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