Healthcare Access and Payment Systems/Care Coordination

Question 1

Sick care

Answer 1

o Hospital
o Clinic
o Federally Qualified Health Centers
o Free Clinics
o Pharmacy
o Help people get better

Question 2

Well care

Answer 2

o Public Health Programs
o Community Events
o Help maintain the health of society

Question 3

3 dimensions of the American HC system

Answer 3

Quality: The degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine).

Access: The timely use of health services to achieve the best health outcomes. This includes: insurance coverage, geographic availability, and personal relationships (Institute of Medicine). Ability to gain health services to achieve health outcomes

Cost: the actual cost of providing services related to the delivery of healthcare, including the cost of procedures, therapies and medications. This does NOT include expenditure costs such as money paid for services or fees (National Institute of Health). Thea actual cost of the services of the delivery of HC. Not just the cost of what the patient would pay, but the actual cost of the HC

Question 4

How do we pay for HC?

Answer 4

Insurance
Cash
Charity Care

Question 5

Insurance - 3 types

Answer 5

Private/Commercial
 Affordable Care Act
 Employer Provided Insurance employer offers health insurance as a benefit. If that is not the case, you are able to go to the marketplace and find a HC plan (made possible by the ACA)

Government
 Medicare (Federal)
* Funded and regulated by federal gov.
* People >65
 Medicaid (State)
* Funded 50% federal and 50% states
* Carried out at state level (regulated)
* For poor people. Definition of ‘poor’ varies from state to state

Self-contained insurer/provider
 VA
 Indian Health Services
* Own all facilities. Provider AND payer of care

Question 6

Cash for payment

Answer 6

o People can go BUY healthcare
o Plastic/cosmetic surgery
o Out-of-pocket
o Lots of providers may not see patients if they do not have providers

Question 7

Charity Care for payment

Answer 7

o Free care for people that can get at places. Free clinics

Question 7

• Premium

Answer 7

the monthly or annual amount you pay in order to have health insurance coverage
what you pay to JUST HAVE health insurance

Question 8

• Deductible

Answer 8

the amount of money you must pay out of pocket, before insurance coverage kicks in
premium + any interaction with HC system and you get a bill, you WILL pay a certain amount of money before the insurance kicks in and pays

Question 9

• Co-pay

Answer 9

flat fee you pay toward cost of medical care. May start before or after the deductible phase. May or may not apply to the deductible amount.

Dependent on insurance plan. EX: If you go to the dr., you have $20 copay regardless of if you have hit your deductible yet

Question 10

• Co-insurance

Answer 10

your shared responsibility for medical costs with the insurance company. Applies after the deductible has been met.

Pay month premiums, interaction if HC system that costs 500$. I have a 200$ deductible. I pay the first 200$, the co-insurance will be an 80/20 split between what the insurance pays and what I pay with the remaining 300$. Insurance will pay 80% and I will be responsible for the last 20%

Question 11

• Out of Pocket Max

Answer 11

The maximum amount you will pay annually for medical care. 1000, 5000, or a few hundred based on variation of these terms and how they apply to different plans

Question 12

Network

Answer 12

o group of providers, hospital systems, physicians/doctors/provider offices that have a specific contract with insurance company and they are ‘in-network’. Providers that do NOT have a contract are ‘out of network’

Question 13

Basic Provisions of the ACA

Answer 13

Guaranteed Coverage
Essential Health Benefits
Individual Mandate to Purchase Insurance
Creation of “Health Exchanges”
Premium Subsidies
Medicaid Expansion
Medicare Reform
Lifetime Spending Limits Erased

Question 14

Guaranteed Coverage

Answer 14

Cannot be denied for pre-existing conditions, children can remain on parent’s insurance until age 26 used to be could stay on parents insurance as long as you were a full-time student, but now ; used to have a gap between graduation and starting a job with your new insurance
o KEY!

Question 15

Essential Health Benefits

Answer 15

Those benefits that MUST be provided under law (preventative care without co-pay, contraceptive management, etc..)
o Insurance companies can NOT offer plans that DO NOT cover preventative cares (well child visits, colonoscopies, mammograms, immunizations). In the past, you could get a plan that did not cover this type of health maintenance/preventative care to be cheaper, but the ACA placed law that insurance companies MUST provide this care

Question 16

Individual mandate to purchase insurance

Answer 16

(No longer applies as of 2019)
o Paid when you file your taxes if you didn’t have insurance, you had to pay a penalty when you filed taxes. Idea is to encourage people to buy and be covered by insurance
o You HAD to have insurance from some source. Supreme court determined that it was not legal to force someone to buy something. Taken out of ACA in 2019

Question 17

Creation of “Health Exchanges”

Answer 17

o If your employer does not provide insurance, you’re self-employed, you have several part-time jobs, you can go to the Health Exchange and access/purchase a health plan much easier than was done in the past

