
States can provide coverage to individuals who meet what criteria?
1) Are citizens and <64yo
2) Do not qualify for Medicaid, Child Health Insurance Program (CHIP), or other min. essential coverage
3) 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) How many? Who manages it?
2) What does it do?
3) What is this called in TN?
1) 9.6 children enrolled (2018)
2) Managed by individual states
Provide free health coverage for pregnant women and children who do not have insurance and do not qualify for TennCare (TN’s Medicaid program)
3) In TN, this is called CoverKids
What kids qualify for CHIP?
1) They are under 19 years of age on the date of application;
2) They are Tennessee residents;
3) They are not eligible for or enrolled in TennCare;
4) They are U.S. citizens orqualified non-citizens.
5) Their household income is at or below 250% of federal poverty level (FPL).
Medicaid covers:
1) Mandatory services such as what?
2) What are states required to provide for kids until 21?
3) What do all states cover?
4) What do many, but not all, states cover?
1) 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 age 21
3) All states cover prescription drugs
4) Optional services such as: dental care, vision services, hearing aids, and personal care services for frail seniors and people with disabilities1
What are the 2 big issues w. medicaid access?
Big issues regarding Medicaid Access:
1) Reimbursement rates to clinicians are often comparatively low
2) Many clinicians will choose not to participate
1) The largest single category of insurance coverage in the US is what?
2) When did it start?
3) When did it grow?
1) Employment based
2) Started during WWII when employers couldn’t raise wages, so they offered healthcare benefits.
3) Grew in the 50s and 60s based on community rating (cost of insurance was the same regardless of the health status of a particular group of employees)
Advent of employer insurance:
1) Community rating was replaced by ___________ rating (employers and employees pay based on their groups’ use of services in previous years)
2) Until the 90s, provided payments to clinicians and hospitals based on ____________ payments (charges paid for specific services provided)
1) experience
2) fee-for-service
*Fee-for-service accused of increasing healthcare costs due to overuse of services
Health Maintenance Organizations (HMOs):
1) When were they introduced and why?
2) Is there a fee? How are clinicians or their organizations paid?
3) Define Capitation
4) What is there the potential for?
1) Introduced in 1973 as alternative to employment-based insurance
2) Monthly fee to cover a comprehensive package of services
Based on the number of individuals who enroll in their practice (based on capitation)
3) Fixed number of dollars per month to provide services to an enrolled member regardless of the number of services provided
4) Underuse of services to save costs
In the 90s Fee-for-service systems became what? Explain these
2) What did Staff model HMOs become? Explain
1) Preferred Provider Organizations (PPOs)
-Work with only a limited number of clinicians called preferred providers
-Providers join the network and agree to a set of conditions that include reduced payments
-If patients use out of network provider, have to pay additional costs out of pocket
2) Point of Service Plans (POSs)
-Patients in an HMO may choose to receive their care outside the system but expect to pay more out of pocket
1) What are health insurance exchanges?
2) What do they provide? Who utilizes these?
3) What is the goal of these exchanges?
1) Online marketplace
2) Access to health insurance (at times subsidized by the federal govt) for citizens and legal residents of the US
Often self-employed or those not offered health insurance through work
3) Create a competitive marketplace to help increase access and control the cost of health insurance
1) Until 2010, ___% of all Americans were uninsured and 7.5% considered underinsured
2) Uninsured: _____% (2023)
1) 15%
2) 9.5%
Who are/were the uninsured?
1) Healthy, often young individuals who choose not to purchase insurance
2) Low-income or near low-income individuals who do not qualify for Medicaid
3) Self-employed persons or employees of small companies
4) Those who could not afford it
1) How does the ACA attempt to address the needs of the uninsured?
2) Under the ACA, all individuals are required to do what?
1) -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
2) Purchase health insurance or pay a substantial state-determined fine
What are the consequences of Lack of Adequate Health Insurance?
1) Receive less preventative care
2) Diagnosed at more advanced stages of disease
3) Receive less treatment once diagnosed
4) More likely to use the ED for routine care
5) Increased mortality rate with an estimated nearly 20,000 excess deaths/year
6) Often billed at undiscounted prices for the services provided so find themselves with large debts
The # of underinsured decreased by requiring insurance to cover Essential Health Benefits; give examples of EHBs
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
List and describe 2 federal/ state programs for those who are injured on the job or have a disabling condition
1) Worker’s Compensation: State programs that provide short-term assistance for traumatic injuries
Long-term disability coverage varies from state to state
2) Federal Programs for Workers: Federal workers (energy employees, long-shore and harbor workers, coal miners) injured on the job/illness
Social Security Disability Insurance (SSDI) and Social Security Income (SSI):
1) What does SSDI require?
2) What does SSI provide?
1) 12mos disability before eligible to apply
a complex disability determination
have paid into the social security system
Medicare is provided 2yrs after the individual is deemed eligible for SSDI
2) Payments for disabled adults and children who meet income levels for eligibility regardless of their contribution to social security
Enrolled in Medicaid immediately upon determination of disability
In order to compare, you must understand the framework of the US system first, which includes things like what?
Method of financing
Method of insurance and reimbursement
Methods for delivering services
Comprehensiveness of insurance
Cost and cost containment
Degree of patient choice
Administrative cost
1) How is the US healthcare system financed?
2) Describe our insurance admin costs
1) Cost approximately 17.6% of GDP
Complicated mix of federal, state, employer, and self-pay
2) 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
Type(s) of insurance:
1) What type makes up most insurance?
2) What provide options for individuals and small business employees (premiums covered by individuals or self-pay)?
1) Employment-based insurance plus government insurance through Medicare and Medicaid provide most insurance.
