106 MLT Flashcards
A Broad Description of the system
Characteristics of the U.S. system
1) Multiplicity of financial arrangements. -
2) Numerous insurance agencies/ MCO that employ various mechanisms for insuring against risk.
3) Multiple payers( Multiple insurance pay) that make their own determination about the cost for each service.
4) Diverse settings where services are delivered.
5) Numerous consulting firms offering expertise in planning, cost containment, electronic systems, quality, and restructuring of resources.
One characteristic of the U.S. system
- Multiplicity of financial arrangements.
Government Finances public insurance through Medicare, Medicare, and the children’s Health Insurance Program (CHIP) for a significant portion of the country’s elderly, low-income, disabled and pediatric populations.
Basic Components of a Health Care Delivery System
Health care delivery system incorporates four (4) functional components:
Learn them:
1. Financing
2.Insurance
3. Delivery
4.Payment
**A quad - function model **
Quad-Function Model
1) Financing- Employers Government-Medicare, Medicaid Individual self-funding.
2) insurance - insurance companies Blue Cross/ Blue Shield self - insurance.
3) Delivery - (providers) physicians Hospitals Nursing home Diagnostic centers Medical equipment vendors community health centers.
4) payment - insurance companies Blue Cross/ Blue Shield Third - party claims processors.
Quad Function Model
Financing
Necessary to obtain health insurance or to pay for health services. -
*The employers finance health care as a fringe benefit for their employees.
* A dependent spouse or children may also be covered.
* most employers purchase health insurance through a managed care organization ( MCO) .
Quad Function Model
Financing {second part }
In public programs, the government functions as the financier; the insurance function may be carved out to the health maintenance organization (HMO) act passed during Nixon administration. Employers with 25 or more employees required to offer an HMO alternative if available in geographic location.
Quad - Function Model
INSURANCE
1.Protects the insured again financial catastrophe by providing expensive health care services when needed.
2.Determines the package of health services that the insured individual is entitled to receive.
3.Specifies how and where health care services may be received. {MO office - charges for service > Billing Dept files to patients insurance.
4. Also function as a claims processor and manages the disbursement of fund to the health care providers.
Quad - Function Model
Delivery
1)* the provisions of health care services by various providers.
2)* provider: any entity that delivers health care services and either independently bills for those services or is supported through tax revenues:
*Physicians
*Dentists
*Optometrists
*Therapists
All in hospitals
Quad - Function Model
Payment
1.* Reimbursement to providers for services delivered.
2.* The insurer determines how much is paid for a certain service.
3.* Funds for actual disbursement come from the premiums paid to the MCO or insurance company.
4.* At the time of service, the patient is usually required to pay an out - of - pocket amount to see a physician.
5.* The remainder is covered by the MCO or insurance company.
6.* In government insurance plans, such as Medicare and Medicaid, tax revenues are used to pay providers.
Insurance and Health Care Reform
- Medicare, Medicaid, and Children’s Health Insurance Program (CHIP)
- Reason employment - based system left some uninsured
- Patient protection and Affordable Care Act
Insurance and Health Care Reform (second part )
Reasons employment - based - system left some uninsured.
- Small business cannot get group insurance at affordable rates and are unable to offer insurance.
- Participation in insurance programs may be voluntary.
Patient Protection and Affordable Care Act
- required all U.S. citizens and legal residents to be coved by public or private insurance.
- Failed to achieve universal coverage that would enable all citizens and legal residents to have health insurance