Question 18

Premium Subsidies

Answer 18

o For people who cannot afford premiums, money from gov. to assist people in paying premiums if they could not

Question 19

Medicaid Expansion

Answer 19

o Supreme court reviewed, decided that federal government cannot force states to pay for something. Many states decided they were not going to expand Medicaid because of money, but some states have now decided to expand Medicaid

Question 20

Medicare Reform

Answer 20

o Largely with preventing fraud and waste in Medicare program

Question 21

Lifetime Spending Limits Erased

Answer 21

o Kind of goes with Guaranteed Coverage
o In past, there was lifetime spending limits. If you got really sick and needed lots of expensive medical care, eventually they would say there is a lifetime spending maximum so they could cut you off when you got to that point. These have been erased

Question 22

Commercial/Private Insurance

Answer 22

TONS of plans. Each are required to meet the requirements of the ACA, however each plan is going to have a premium/deductible/copay/coinsurance/out of pocket maximum, and the insurance companies will have a ‘network’ if you go with those providers within vs outside the network the prices will change

Question 23

Government Sponsored Insurance

Answer 23

Medicare
Medicaid
Indian Health Services
Veteran’s Affairs

Question 24

Medicare

Answer 24

WHAT TO UNDERSTAND: this is for people who are 65 and older, some disabled people and some with specific illnesses or diagnoses. Largely, think of as geared towards elderly.
***Entirely a federally funded and managed program! Medicare across the entire country will be the same! Providers can vary, but COVERAGE will be the same and payment will be the same

Question 25

Medicaid

Answer 25

Insurance for low-income populations. Managed/paid for in part by US government, and remainder is paid for by the state
MANAGED at the state level – from state to state, you will see very different levels of Medicare programs
ALWAYS for low income and children up to 18/19 depending on state
Highly variable to eligibility criteria: typically preggo women 100% covered, disabled people, very low income seniors

NE MEDICAID
 Annual Income less that 100% FPL federal poverty level
* 12,140 for a single person
 Savings/Assets (including home, cars, bank accounts) must be less than $4000

Question 26

Medicare VS Medicaid

Answer 26

• Two different plans
• Two different applications
• Two different payers
• Two different managers
• Medicare: elderly, Medicaid: poor people
• Medicare: managed and paid for at federal level
• Medicaid: paid for at federal and state level but managed at STATE level. Highly variable of coverage based on state.
• If you are poor enough to qualify for Medicaid, its really good insurance. Typically, 100% coverage of hospital care, SNF, dr. offices, including prescriptions (may have extra cost)

Question 27

Indian Health Services

Answer 27

• People registered with a tribe can get payment for their care and their care
• Typically on reservations

Question 28

Veterans Affairs

Answer 28

• National health insurance plan. Services provided at government owned facilities. Insurance coverage is totally paid for

Question 29

Cash and Charity care: Federally Qualified Health Centers

Answer 29

o Federally qualified health centers: meet requirements through federal government and they can apply for that status. Provide very comprehensive care (dental, vision, pharmacy, mental health, transportation). Charles drew, One World, All Care. These clinics meet federal requirements and operate on a ‘sliding fee’ scale: based on income. When you go, you take pay stubs/income tax forms to provide evidence of income, then they determine how much you have to pay for each service. Some slide down to 0$, some don’t. While they have to meet standards and qualifications, may still look different depending on clinic. May continue to see patients if they cannot pay, and some may not. Theoretically should be very similar, but in practice may look a lot different.

Question 30

Charity Care

Answer 30

o Care is charged, then ‘written off’ if patient cannot pay. Acknowledged the fact they the will never receive payment
 Hospitals are subsidized by federal government to do this because government recognizes that they have required hospitals to see people in emergency situations and also they acknowledge that we NEED hospitals, and if there are too many ‘nonpayers’, the hospitals will not be able to remain open

Question 31

What do we mean by HC access?

Answer 31

• Financing/paying for HC. Paying for preventative services. Paying for health care, exercise.

Question 32

What are HC access issues?

Answer 32

• Transportation: far distance to HC, urban where it can be difficult to get to
• Language: inability to speak English should NOT impede available of healthcare. Providing culturally and linguist care. MARTY, interpreting device. Interpreters that should not be used: young children, someone in the hallway who speaks the language. Long wait to get appropriate interpreter
• Rural: what is available and what is quality
• Urban can I get it?
• Populations with specific access issues: migrants, undocumented. Language.
• People with disabilities: yes get Medicaid, but providers may not provide services needed to get care (people with disabilities may need general anesthesia for dental care, but many dentists do not do that service). Or just being a in wheelchair with public transportation
• Poverty: not just paying for HC, but all things that contribute to health healthy life- safe household (no allergens, lead), healthy foods (time and energy to cook healthy foods), education available and its quality