Lecture 23+FC+DLA

Question 1

what is primary care?

Answer 1

common health problems, minor interventions, preventative measures

can be taken care of by general practitioner

80-90 of health care visits

Question 2

what is secondary care?

Answer 2

problems that require more specialized care,
clinical expertise

usually involve hospital setting for care and specific specialties such as general surgery

Question 3

what is tertiary care?

Answer 3

more complex and often rare disorders, requiring extensive clinical expertise and hospital care

Involves subspecialties such as cardiac surgeons, immunologists, hematologists

Question 4

dispersed model of healthcare

Answer 4

multiple access points (patient choice or doctor referral)

more fluid roles for providers

less distinction in hospital care

higher value on tertiary care

Question 5

HMO for patients

health maintenance organization

Answer 5

most of your care is from a network provider

you choice of a primary care doctor

specialist care diagnostic services require an approved referral

Question 6

first-generation HMO

Answer 6

Consolidated model, salaried physicians, global budget hospitals

vertical integration (Kaiser-Permanente)

Question 7

second-generation HMO

Answer 7

virtual integration

group model:
prepaid group practice
IPA’s

network model:
Mix of IPAs, home health agencies, pharmacies,
hospitals, etc

Question 8

IPA’s or independent practice associations

Answer 8

An IPA is a loose collection of private doctors
who work in their own practices

IPA contracts with HMO on behalf of the doctors

IPA receives a capitation payment from the HMO and pays its doctors either through capitation or fee-for-service

Question 9

Preferred Provider Organizations (PPO)

Answer 9

The PPO payer receives monthly premiums from
subscribers and employers

Patients are required to select physicians and
hospitals approved (“preferred”) by the payer

Providers discount their fees or allow payer to
“manage” the care they give

Question 10

Accountable Care Organizations (ACO)

Answer 10

Affordable care act allowed Medicare to start this program

Question 11

financial barriers to healthcare

Answer 11

lack of insurance (part time workers, low-income employee’s)

underinsurance: 
does not guarantee financial access to care 
limited coverage 
gaps in medicare 
high co-payments and deductibles

Question 12

non-financial barriers to healthcare

Answer 12

lack of prompt access
gender
race
literacy level 
disability status 
sexual orientation 
location 
age

Question 13

Children Health Insurance Program

Answer 13

Covers low income children, up to age 19, who
are not eligible for Medicaid but who cannot
afford health insurance.

Question 14

Consolidated Omnibus Budget Reconciliation Act

(COBRA) 1985

Answer 14

Allows workers who lose their health insurance benefits because of job loss the right to continue under group coverage

up to 18 months

must pay the premium

Question 15

Emergency Medical Treatment and Active
Labor Act (EMTALA) 1986

Answer 15

To prevent hospitals «dumping» indigent or uninsured patients

All hospitals receiving federal payments must screen and stabilize ER patients

Question 16

The causes of health disparities

Answer 16

Social determinants of health
Behavioral determinants of health
Environmental determinants of health
Biological and genetic determinants of health

Question 17

fee-for-service

Answer 17

unit of payment = visit/procedure preformed

physician / hospital is paid a free for each treatment

Question 18

FINANCIAL RISK

Answer 18

potential to lose money, earn less money, or [as a
physician] spend more time without additional payment on a transaction

for a fee-for-service system, the party paying the bill absorbs the the risk (ex. insurance)

Question 19

bundling of services

Answer 19

in this type of system some of the financial risk is transferred from the payer to the doctor

more treatments bundled into one payment the larger the financial risk

Question 20

unit of payment

Answer 20

The physician is paid one sum for all services
delivered during one illness/surgical procedure

economic incentive for surgeons to limit post-operative visits and preform more surgery

Question 21

Capitation

Answer 21

monthly payments made to a physician for each patient
signed up to receive care from them—usually for primary care physicians

It requires patients to register with a physician/group of physicians

Shifts financial risk from INSURERS to PROVIDERS

Question 22

Methods to decrease financial risk of capitation

Answer 22

1. carve outs
   specific services not covered by capitation & paid
   separately as fee-for-service
2. risk-adjusted
   patients with greater health needs need more time with their physician – thus higher monthly payments for elderly patients & those with chronic illnesses

Question 23

benefits of capitation

Answer 23

Controls cost versus the inflationary tendencies of fee-for-service

monitoring appropriate use of services & planning for patients’ needs

better allocation of resources & develop better ways for service delivery

Question 24

TWO – TIERED CAPITATION (UK)

Answer 24

under the NHS each person enrolls with a general practitioner

One tier: is the HEALTH PLAN (the Government in the UK)

Other tier: is the INDIVIDUAL PCP/GROUP PRACTICE (w/ several physicians)

Question 25

THREE – TIERED CAPITATION

Answer 25

HMOs do not pay capitation fees directly to doctors

IPA’s still are private, but join physician groups

Question 26

payment per time - salary

Answer 26

physicians in the public vector are normally salary

they have little financial risk
high volume of patients
no over time pay

health plan… prepaid group practice… doctor

Question 27

payment per procedure (fee for service)

Answer 27

private & public payers question hospital charges & negotiated lower payments → shifts financial risk to hospitals

: insurance companies made fee-for-service payments to private hospitals based on “Reasonable Cost” → hospitals influenced payment amt.

Question 28

payment per day / per diem

Answer 28

Many insurance companies & Medicaid plans contract with hospitals for per diem payments

Per diem payments: bundles all services provided for a patient on one day into one payment

This bundling of services into one fee removes the hospital’s financial incentive as it loses money by performing expensive studies

the insurer is at risk for the number of days (utilization reviews are done to limit days)
the hospital is at risk for the number of services

Question 29

Diagnosis related groups (DRG)

Answer 29

DRG payment lumps together all services performed during one acute care hospital episode vs per diem payment lumps together all services performed during 1 day

medicare is at risk for the number of admissions

the hospital is at risk for the length of stay and number of treatments (use internal utilization reviews to reduce cost)

Question 30

PAYMENT PER INSTITUTION (global)

Answer 30

A fixed payment made for all services performed on every patient during 1 year

Used in Veterans Health Administration & Department of Defense hospitals in the United States

hospital is at full risk

Question 31

financing controls

Answer 31

Limits how much money flows from individuals &
employers to health care plans

difficult to do in the US

Question 32

reimbursement controls

Answer 32

Control how much money flows from insurance plans to
doctors/hospitals/etc.

price controls

Question 33

Utilization controls

Answer 33

Restrict consumption by patients & avoid excessive
care by physicians

patient cost sharing - out of pocket costs

reducing supplier induced demand:
with utilization reviews

Question 34

value based payment or pay for performance

Answer 34

paying for units of service [visits, hospital episodes, or hours of work] & how well physicians/other providers deliver those services