2) New exchanges
1) Describe the delivery of care in the US
2) What is there a need for?
1) Mix of practice types with private practice dominant
Physicians: 1/3 primary care, 2/3 specialists
Primary care increasingly based upon nurse practitioners and Physician Assistants
Hospitalists increasingly coordinate inpatient care
2) Better continuity of care between institutions and between clinicians.
New Accountable Care Orgs (ACOs) are aiming to coordinate care for Medicare recipients
Comprehensiveness of insurance:
1) Health insurance with cost sharing offered through __________-based insurance and through health insurance exchanges, as well as ___________/__________.
2) What happened under the ACA?
3) Generally, insurance plans require coverage of what?
1) employment-based; Medicaid/Medicare
2) Preventive services increased, insurance required coverage of approved preventive services and no copayments.
3) Essential Health Benefits.
1) Describe patient choice in the US
2) Describe cost and cost containment in the US
1) Considerable choice of primary care and often direct access to specialty care
Greatly increased access for those with comprehensive insurance with high levels of provider reimbursement
2) Emphasis on competition as means of controlling costs
Cost-sharing by patients
Canada:
1) Describe their healthcare system’s financing
2) Describe their administrative costs
1) 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
2) Low: approximately 15% or less of total costs
Canada: Describe what types of insurance there are
-Government insurance for basic health services
-Individual policies with subsidies for the poor for most other services
-Negotiated fee-for-service reimbursement with single payer for basic services
Canada: Describe their delivery of care
1) Mix of practice types with private practice dominant—emphasis on physicians in primary care
2) Physicians: 1/2 primary care, 1/2 specialists
3) Primary care docs admit to hospitals
4) May have Limited access to high-tech procedures
Describe the comprehensiveness of insurance (three tiered) in Canada
1) Universal coverage. Government funded and guaranteed to all; no private insurance allowed for medically necessary services
2) Private and government-subsidized insurance for other
drugs(long-term care, home care, bulk purchasing of drugs on formulary (decreased costs))
-Private insurance or self-pay for dental, vision, and many non-physician services
Canada:
1) Describe patient choice
2) Describe cost and cost containment
1) Choice of primary care physician
Referral needed to see specialists
2) Capital purchases, such as of high-tech diagnostic equipment, are regulated/ restricted
Concern about waiting time for access
Negotiated fees between providers and government with government as single payer having considerable negotiating power
UK
1) Financing of healthcare?
2) Is there a private system/
1)Spend about 12% of GDP
But rising, excluding private insurance costs
Tax supported comprehensive and universal coverage through National Health Service (NHS)
2) Private insurance system with overlapping coverage purchased as additional coverage by about 10% of the population
Type(s) of insurance and reimbursement in the UK
1) NHS and Private options
a) Single payer with capitation plus incentives for general practitioners
b) Specialists generally salaried in NHS and often earn substantial additional income through private insurance system
Describe delivery of care in the UK
1) Governmental system of healthcare delivery in National Health Services, including government owned and administered hospitals
->500 private hospitals
2) Emphasis on physicians (*Do now use Physician Associates)
3) Primary care general practitioners about two-thirds
Specialist physicians about one-third
General practitioners generally do not admit to hospital
UK:
1) Comprehensiveness of insurance?
2) Cost and cost containment?
2) National Health Service comprehensive with little cost sharing, plus may cover transportation costs
Incentives to provide preventive services and home care
2) “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
Describe the degree of patient choice in the UK
1) National Health Service provides limited choice of general practitioners
2) Waiting lines for services, especially specialists and high-tech procedures
Referral to specialists generally needed
Greater choice with private insurance
US:
1) Describe our healthcare issues (imo)
2) Describe our strengths
1) 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
-Has a more complex system for ensuring quality and a unique system of malpractice law
2) Places greater emphasis on giving patients a wider choice of clinicians
-Places more emphasis on specialized physicians with more nurse practitioners and physician assistants providing primary care
-Encourages rapid adoption of technology
Why are costs of healthcare increasing? (4 reasons)
(hint: nearly all developed countries face these forces to a greater or less extent)
1) The aging of the population
2) Rising drug costs
3) Technological innovations have greatly expanded treatment options.
4) The successes of medical care over the last half century have raised the expectations of patients.
Explain how the The complexity of the US healthcare system creates more issues.
1) Because of the complexity, multiple layers of administration are required
-(care in other countries is often paid by a single payer).
2) Complex insurance application and claims forms
3) Clinicians bill for each service provided, justify the services provided in their documentation, and occasionally obtain approval for payments prior to treating the individual
4) Quality control continues to evolve: accreditation, certification, licensure, malpractice, etc.
Six categories identified by the National Academy of Medicine and potential savings:
1) Describe Unnecessary services and overuse (potential annual savings of $210 billion)
2) Describe Inefficiently delivered services (potential annual savings of $130 billion)
1) Discretionary use beyond benchmarks
Overuse, unnecessary choice of higher-cost services
2) Mistakes: errors, preventable complications
Care fragmentation
Unnecessary use of higher-cost providers
Operational inefficiencies
Six categories identified by the National Academy of Medicine and potential savings:
1) Describe Excess Administrative costs (potential annual savings of $190 billion)
2) Describe Prices that are too high (potential annual savings of $105 billion)
1) Insurance paperwork costs
Insurers’ administrative inefficiencies
Inefficiencies due to care documentation requirements
2) Service and product prices beyond competitive benchmarks
Six categories identified by the National Academy of Medicine and potential savings:
1) Describe Missed prevention opportunities (potential annual savings of $55 billion)
2) Describe Fraud (potential annual savings of $75 billion)
1) Primary, secondary, tertiary prevention
2) ALL sources (payers, clinicians, patients)
